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Pabst L, Aylward BS, Rogers DL, Aylward SC. Persistent Elevation of Opening Pressure Despite Treatment and Symptom Resolution in Pediatric Intracranial Hypertension. Pediatr Neurol 2024; 153:92-95. [PMID: 38354628 DOI: 10.1016/j.pediatrneurol.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 11/04/2023] [Accepted: 12/18/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Currently no guidelines for repeating a lumbar puncture to guide management in primary intracranial hypertension (PIH) exist. METHODS An institutional database of patients 18 years and younger followed in the institution's pediatric intracranial hypertension clinic was examined for opening pressure changes in PIH at diagnosis, before medication wean, and following medication wean, as well as to examine whether measurements at the time of diagnosis differed between those with and without disease recurrence. RESULTS Forty-two patients were included in this study; 36% were male and the mean age at diagnosis was 11.01 years. Treatment duration averaged 9.68 months in those without recurrence and 8.5 months in those with recurrence. Average body mass index percentile of patients with disease recurrence was 83.7 and 72.1 in those without recurrence (P = 0.16). Average opening pressure values of all patients at diagnosis, prewean, and postwean was 36.53 cm H2O, 30.7 cm H2O, and 31.1 cm H2O, respectively. There was no statistically significant difference in opening pressures across these time points (P = 0.14). The change in opening pressure from diagnosis to postwean was statistically significant with a reduction of 5.18 cm H2O (P = 0.04). There was no statistical difference between change in opening pressure at diagnosis versus postwean between those with and without recurrence (P = 0.17). CONCLUSIONS This clinical observational study suggests that mean opening pressure measurements in patients with PIH remain elevated both before and after medication wean despite papilledema resolution and patient-reported PIH symptoms. Clinically, this suggests that other features such as signs of optic disc edema and symptoms should be used to inform a clinical determination of disease recurrence and treatment course.
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Affiliation(s)
- Lisa Pabst
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio
| | - Brandon S Aylward
- RTI Health Advance, RTI International, Research Triangle Park, North Carolina
| | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
| | - Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio.
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2
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Aylward SC, Aylward BS, Fedel GM. Effect of Inhaled Sevoflurane on Pediatric Cerebrospinal Fluid Pressure During Lumbar Puncture; Implications for Intracranial Hypertension. J Child Neurol 2024; 39:5-10. [PMID: 38086759 DOI: 10.1177/08830738231220253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Objective: To determine influence of sevoflurane on changes in cerebrospinal fluid pressure in children presenting for lumbar puncture. Methods: Cerebrospinal fluid pressure, end tidal carbon dioxide, and end tidal sevoflurane concentration measurements were obtained at 2-minute intervals for a total of 10 minutes (T0 to T5). Because of concerns regarding patient safety and comfort, the study measurements were completed at the end of the lumbar procedure, starting with the closing pressure and when sevoflurane was stopped. Results: As end tidal sevoflurane concentration decreased, cerebrospinal fluid pressure initially increased up to T2 before decreasing back to around the initial point. There was no significant correlation between sevoflurane level and cerebrospinal fluid pressure. Both weight status and presence or absence of optic edema did not have a significant impact on pressure over time. However, there was a statistically significant difference in the cerebrospinal fluid pressure over time between those with spontaneous respirations compared to those without. Conclusions: There was no significant correlation between the end tidal sevoflurane concentration and cerebrospinal fluid pressure. Assisted ventilation did produce a statistically significant increase in cerebrospinal fluid pressure and suggests that the most accurate measurements are in those with spontaneous respirations.
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Affiliation(s)
- Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brandon S Aylward
- RTI Health Advance, RTI International, Research Triangle Park, NC, USA
| | - Gina M Fedel
- Department of Anesthesia, Nationwide Children's Hospital, Columbus, OH, USA
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3
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Aylward BS, Abbas H, Taraman S, Salomon C, Gal-Szabo D, Kraft C, Ehwerhemuepha L, Chang A, Wall DP. An Introduction to Artificial Intelligence in Developmental and Behavioral Pediatrics. J Dev Behav Pediatr 2023; 44:e126-e134. [PMID: 36730317 PMCID: PMC9907689 DOI: 10.1097/dbp.0000000000001149] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 09/12/2022] [Indexed: 02/03/2023]
Abstract
ABSTRACT Technological breakthroughs, together with the rapid growth of medical information and improved data connectivity, are creating dramatic shifts in the health care landscape, including the field of developmental and behavioral pediatrics. While medical information took an estimated 50 years to double in 1950, by 2020, it was projected to double every 73 days. Artificial intelligence (AI)-powered health technologies, once considered theoretical or research-exclusive concepts, are increasingly being granted regulatory approval and integrated into clinical care. In the United States, the Food and Drug Administration has cleared or approved over 160 health-related AI-based devices to date. These trends are only likely to accelerate as economic investment in AI health care outstrips investment in other sectors. The exponential increase in peer-reviewed AI-focused health care publications year over year highlights the speed of growth in this sector. As health care moves toward an era of intelligent technology powered by rich medical information, pediatricians will increasingly be asked to engage with tools and systems underpinned by AI. However, medical students and practicing clinicians receive insufficient training and lack preparedness for transitioning into a more AI-informed future. This article provides a brief primer on AI in health care. Underlying AI principles and key performance metrics are described, and the clinical potential of AI-driven technology together with potential pitfalls is explored within the developmental and behavioral pediatric health context.
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Affiliation(s)
| | | | - Sharief Taraman
- Cognoa, Inc, Palo Alto, CA
- CHOC (Children's Health of Orange County), Orange, CA
- University of California Irvine, Irvine, CA
- Chapman University, Orange, CA
- Medical Intelligence and Innovation Institute (M13), CHOC, Orange, CA
| | | | | | - Colleen Kraft
- Cognoa, Inc, Palo Alto, CA
- University of Southern California, Los Angeles, CA
- Children's Hospital of Los Angeles, Los Angeles, CA; and
| | - Louis Ehwerhemuepha
- CHOC (Children's Health of Orange County), Orange, CA
- Chapman University, Orange, CA
- Medical Intelligence and Innovation Institute (M13), CHOC, Orange, CA
| | - Anthony Chang
- CHOC (Children's Health of Orange County), Orange, CA
- University of California Irvine, Irvine, CA
- Medical Intelligence and Innovation Institute (M13), CHOC, Orange, CA
| | - Dennis P. Wall
- Cognoa, Inc, Palo Alto, CA
- Stanford Medical School, Palo Alto, CA
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Kraft C, Chamanadjian C, Aylward BS. Autism Spectrum Disorder: The New Asthma? Clin Pediatr (Phila) 2022:99228221144146. [PMID: 36539943 DOI: 10.1177/00099228221144146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
While autism spectrum disorder (ASD) has traditionally been diagnosed in specialty care, rising prevalence rates have strained specialist capacity and created significant diagnostic bottlenecks. With long wait times for specialist evaluations, pediatricians are increasingly being asked to play a greater role in identifying, diagnosing, and managing ASD within the medical home. In this commentary we draw parallels between the challenges pediatricians faced two decades ago learning how to manage pediatric asthma in the medical home, to those faced today in the field of primary care ASD management. Reflecting on the lessons learnt in primary care asthma management may help us construct a roadmap towards a higher and more consistent standard of ASD primary care for patients and their families.
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Affiliation(s)
- Colleen Kraft
- University of Southern California, Los Angeles, CA, USA.,Cognoa, Inc., Palo Alto, CA, USA
| | | | - Brandon S Aylward
- Cognoa, Inc., Palo Alto, CA, USA.,RTI Health Advance, Research Triangle Park, NC, USA
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5
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Graziani G, Aylward BS, Kunkle S, Shih E. Changes in Resilience Following Engagement with A Virtual Mental Health System: A Real World Observational Study (Preprint). JMIR Form Res 2022; 6:e37169. [PMID: 35904875 PMCID: PMC9377433 DOI: 10.2196/37169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background Objective Methods Results Conclusions
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Affiliation(s)
| | | | | | - Emily Shih
- Ginger, San Francisco, CA, United States
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6
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Shih E, Aylward BS, Kunkle S, Graziani G. Association between Care Modality and Utilization with Treatment Response among Members Accessing Virtual Mental Health Services: A Real-World Observational Study (Preprint). JMIR Form Res 2022; 6:e36956. [PMID: 35867401 PMCID: PMC9356339 DOI: 10.2196/36956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background There is a growing bottleneck in mental health care, as the demand for services has outpaced the availability of mental health professionals. Consequently, many health systems have shifted to teletherapy as a scalable approach to increasing accessibility to care. Within these care models, various treatment modalities (eg, coaching and clinical care) are used to deliver support for anxiety and depression. However, more research is needed to better understand the differences in treatment responses. Objective The purpose of this study was to examine the association between different care modalities and the levels of use with symptom score changes for members seeking virtual care services. Methods We conducted an observational study of 4219 members who accessed Ginger, an on-demand mental health service, between September 2020 and September 2021. Using a mobile app, members can access text-based behavioral health coaching and virtual clinical services. This study focused on members with clinically elevated depression or anxiety levels at baseline. Logistic regressions were used to assess the association between care modalities and the levels of use with treatment response in depression and anxiety, using the Patient Health Questionnaire and Generalized Anxiety Disorder Assessment, respectively. Results Of the 4219 members, 1623 (38.47%) demonstrated a full response to depression, and 1684 (39.91%) demonstrated a full response to anxiety. Members who completed care (ie, text-based coaching, virtual clinical therapy, hybrid of coaching, and clinical care) beyond the introductory session showed significantly increased odds of a full response compared with those who completed only limited care. Members who completed a hybrid of care had the highest odds of improvement; the odds of showing a full response in depression were 2.31 times higher (95% CI 1.91-2.80; P<.001) and in anxiety were 2.23 times higher (95% CI 1.84-2.70; P<.001) compared with members who completed limited care. For members who completed only coaching or clinical care, the largest effects were observed among those with high use. For members who completed a hybrid care program, we observed similar treatment responses across all levels of use. Conclusions Our real-world study found that members who completed text-based coaching achieved full treatment responses at similar rates compared with members who completed virtual clinical care and members who completed a hybrid of care. There were no significant differences in the predicted probabilities of full treatment response between coaching and clinical care. Generally, the odds for a full response were highest among members with high use within each care modality; however, there were no differences in full-response treatment odds across levels of use with hybrid care. The results support the utility of digital behavioral health interventions and further highlight text-based coaching protocols as an accessible and suitable option when considering virtual care for treating anxiety and depression.
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Affiliation(s)
- Emily Shih
- Ginger, San Francisco, CA, United States
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7
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Graziani G, Aylward BS, Fung V, Kunkle S. Changes in healthcare costs following engagement with a virtual mental health system: a matched cohort study of healthcare claims data. Procedia Comput Sci 2022; 206:173-182. [PMID: 36158864 PMCID: PMC9489472 DOI: 10.1016/j.procs.2022.09.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The COVID-19 pandemic has exacerbated the pressing need for mental health services. Digital mental health interventions could increase access to care and be an effective approach to reducing anxiety and depression at scale; however, research on their impact on healthcare expenditure is in the nascent stage and requires further investigation. The current study used claims data to examine the associations between use of an on-demand digital mental health platform and healthcare utilization costs compared to a matched control cohort. The study found that there were no significant differences between cohorts in total healthcare costs and pharmacy costs. There was a 16.8% reduction in outpatient costs (p=.08). On-demand digital mental health interventions can serve as a scalable approach to addressing the current mental health demands and potentially lower outpatient costs.
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Affiliation(s)
- Grant Graziani
- Ginger, 116 New Montgomery St Suite 500, San Francisco, CA 94105, USA
| | | | - Vicki Fung
- Massachusetts General Hospital, Mongan Institute for Health Policy 50 Staniford Street Boston MA 02114, USA
| | - Sarah Kunkle
- Massachusetts General Hospital, Mongan Institute for Health Policy 50 Staniford Street Boston MA 02114, USA
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8
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Shih E, Aylward BS, Kunkle S, Graziani G. Health-Related Quality of Life among Members using an On-Demand Behavioral Health Platform: A Pilot Observational Study (Preprint). JMIR Form Res 2021; 6:e35352. [PMID: 35802408 PMCID: PMC9308074 DOI: 10.2196/35352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/21/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Despite the well-known adverse health conditions and negative economic outcomes associated with mental health problems, accessing treatment is difficult due to reasons such as availability and cost. As a solution, digital mental health services have flooded the industry, and new studies are quickly emerging that support their potential as an accessible and cost-effective way to improve mental health outcomes. However, many mental health platforms typically use clinical tools such as the Patient Health Questionnaire-9 (PHQ-9) or General Anxiety Disorder-7 (GAD-7). Yet, many individuals that seek out care do not have clinical symptomatology and thus, traditional clinical measures may not adequately capture symptom improvement in general well-being. As an alternative, this study used the health-related quality of life (HRQoL) tool from the Centers for Disease Control and Prevention “Healthy Days” measure. This subjective measure of well-being is an effective way to capture HRQoL and might be better suited as an outcome measure for treatments that include both clinical and subclinical individuals. Objective The purpose of this study was to describe changes in HRQoL in clinical and subclinical members assessing virtual care and to examine the association between text-based behavioral coaching and virtual clinical sessions with changes in HRQoL. Methods A total of 288 members completed the 4-item HRQoL measure at baseline and at 1 month following use of the Ginger on demand behavioral health platform. Baseline anxiety and depression levels were collected using the GAD-7 and PHQ-9, respectively. Results Members completed on average 1.92 (SD 2.16) coaching sessions and 0.91 (SD 1.37) clinical sessions during the assessment month. Paired samples t tests revealed significant reductions in the average number of unhealthy mental health days between baseline (mean 16, SD 8.77 days) and follow-up (mean 13.2, SD 9.02 days; t287=5.73; P<.001), and in the average number of days adversely impacted (meanbaseline 10.9, meanfollow-up 8.19; t287=6.26; P<.001). Both subclinical members (t103=3.04; P=.003) and clinical members (t183=5.5; P<.001) demonstrated significant improvements through reductions in adversely impacted days over a month. Clinical members also demonstrated significant improvements through reductions in unhealthy mental health days (t183=5.82; P<.001). Finally, member engagement with virtual clinical sessions significantly predicted changes in unhealthy mental health days (B=–0.96; P=.04). Conclusions To our knowledge, this study is one of the first to use the HRQoL measure as an outcome in an evaluation of a digital behavioral health platform. Using real-world longitudinal data, our preliminary yet promising results show that short-term engagement with virtual care can be an effective means to improve HRQoL for members with subclinical and clinical symptoms. Further follow-up of reported HRQoL over several months is needed.
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Affiliation(s)
- Emily Shih
- Ginger, San Francisco, CA, United States
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9
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Aylward BS, Gal-Szabo DE, Taraman S. Racial, Ethnic, and Sociodemographic Disparities in Diagnosis of Children with Autism Spectrum Disorder. J Dev Behav Pediatr 2021; 42:682-689. [PMID: 34510108 PMCID: PMC8500365 DOI: 10.1097/dbp.0000000000000996] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT This special article uses a biosocial-ecological framework to discuss findings in the literature on racial, ethnic, and sociodemographic diagnostic disparities in autism spectrum disorder. We draw explanations from this framework on the complex and cumulative influences of social injustices across interpersonal and systemic levels.
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Affiliation(s)
| | | | - Sharief Taraman
- Cognoa, Inc, Palo Alto, CA; and
- Department of Neurology, CHOC Children's, Orange, CA
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10
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Dsouza S, Aylward BS, Rogers DL, Aylward SC. Presenting Symptomatology and Risk Factors in Pediatric Secondary Intracranial Hypertension due to Venous Sinus Thrombosis. Pediatr Neurol 2019; 101:53-56. [PMID: 31601452 DOI: 10.1016/j.pediatrneurol.2019.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/22/2019] [Accepted: 04/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND There remains debate regarding the need for venous imaging in pediatric intracranial hypertension. METHODS Records of patients aged 18 years or younger who were evaluated in the intracranial hypertension clinic at Nationwide Children's Hospital in Columbus, Ohio, were reviewed. Past medical history, diagnostic evaluation, and presenting symptoms were examined to evaluate differences in symptomatology presentation and risk factors in patients with pediatric intracranial hypertension with and without thrombosis. RESULTS A total of 226 patients met inclusion criteria, 145 were diagnosed with primary intracranial hypertension, 81 with secondary intracranial hypertension, with 17 noted to have venous sinus thrombosis as the cause of their secondary intracranial hypertension. Of those with thrombosis, 41.2% did not have any thrombosis risk factors. Headache was the most prominent symptom, present in 73.8% (n = 107) of patients with primary intracranial hypertension, 87.5% (n = 56) of patients with secondary intracranial hypertension without thrombosis, and 82.4% (n = 14) with thrombosis. CONCLUSIONS The only clinically significant difference in presenting symptomatology between the thrombosis and the other groups was nausea or vomiting. Predisposing factors to develop thrombosis were absent in 41.2% of patients. Hence, the need for venous imaging in pediatric intracranial hypertension cannot be clearly determined by clinical presentation or risk factors alone. Patients with indwelling catheters should receive imaging in the region of their catheter to rule out catheter-associated thrombosis.
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Affiliation(s)
- Shalome Dsouza
- Department of Neurology, University of South Dakota Sanford School of Medicine, Vermillion, South Dekota
| | | | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
| | - Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio.
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Bishop MN, Gise JE, Donati MR, Shneider CE, Aylward BS, Cohen LL. Parenting Stress, Sleep, and Psychological Adjustment in Parents of Infants and Toddlers With Congenital Heart Disease. J Pediatr Psychol 2019; 44:980-987. [DOI: 10.1093/jpepsy/jsz026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 02/06/2023] Open
Abstract
Abstract
Objective
Parents of children with chronic medical needs report increased parenting challenges, poor sleep, and maladjustment. The impact of parenting stress on both sleep and adjustment has yet to be evaluated for parents of infants and young children with congenital heart disease (CHD). We studied the relations among parenting stress, sleep, and adjustment in parents of infants and toddlers with CHD. We expected that sleep quality would mediate the relationship between parenting stress and adjustment.
Methods
Sixty-nine parents of infants and toddlers with CHD were evaluated on self-report measures of illness-related parenting stress (Pediatric Inventory for Parents), sleep (Pittsburgh Sleep Quality Index), and psychological adjustment (Brief Symptom Index-18).
Results
The parents of infants and toddlers with CHD reported elevated levels of parenting stress, sleep problems, and maladjustment. The positive relationship between parenting stress and parent maladjustment was mediated by sleep quality.
Conclusions
Findings suggest that parents of infants and toddlers with CHD report high parenting stress, poor sleep, and maladjustment. Analyses indicate the stress-adjustment relationship is mediated by quality of sleep. Given the multiple demands on parents of infants and children with CHD, it is important to attend to parents’ overall functioning and mental health. Our findings highlight targets for intervention to improve the well-being of parents of young children with CHD.
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Affiliation(s)
| | - Jensi E Gise
- Department of Psychology, Georgia State University
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12
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Ramsey RR, Ryan JL, Hershey AD, Powers SW, Aylward BS, Hommel KA. Treatment adherence in patients with headache: a systematic review. Headache 2014; 54:795-816. [PMID: 24750017 DOI: 10.1111/head.12353] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To review and critically evaluate the extant research literature pertaining to adherence in youth and adults with headache and to provide recommendations for future research. BACKGROUND This article provides the first systematic review of pediatric headache adherence and updates a previous review of treatment adherence in adults with headache. DESIGN Systematic review of empirical literature. METHODS A literature search with no date restriction was conducted using PubMed and PsycINFO electronic databases and bibliographies of relevant articles. RESULTS Adherence rates in adults with headache range considerably from 25% to 94% across treatment, assessment method, and definition of adherence utilized. Methods to assess adherence included retrospective prescription claims data, paper or electronic diaries, follow-up appointment attendance, written and verbal self-report of general adherence, verbal self-report of adherence over a specific amount of time via in person interview or telephone, validated adherence measures, adherence questionnaires without validation, and counselor ratings of homework. Each methodology and assessment tool demonstrated strengths and weaknesses. No studies have systematically examined medication adherence in children with headache, and the few available studies examining adherence to behavioral treatment have documented adherence rates ranging from 52% to 86%. CONCLUSIONS Adherence research in adults with headache is growing, but studies demonstrate a number of methodological shortcomings. Adherence research in children with headache, and adherence intervention research in both adults and children, is scant. Future research should use objective measures of adherence, consider over-the-counter medications and medication overuse, examine demographic, psychological, and behavioral correlates of adherence, assess adherence to botulinum toxin type A, and examine the efficacy of adherence interventions in individuals with headache.
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Affiliation(s)
- Rachelle R Ramsey
- Department of Psychology, Oklahoma State University, Stillwater, OK, USA; Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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13
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Aylward BS, Rausch JR, Modi AC. An examination of 1-year adherence and persistence rates to antiepileptic medication in children with newly diagnosed epilepsy. J Pediatr Psychol 2014; 40:66-74. [PMID: 24648257 DOI: 10.1093/jpepsy/jsu010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The primary aim of the current study was to use new methods to examine 1-year quality of medication dosing (adherence) and continuation with medication treatment (persistence) rates to antiepileptic drugs (AEDs) in children with newly diagnosed epilepsy. METHODS Medication-taking behaviors of AEDs were assessed using electronic monitors for 117 children with newly diagnosed epilepsy for the first year after diagnosis. RESULTS Approximately 15% of participants were categorized as nonpersistent (i.e., failed to take medication for >15 consecutive days) 6 months after AED initiation, which increased to 26.6% of participants at 1 year. The majority of medication dosing events took place within a +/-2-hr interval as recommended. The group with lower socioeconomic status demonstrated more nonpersistence over time. CONCLUSION Examining adherence and persistence in medication taking behaviors may yield different types of data for clinical and research purposes.
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Affiliation(s)
- Brandon S Aylward
- Department of Pediatrics, Emory University School of Medicine, Department of Neurology and Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center Department of Pediatrics, Emory University School of Medicine, Department of Neurology and Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center Department of Pediatrics, Emory University School of Medicine, Department of Neurology and Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Joseph R Rausch
- Department of Pediatrics, Emory University School of Medicine, Department of Neurology and Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Avani C Modi
- Department of Pediatrics, Emory University School of Medicine, Department of Neurology and Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
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14
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Kashikar-Zuck S, Zafar M, Barnett KA, Aylward BS, Strotman D, Slater SK, Allen JR, LeCates SL, Kabbouche MA, Ting TV, Hershey AD, Powers SW. Quality of life and emotional functioning in youth with chronic migraine and juvenile fibromyalgia. Clin J Pain 2013; 29:1066-72. [PMID: 23446072 PMCID: PMC3675174 DOI: 10.1097/ajp.0b013e3182850544] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
SUMMARY Chronic pain in children is associated with significant negative impact on social, emotional, and school functioning. Previous studies on the impact of pain on children's functioning have primarily used mixed samples of pain conditions or single pain conditions (eg, headache and abdominal pain) with relatively small sample sizes. As a result, the similarities and differences in the impact of pain in subgroups of children with chronic pain have not been closely examined. OBJECTIVE To compare pain characteristics, quality of life, and emotional functioning among youth with pediatric chronic migraine (CM) and juvenile fibromyalgia (JFM). METHODS We combined data obtained during screening of patients for 2 relatively large intervention studies of youth (age range, 10 to 18 y) with CM (N=153) and JFM (N=151). Measures of pain intensity, quality of life (Pediatric Quality of Life; PedsQL, child and parent-proxy), depressive symptoms (Children's Depression Inventory), and anxiety symptoms (Adolescent Symptom Inventory-4-Anxiety subscale) were completed by youth and their parent. A multivariate analysis of covariance controlling for effects of age and sex was performed to examine differences in quality of life and emotional functioning between the CM and JFM groups. RESULTS Youth with JFM had significantly higher anxiety and depressive symptoms, and lower quality of life in all domains. Among children with CM, overall functioning was higher but school functioning was a specific area of concern. DISCUSSION Results indicate important differences in subgroups of pediatric pain patients and point to the need for more intensive multidisciplinary intervention for JFM patients.
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Affiliation(s)
- Susmita Kashikar-Zuck
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
- Department of Pediatrics, University of Cincinnati, College of Medicine
| | - Marium Zafar
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Kimberly A. Barnett
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Brandon S. Aylward
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Daniel Strotman
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Shalonda K. Slater
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
- Department of Pediatrics, University of Cincinnati, College of Medicine
| | - Janelle R. Allen
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
| | - Susan L. LeCates
- Division of Neurology, Cincinnati Children's Hospital Medical Center
| | - Marielle A. Kabbouche
- Department of Pediatrics, University of Cincinnati, College of Medicine
- Division of Neurology, Cincinnati Children's Hospital Medical Center
| | - Tracy V. Ting
- Department of Pediatrics, University of Cincinnati, College of Medicine
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center
| | - Andrew D. Hershey
- Department of Pediatrics, University of Cincinnati, College of Medicine
- Division of Neurology, Cincinnati Children's Hospital Medical Center
| | - Scott W. Powers
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center
- Department of Pediatrics, University of Cincinnati, College of Medicine
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15
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Brannon EE, Kuhl ES, Boles RE, Aylward BS, Ratcliff MB, Valenzuela JM, Johnson SL, Powers SW. Strategies for Recruitment and Retention of Families from Low-Income, Ethnic Minority Backgrounds in a Longitudinal Study of Caregiver Feeding and Child Weight. Child Health Care 2013; 42:198-213. [PMID: 24078763 DOI: 10.1080/02739615.2013.816590] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Children from low-SES and ethnic minority backgrounds are at heightened risk for overweight, yet are underrepresented in the pediatric obesity literature. METHODS The current paper describes strategies employed to minimize barriers to recruitment and retention of African-American families receiving WIC services in a longitudinal study examining caregiver feeding and child weight. RESULTS Seventy-six families enrolled in the study over 3.5 years, and 50% of the families completed the study. IMPLICATIONS FOR PRACTICE Despite effortful planning, unanticipated barriers likely contributed to lengthy recruitment and a modest retention rate. Future research should incorporate lessons learned to modify and develop effective strategies for increasing engagement of low-SES and ethnic minority families in research.
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Affiliation(s)
- Erin E Brannon
- Department of Psychology, Oklahoma State University, Stillwater, OK
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16
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Abstract
The objective of this study was to evaluate demographic and psychosocial predictors of attendance in a family-based behavioral weight management clinical trial. Ninety-three children and adolescents aged 7-17 (Mean age = 11.59, s.d. = 2.6) who were either overweight or obese (Mean BMI percentile = 98.2) and their parents received either a 10-session behavioral treatment or a three-session brief family intervention in the context of a randomized clinical trial (10). Psychosocial and anthropometric measures were obtained before enrollment and at the end of 10 weeks for both treatment groups. Univariate linear regression and hierarchical multiple regression analyses were used to identify predictors of attendance to treatment from an a priori set of hypothesized predictors. Three variables demonstrated significant associations with the dependent variable, percent of treatment sessions attended. Specifically, distance from participant's home to treatment site, lower gross family income, and youth self-report of depressive symptoms were each associated with lower percent attendance (all Ps < 0.05). These results corroborate (i.e., income, depressive symptoms) and expand (i.e., distance from treatment site) previous reports in the literature of potential barriers to effective treatment for pediatric obesity, and suggest the need for research on treatment delivery methods that could increase participation among low-income families (e.g., eHealth, mHealth options). Depressive symptoms could represent an additional barrier to treatment attendance, suggesting that assessment and treatment for these symptoms may be appropriate before commencing weight management treatment.
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Affiliation(s)
- Chad D Jensen
- Department of Psychology, Brigham Young University, Provo, Utah, USA.
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17
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Wu YP, Aylward BS, Roberts MC, Evans SC. Searching the scientific literature: implications for quantitative and qualitative reviews. Clin Psychol Rev 2012; 32:553-7. [PMID: 22819996 DOI: 10.1016/j.cpr.2012.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 06/14/2012] [Accepted: 06/26/2012] [Indexed: 10/28/2022]
Abstract
Literature reviews are an essential step in the research process and are included in all empirical and review articles. Electronic databases are commonly used to gather this literature. However, several factors can affect the extent to which relevant articles are retrieved, influencing future research and conclusions drawn. The current project examined articles obtained by comparable search strategies in two electronic archives using an exemplar search to illustrate factors that authors should consider when designing their own search strategies. Specifically, literature searches were conducted in PsycINFO and PubMed targeting review articles on two exemplar disorders (bipolar disorder and attention deficit/hyperactivity disorder) and issues of classification and/or differential diagnosis. Articles were coded for relevance and characteristics of article content. The two search engines yielded significantly different proportions of relevant articles overall and by disorder. Keywords differed across search engines for the relevant articles identified. Based on these results, it is recommended that when gathering literature for review papers, multiple search engines should be used, and search syntax and strategies be tailored to the unique capabilities of particular engines. For meta-analyses and systematic reviews, authors may consider reporting the extent to which different archives or sources yielded relevant articles for their particular review.
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Affiliation(s)
- Yelena P Wu
- Clinical Child Psychology Program, University of Kansas, 2010 Dole Human Development Center, 1000 Sunnyside Avenue, Lawrence, KS 66045, USA
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18
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19
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Jensen CD, Cushing CC, Aylward BS, Craig JT, Sorell DM, Steele RG. Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. J Consult Clin Psychol 2011; 79:433-40. [PMID: 21728400 DOI: 10.1037/a0023992] [Citation(s) in RCA: 234] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This study was designed to quantitatively evaluate the effectiveness of motivational interviewing (MI) interventions for adolescent substance use behavior change. METHOD Literature searches of electronic databases were undertaken in addition to manual reference searches of identified review articles. Databases searched include PsycINFO, PUBMED/MEDLINE, and Educational Resources Information Center. Twenty-one independent studies, representing 5,471 participants, were located and analyzed. RESULTS An omnibus weighted mean effect size for all identified MI interventions revealed a small, but significant, posttreatment effect size (mean d = .173, 95% CI [.094, .252], n = 21). Small, but significant, effect sizes were observed at follow-up suggesting that MI interventions for adolescent substance use retain their effect over time. MI interventions were effective across a variety of substance use behaviors, varying session lengths, and different settings, and for interventions that used clinicians with different levels of education. CONCLUSIONS The effectiveness of MI interventions for adolescent substance use behavior change is supported by this meta-analytic review. In consideration of these results, as well as the larger literature, MI should be considered as a treatment for adolescent substance use.
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Affiliation(s)
- Chad D Jensen
- Clinical Child Psychology Program, University of Kansas, KS, USA
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20
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Canter KS, Kessler ED, Odar C, Aylward BS, Roberts MC. Perceived benefits of mentoring in pediatric psychology: a qualitative approach. J Pediatr Psychol 2011; 37:158-65. [PMID: 21873275 DOI: 10.1093/jpepsy/jsr064] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To identify tangible and intangible benefits of mentoring cited by a select group of identified mentors. METHODS Twenty frequently named mentors within pediatric psychology provided responses to open-ended questions regarding benefits they have experienced through the mentoring process. RESULTS Mentors identified many personal and professional benefits of the mentoring relationship, although they did not clearly distinguish between tangible and intangible advantages to the relationship. The most commonly reported benefits included career development of the mentee, mentor's career enhancement, and a sense of giving back to the field of pediatric psychology. CONCLUSIONS A bidirectional definition of mentoring more accurately describes the relationship than a more traditional unidirectional definition. These results suggest that mentors experience a wide variety of benefits that could be examined more closely within the field.
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Affiliation(s)
- Kimberly S Canter
- University of Kansas, Clinical Child Psychology Program, 2010 Dole Human Development Center, 1000 Sunnyside Avenue, Lawrence, Kansas 66045, USA.
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21
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Steele RG, Aylward BS, Jensen CD, Cushing CC, Davis AM, Bovaird JA. Comparison of a family-based group intervention for youths with obesity to a brief individual family intervention: a practical clinical trial of positively fit. J Pediatr Psychol 2011; 37:53-63. [PMID: 21852343 DOI: 10.1093/jpepsy/jsr057] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To examine the effectiveness of a family-based behavioral group intervention (Positively Fit; PF) for pediatric obesity relative to a brief family intervention (BFI) in a sample of treatment-seeking children and adolescents. METHODS Families (n = 93) were randomized to treatment condition. Assessments were conducted at pre- and posttreatment and at 12-month follow-up. Outcome indices included standardized body mass index (BMI) and quality of life (QOL). RESULTS Results indicated a significant reduction in zBMI at posttreatment and follow-up across both conditions. At follow-up, BFI and PF participants evidenced average reductions of .12 and .19 zBMI units, respectively. Children demonstrated better outcomes than adolescents across both conditions. Results indicated clinically significant improvements in parent-reported QOL at postintervention and in self-reported QOL at follow-up for PF participants. CONCLUSIONS Results suggest the effectiveness of family-based interventions for pediatric obesity in clinical settings among younger children. Neither intervention was effective in terms of reducing zBMI among adolescents.
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Affiliation(s)
- Ric G Steele
- Clinical Child Psychology Program, University of Kansas, USA.
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22
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Nelson TD, Aylward BS, Rausch JR. Dynamic p-technique for modeling patterns of data: applications to pediatric psychology research. J Pediatr Psychol 2011; 36:959-68. [PMID: 21486938 DOI: 10.1093/jpepsy/jsr023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Dynamic p-technique (DPT) is a potentially useful statistical method for examining relationships among dynamic constructs in a single individual or small group of individuals over time. The purpose of this article is to offer a nontechnical introduction to DPT. METHOD An overview of DPT analysis, with an emphasis on potential applications to pediatric psychology research, is provided. To illustrate how DPT might be applied, an example using simulated data is presented for daily pain and negative mood ratings. RESULTS The simulated example demonstrates the application of DPT to a relevant pediatric psychology research area. In addition, the potential application of DPT to the longitudinal study of adherence is presented. CONCLUSION Although it has not been utilized frequently within pediatric psychology, DPT could be particularly well-suited for research in this field because of its ability to powerfully model repeated observations from very small samples.
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Affiliation(s)
- Timothy D Nelson
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE 68588-0308, USA.
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23
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Steele RG, Wu YP, Jensen CD, Pankey S, Davis AM, Aylward BS. School nurses' perceived barriers to discussing weight with children and their families: a qualitative approach. J Sch Health 2011; 81:128-137. [PMID: 21332477 DOI: 10.1111/j.1746-1561.2010.00571.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Previous studies have documented the presence of specific barriers to school nurses' communications with families about weight-related health. The purpose of the present study was to contribute to the literature by further analyzing, using focus group methodology, school nurses' perceived barriers to addressing weight-related health issues with children and their families. METHODS Twenty-two school nurses from urban and rural school districts in the Midwestern United States participated in 7 focus groups during the spring semester of 2008. Sessions were recorded and transcribed in their entirety. Study authors reviewed the focus group content and identified themes of perceived barriers. NVivo 8 was used to code and evaluate themes. RESULTS Consistent with the extant literature, nurses identified a lack of knowledge and resources, personal weight challenges, lack of institutional support, and lack of time as barriers to weight-related communications with families. However, in addition to these previously identified barriers, nurses also identified family characteristics, child motivation, fear of reactions, and difficulty establishing relationships with children as barriers that impeded their communication with families about weight-related health. CONCLUSIONS As expected, the use of focus group methodology yielded evidence of barriers to communication that had not been previously identified in the literature, as well as those that had been well documented. Consistent with a socioecological view of pediatric healthcare, results suggest a number of systems that could be targeted to improve nurses' weight-related communications with families.
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Affiliation(s)
- Ric G Steele
- Clinical Child Psychology Program, University of Kansas, 2011 Dole Human Development Center, 1000 Sunnyside Ave., Lawrence, KS 66045, USA.
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Wu YP, Aylward BS, Steele RG. Associations between internalizing symptoms and trajectories of medication adherence among pediatric renal and liver transplant recipients. J Pediatr Psychol 2010; 35:1016-27. [PMID: 20231258 DOI: 10.1093/jpepsy/jsq014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To examine medication adherence trajectories posttransplantation and the association between adherence trajectories and self-reported internalizing symptoms in a pediatric population. METHODS Multilevel modeling was used to examine internalizing symptoms and longitudinal medication adherence, as assessed by electronic monitoring, among 55 children and adolescents who received liver or kidney transplantation. RESULTS Medication adherence generally declined over the study assessment window, and higher levels of anxiety were associated with higher and more stable patterns of medication adherence. CONCLUSIONS Anxiety may be an important factor to consider when assessing and intervening with posttransplantation medication adherence. Future research should consider the potential reactivity effects of adherence monitoring, as well as individual and family behaviors associated with anxiety that may influence adherence.
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Affiliation(s)
- Yelena P Wu
- University of Kansas, Lawrence, KS 66047, USA
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25
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Roberts MC, Bender JA, Aylward BS. Problems with nomenclature of specialty training and practice and disclosure of information within clinical psychology. Clinical Psychology: Science and Practice 2009. [DOI: 10.1111/j.1468-2850.2009.01174.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Steele RG, Aylward BS, Jensen CD, Wu YP. Parent- and Youth-Reported Illness Uncertainty: Associations With Distress and Psychosocial Functioning Among Recipients of Liver and Kidney Transplantations. Children's Health Care 2009. [DOI: 10.1080/02739610903038768] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
The current study examined child- and parent-reported child psychosocial functioning in a large sample of children who received solid organ transplantation. Participants included 64 children who received kidney or liver transplantation and 64 parents who completed a standardized measure of children's psychosocial functioning (BASC; Reynolds & Kamphaus, 1992). Although post-transplant children reported significantly fewer psychosocial difficulties than the normative average, parents reported that children had some psychosocial difficulties, particularly internalizing problems. There were no differences in psychosocial functioning between deceased donor organ and living donor organ recipients. Given the discrepancy between parent and child report, the results suggest that children may underreport psychosocial difficulties following transplantation or parents may over-report children's difficulties. Clinicians and researchers are encouraged to obtain assessment information from multiple reporters when assessing psychosocial functioning in this population.
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Affiliation(s)
- Yelena P Wu
- Clinical Child Psychology Program, University of Kansas, Lawrence, KS 66045-7555, USA
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Rosno EA, Steele RG, Johnston CA, Aylward BS. Parental Locus of Control: Associations to Adherence and Outcomes in the Treatment of Pediatric Overweight. Children's Health Care 2008. [DOI: 10.1080/02739610802006544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Aylward BS, Roberts MC, Colombo J, Steele RG. Identifying the Classics: An Examination of Articles Published in the Journal of Pediatric Psychology from 1976–2006. J Pediatr Psychol 2007; 33:576-89. [DOI: 10.1093/jpepsy/jsm122] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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30
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Affiliation(s)
- Ric G Steele
- Clinical Child Psychology Program, University of Kansas, Lawrence, KS, USA.
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