Early childhood sleep quantity, but not caregiver-reported sleep problems, predicts impulse control in children at age 8 years

Short duration of sleep and poor sleep quality have been linked to poor attention and impulse control in children. We aimed to determine the longitudinal predictive value of sleep quantity and quality during early childhood on objective and caregiver-report measures of attention, impulse control, and executive function in children at age 8 years. We used data from the Health Outcomes and Measures of the Environment (HOME) Study, a pregnancy and birth cohort. Caregivers reported on their child's sleep at ages 2, 2.5, 3, 4, and 5 years. Analysis included 410 participants. We used longitudinal growth curve models of early childhood sleep patterns to predict neurobehavioral functioning at age 8 years. Sleep problems did not predict any of our outcome measures at age 8 years. Sleep duration trended shorter as children matured, so predictive models examined both intercept and slope. Children with the least decline in sleep duration across early childhood had fewer impulsive errors at age 8 years on a continuous performance test (unadjusted p = .013; adjusted p = .013). Children with shorter duration of sleep across early childhood had worse caregiver-reported behavioral regulation at age 8 years (unadjusted p = .002; adjusted p = .043). Neither sleep duration slope nor intercept predicted inattention or metacognitive skills at age 8 years (p > .05). Total sleep time across early childhood predicts behavior regulation difficulties in school-aged children. Inadequate sleep during early childhood may be a marker for, or contribute to, poor development of a child's self-regulatory skills.

Examining Patterns and Predictors of ADHD Teens' Skill-Learning Trajectories During Enhanced FOrward Concentration and Attention Learning (FOCAL+) Training

OBJECTIVE

Examine patterns and predictors of skill learning during multisession Enhanced FOrward Concentration and Attention Learning (FOCAL+) training.

BACKGROUND

FOCAL+ teaches teens to reduce the duration of off-road glances using real-time error learning. In a randomized controlled trial, teens with ADHD received five sessions of FOCAL+ training and demonstrated significant reductions in extended glances (>2-s) away from the roadway (i.e., long-glances) and a 40% reduced risk of a crash/near-crash event. Teens' improvement in limiting long-glances as assessed after each FOCAL+ training session has not been examined.

METHOD

Licensed teen (ages 16-19) drivers with ADHD (n = 152) were randomly assigned to five sessions of either FOCAL+ or modified standard driver training. Teens completed driving simulation assessments at baseline, after each training session, and 1 month and 6 months posttraining. Naturalistic driving was monitored for one year.

RESULTS

FOCAL+ training produced a 53% maximal reduction in long-glances during postsession simulated driving. The number of sessions needed to achieve maximum performance varied across participants. However, after five FOCAL+ training sessions, number of long-glances was comparable irrespective of when teens achieved their maximum performance. The magnitude of reduction in long-glances predicted levels of long-glances during simulated driving at 1 month and 6 months posttraining but not naturalistic driving outcomes. FOCAL+ training provided the most benefit during training to teens who were younger and had less driving experience.

CONCLUSION

FOCAL+ training significantly reduces long-glances beginning at the 1st training session.

APPLICATION

Providing five FOCAL+ training sessions early on during teen driving may maximize benefit.

Executive Functioning as a Predictor of Adverse Driving Outcomes in Teen Drivers With ADHD

OBJECTIVE

The present study examined the association between executive functioning (EF) and risky driving behaviors in teens with ADHD.

METHOD

Teens diagnosed with ADHD (n = 179; Mage = 17.4 years) completed two 15-min drives in a fixed-base driving simulator. EF was assessed using parent- and self-report Behavior Rating Inventory of Executive Functioning (BRIEF-2), a temporal reproduction task, and a Go/No-Go task (GNG). Driving outcomes included known predictors of crashes: count of long (>2 s) off-road glances, standard deviation (SD) of lane position (SDLP), mean speed, and SD speed. Generalized linear mixed models, controlling for intelligence and driving experience, were conducted.

RESULTS

Higher rates of GNG commission errors predicted higher rates of long off-road glances. Lower parent-rated EF and increased rates of GNG omission errors predicted SDLP. Higher rates of GNG commission errors also predicted faster average driving speed.

CONCLUSION

Heterogeneity in EF is associated with differences in teen ADHD risky driving behaviors.

Longitudinal mental health trends in cystic fibrosis

BACKGROUND

Mental health screening in accordance with consensus guidelines became routine clinical practice in our cystic fibrosis (CF) Center in 2015. We hypothesized improvement in anxiety and depression symptoms over time and associations between elevated screening scores and disease severity. We aimed to observe the impact of the COVID-19 pandemic and modulator use on mental health symptoms.

METHODS

Retrospective chart reviews were conducted for people 12 years and older with at least one Generalized Anxiety Disorder-7 (GAD-7) or Patient Health Questionnaire-9 (PHQ-9) screening for six years. Descriptive statistics were used to summarize demographic variables and logistic regression and linear mixed models were used to evaluate the relationship between screening scores and clinical variables.

RESULTS

Analyses included 150 participants (ages 12-22 years). The percentage of minimal to no symptom scores increased over time for anxiety and depression. Increased mental health visits and CFRD were associated with higher PHQ-9 and GAD-7 scores. Higher FEV1pp was associated with lower GAD-7 and PHQ-9 scores. More effective modulator use was associated with lower PHQ-9 scores. Mean PHQ-9 and GAD-7 scores were not significantly different when comparing pre-pandemic and pandemic scores.

CONCLUSION

Disruptions in screening during the pandemic were minimal and symptom scores remained stable. Individuals with higher mental health screening scores were more likely to have CFRD and utilization of mental health services. Consistent mental health monitoring and support is needed so individuals with CF can endure anticipated and unanticipated stressors including changes in physical health, healthcare, and societal stressors such as COVID-19 pandemic.

Communication of pain intensity and unpleasantness through magnitude ratings: Influence of scale type, but not gender of the participant

BACKGROUND

A critical aspect for most human pain research is the ability of participants to communicate their first-person, experiential perspective to a third-person observer. This communication is frequently accomplished via pain ratings. The scale type can influence the communication of pain experiences and can contribute to gender differences in pain. This study examined the role of gender on pain ratings using noxious and innocuous stimuli across two types of rating scales.

METHODS

Healthy participants (n = 46) underwent noxious heat, auditory and visual stimulation paradigms. Pain intensity and unpleasantness ratings were collected using the visual analogue scale (VAS) and numerical rating scale (NRS). To determine if one rating scale allows a better report of small differences between different stimulus intensities, the sensitivity to small differences was calculated.

RESULTS

Significant effects for rating scale were found for all stimulus modalities (noxious heat, auditory and visual, p < 0.001) with higher intensity and unpleasantness ratings for the NRS compared to the VAS. Overall, no effects of gender or interactions with gender were found. No differences in rating scale and gender were detected for sensitivity to small differences between stimuli.

CONCLUSIONS

These findings confirm differences in rating scale usage; however, the different usage might not contribute significantly to gender differences in pain.

SIGNIFICANCE

There are differences in the usage of rating scales in which ratings for auditory, visual and noxious somatosensory stimuli are higher with NRS compared to VAS. Choosing a rating scale for research or clinical use should take this different item functioning into account.

Impact of preventive pill-based treatment on migraine days: A secondary outcome study of the Childhood and Adolescent Migraine Prevention (CHAMP) trial and a comparison of self-report to nosology-derived assessments

OBJECTIVE

To examine group differences in self-reported migraine days among youth who completed the Childhood and Adolescent Migraine Prevention (CHAMP) trial prior to its closure and explore the relationship between self-reported and "nosology-derived" (i.e., International Classification of Headache Disorders, 3rd edition [ICHD-3]) migraine days.

BACKGROUND

The CHAMP trial compared amitriptyline and topiramate to placebo for migraine prevention in youth and proposed to analyze change in migraine days as a secondary outcome. There is considerable variability in the field regarding what constitutes a "migraine day," how this is determined and reported in trials, and how consistent these measures are with diagnostic nosology.

METHODS

CHAMP trial completers (N = 175) were randomized to receive amitriptyline (n = 77), topiramate (n = 63), or placebo (n = 35). Participants maintained daily headache diaries where they reported each day with headache and if they considered that headache to be a migraine. For each headache day, participants completed a symptom record and reported about symptoms such as pain location(s) and presence of nausea/vomiting or photophobia and phonophobia. We examined group differences in self-reported migraine days at trial completion (summed from trial weeks 20-24) compared to baseline. We also used an algorithm to determine whether participants' symptom reports met ICHD-3 criteria for migraine without aura, and examined the association between self-reported and "nosology-derived" migraine days.

RESULTS

Results showed no significant differences between groups in self-reported migraine days over the course of the trial. Self-reported and "nosology-derived" migraine days during the baseline and treatment phases were strongly associated (r's = 0.73 and 0.83, respectively; p's < 0.001).

CONCLUSION

Regardless of treatment, CHAMP trial completers showed clinically important reductions in self-reported migraine days over the course of the trial (about 3.8 days less). The strong association between self-reported and "nosology-derived" migraine days suggests youth with migraine can recognize a day with migraine and reliably report their headache features and symptoms. Greater rigor and transparency in the calculation and reporting of migraine days in trials is needed.

Spatial tuning in nociceptive processing is driven by attention

When the source of nociception expands across a body area, the experience of pain increases due to the spatial integration of nociceptive information. This well-established effect is called spatial summation of pain (SSp) and has been the subject of multiple investigations. Here, we used cold-induced SSp to investigate the effect of attention on the spatial tuning of nociceptive processing. Forty pain-free volunteers (N=40, 20 females) participated in this experiment. They took part in an SSp paradigm based on three hand immersions into cold water (5°C): Participants either immersed the radial segment ("a"), ulnar segment ("b") or both hand segments ("a+b") and provided overall pain ratings. In some trials based on "a+b" immersions, they were also asked to provide divided (i.e., first pain in "a" then in "b"; or reversed) and directed attention ratings (i.e., pain only in "a" or "b"). Results confirmed a clear SSp effect in which reported pain during immersions of "a" or "b" was less intense than pain during immersions of "a+b" (p<0.001). Data also confirmed that spatial tuning was altered. SSp was abolished when participants provided two ratings in a divided fashion (p<0.001). Furthermore, pain was significantly lower when attention was directed only to one segment ("a" OR "b") during "a+b" immersion (p<0.001). We conclude that spatial tuning is dynamically driven by attention as reflected in abolished SSp. Directed attention was sufficient to focus spatial tuning and abolish SSp. Results support the role of cognitive processes such as attention in spatial tuning. PERSPECTIVE: This article presents experimental investigation of spatial tuning in pain and offers mechanistic insights of contiguous spatial summation of pain in healthy volunteers. Depending on how pain is evaluated in terms of attentional derivative (overall pain, directed, divided attention) the pain is reduced and spatial summation abolished.

Trial of Training to Reduce Driver Inattention in Teens with ADHD

BACKGROUND

Teens with attention deficit-hyperactivity disorder (ADHD) are at increased risk for motor vehicle collisions. A computerized skills-training program to reduce long glances away from the roadway, a contributor to collision risk, may ameliorate driving risks among teens with ADHD.

METHODS

We evaluated a computerized skills-training program designed to reduce long glances (lasting ≥2 seconds) away from the roadway in drivers 16 to 19 years of age with ADHD. Participants were randomly assigned in a 1:1 ratio to undergo either enhanced Focused Concentration and Attention Learning, a program that targets reduction in the number of long glances (intervention) or enhanced conventional driver's education (control). The primary outcomes were the number of long glances away from the roadway and the standard deviation of lane position, a measure of lateral movements away from the center of the lane, during two 15-minute simulated drives at baseline and at 1 month and 6 months after training. Secondary outcomes were the rates of long glances and collisions or near-collisions involving abrupt changes in vehicle momentum (g-force event), as assessed with in-vehicle recordings over the 1-year period after training.

RESULTS

During simulated driving after training, participants in the intervention group had a mean of 16.5 long glances per drive at 1 month and 15.7 long glances per drive at 6 months, as compared with 28.0 and 27.0 long glances, respectively, in the control group (incidence rate ratio at 1 month, 0.64; 95% confidence interval [CI], 0.52 to 0.76; P<0.001; incidence rate ratio at 6 months, 0.64; 95% CI, 0.52 to 0.76; P<0.001). The standard deviation of lane position (in feet) was 0.98 SD at 1 month and 0.98 SD at 6 months in the intervention group, as compared with 1.20 SD and 1.20 SD, respectively, in the control group (difference at 1 month, -0.21 SD; 95% CI, -0.29 to -0.13; difference at 6 months, -0.22 SD; 95% CI, -0.31 to -0.13; P<0.001 for interaction for both comparisons). During real-world driving over the year after training, the rate of long glances per g-force event was 18.3% in the intervention group and 23.9% in the control group (relative risk, 0.76; 95% CI, 0.61 to 0.92); the rate of collision or near-collision per g-force event was 3.4% and 5.6%, respectively (relative risk, 0.60, 95% CI, 0.41 to 0.89).

CONCLUSIONS

In teens with ADHD, a specially designed computerized simulated-driving program with feedback to reduce long glances away from the roadway reduced the frequency of long glances and lessened variation in lane position as compared with a control program. During real-world driving in the year after training, the rate of collisions and near-collisions was lower in the intervention group. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT02848092.).

Dissociation between individual differences in self-reported pain intensity and underlying fMRI brain activation

Pain is an individual experience. Previous studies have highlighted changes in brain activation and morphology associated with within- and interindividual pain perception. In this study we sought to characterize brain mechanisms associated with between-individual differences in pain in a sample of healthy adolescent and adult participants (N = 101). Here we show that pain ratings varied widely across individuals and that individuals reported changes in pain evoked by small differences in stimulus intensity in a manner congruent with their pain sensitivity, further supporting the utility of subjective reporting as a measure of the true individual experience. Furthermore, brain activation related to interindividual differences in pain was not detected, despite clear sensitivity of the Blood Oxygenation Level-Dependent (BOLD) signal to small differences in noxious stimulus intensities within individuals. These findings suggest fMRI may not be a useful objective measure to infer reported pain intensity.

Previous work had suggested that fMRI measures can be used as a marker of pain experience. Here the authors find no evidence for a link between perceived pain intensity and fMRI activation.

0540 First Year PAP Trajectories among Treatment-Naive Youth with Sleep Disordered Breathing

Introduction

Little is known about the time course for youth adjusting to and achieving optimal PAP adherence.

Methods

This retrospective study identified 12-month PAP trajectories and treatment persistence following treatment initiation in youth. Participants were first-time PAP initiators receiving care at Cincinnati Children’s Hospital from 07/2017-12/2019. Electronic downloads provided monthly PAP use. Adherence indicators were frequency (percentage of nights PAP used each month) and duration of use (average usage hours on nights used each month). Persistence of group-level adherence (frequency and duration) was measured via descriptive statistics in SPSS. Adherence sub-groups were identified using longitudinal mixed models in MPlus.

Results

The sample was 169 youth ages 2-22yrs started on PAP. Within the first month, 55% of participants were using PAP &gt;50% of nights and 43% were using for &gt;4 hours/night. Adherence (frequency and duration, respectively) decreased by month as follows: month 3 - 48% and 42%; month 6 - 41% and 41%; month 12 - 36% and 32%. Longitudinal mixed models identified 5 trajectories for frequency of use (based on the model of best fit using BIC index): “starts high, stays high” (34% of sample); “starts high, slowly decreasing” (7%); “starts high, rapidly decreasing” (12%); “starts low, slowly increasing” (8%); “starts low, stays low” (39%). Two trajectories were identified for duration (average hours worn on nights used, also based on model of best fit) and included: “starts high, slowly increasing” (40%) and “starts low, stays low” (60%).

Conclusion

At the group level, PAP adherence was sub-optimal in the first month of use (around half of participants using PAP &gt;50% of nights or for &gt;4 hours) and declined over the subsequent 11 months. However, mixed models identified distinct adherence subgroups, with about 40% of the sample falling into subgroups with relatively high adherence by month 12. This suggests acclimation to PAP takes time in a pediatric population. Findings may help clinicians/policy makers set realistic expectations around time to achieve optimal PAP adherence among youth, and highlights the need for further PAP adherence promotion interventions.

Support (If Any)

First, and fourth authors’ time supported by NIH post-doctoral training grants (T32 DK063929 and T32HD068223, respectively).

Multimodal Assessment of Medication Adherence Among Youth With Migraine: An Ancillary Study of the CHAMP Trial

OBJECTIVE

Examine preventive medication adherence among youth with migraine.

METHODS

Adherence (self-report, pill count, and blood serum drug levels) was assessed as an ancillary study that utilized data from 328 CHAMP Study participants (ages 8-17). CHAMP was a multisite trial of preventive medications. Participants completed a prospective headache diary during a six-month active treatment period during which youth took amitriptyline, topiramate, or placebo pill twice daily. Self-reported medication adherence was collected via daily diary. At monthly study visits, pill count measures were captured. At trial month 3 (trial midpoint) and 6 (end of active trial), blood serum drug levels were obtained. Self-report and pill count adherence percentages were calculated for the active trial period, at each monthly study visit, and in the days prior to participants' mid-trial blood draw. Percentages of nonzero drug levels were calculated to assess blood serum drug level data. Adherence measures were compared and assessed in context of several sociodemographic factors. Multiple regression analyses investigated medication adherence as a predictor of headache outcomes.

RESULTS

Self-report and pill count adherence rates were high (over 90%) and sustained over the course of the trial period. Serum drug level adherence rates were somewhat lower and decreased significantly (from 84% to 76%) across the trial period [t (198) = 3.23, p = .001]. Adherence measures did not predict headache days at trial end; trial midpoint serum drug levels predicted headache-related disability.

CONCLUSIONS

Youth with migraine can demonstrate and sustain relatively high levels of medication adherence over the course of a clinical trial.

The effect of subconcussive head impact exposure and jugular vein compression on behavioral and cognitive outcomes after a single season of high-school football: A prospective longitudinal trial

This prospective longitudinal trial aimed to 1) determine the role of head impact exposure on behavioral/cognitive outcomes, and 2) assess the protective effect(s) of a jugular vein compression (JVC) collar on behavioral/cognitive outcomes following one season of high-school football. Participants included 284 male high-school football players aged 13-18 years enrolled from seven midwestern high-schools. Schools were allocated to the JVC collar intervention(four teams, 140 players) or non-collar/no intervention control (three teams, 144 players) condition. Head impact exposure was measured throughout the season using CSx accelerometers. Outcome measures included post season parent and adolescent report on Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Scale (SWAN) and Post-Concussion Symptom Inventory (PCSI), as well as adolescent performance on Attention Network Task (ANT), digital Trail Making Task (dTMT), and Cued Switching task. No significant effect of head impact exposure or JVC collar use on post-season SWAN or PCSI scores or performance on dTMT and Cued Switching task were noted. There was no effect of head impact exposure on ANT performance; however, the JVC collar group had greater post-season Alerting network scores than the non-collar group (p=.026, d=.22). Findings provide preliminary evidence that the JVC collar may provide some protection to the alerting attention system. These findings should be interpreted cautiously as a greater understanding of the long-term sequalae of head impact exposure and the role of cumulative head impact exposure behavioral/cognitive outcomes is required.

Mobile health use predicts self-efficacy and self-management in adolescents with sickle cell disease

Sickle cell disease (SCD) is associated with significant health challenges that often worsen during adolescence. Living with SCD requires a substantial amount of self-management and mobile health (mHealth) holds considerable promise for assessing and changing behaviors to improve health outcomes. We integrated a mobile app as an adjunct to a group intervention (SCThrive) and hypothesized that more engagement with the mHealth app would increase self-management and self-efficacy for adolescents and young adults (AYA) with SCD. Twenty-six AYA ages 13-21 years (54% female; 46% HbSS genotype; all African-American/Black) received six weekly group sessions (three in-person, three online). Participants were provided with the mobile app (iManage for SCD) to record progress on their self-management goals and log pain and mood symptoms. The Transition Readiness Assessment Questionnaire (TRAQ-5) assessed self-management skills and the Patient Activation Measure (PAM-13) assessed self-efficacy at baseline and post-treatment. Logging on to the app more frequently was associated higher mood ratings (r = .54, CI[.18, .77], p = .006) and lower pain ratings (r = -.48, CI[-.77, -.02], p = .04). Regression analyses demonstrated that after controlling for scores at baseline, the number of logins to the app predicted self-management skills (p = .05, η2 = .17) and possibly self-efficacy (p = .08, η2 = .13). Our study findings indicate that it can be challenging to maintain engagement in mHealth for AYA with SCD, but for those who do engage, there are significant benefits related to self-management, self-efficacy, and managing pain and mood.

Bidirectional effects of behavior problems and parenting behaviors following adolescent brain injury

Purpose/Objective: Existing evidence suggests that the relationship between adolescent behavior problems following traumatic brain injury (TBI) and injury-related family burden may be bidirectional, with increased child behavior problems contributing to greater family burden over the first year postinjury and vice versa. We extended existing evidence by prospectively examining reciprocal influences between parent-adolescent interactions and adolescent behavior problems over the initial 2 years postinjury. Research Method/Design: Participants included 117 adolescents ages 12-17 with moderate-to-severe TBIs and their parents who participated in a randomized controlled trial. At baseline, adolescent-parent dyads completed a videotaped problem-solving task that yielded composites of negativity, effective communication, and warmth. Parents also completed a structured interview and problem checklists. Families repeated assessments at 6, 12, and 18 months postbaseline. Bidirectional associations between observed parenting behavior and adolescent behavior were examined with autoregressive cross-lagged panel analyses collapsed across the trial arms. Results: One cross-lagged model was significant, with higher observed effective communication predicting fewer externalizing behavior problems at subsequent time points, and fewer externalizing behavior problems predicting more effective communication. Other models indicated that effects were unidirectional, with observed parenting behaviors predicting externalizing behavior and everyday functioning. Conclusions/Implications: The bidirectional relationship between effective communication and adolescent externalizing behavior suggests a transactional model in pediatric TBI in which effective communication leads to reduced adolescent behavior problems and reduced behavior problems lead to improved communication over time. Findings yielded stronger evidence for parenting effects as compared to adolescent behavior effects, providing further support for clinical interventions targeting parent-adolescent interactions following TBI. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trajectory of treatment response in the child and adolescent migraine prevention (CHAMP) study: A randomized clinical trial

OBJECTIVE

Identify preventive medication treatment response trajectories among youth participating in the Childhood and Adolescent Migraine Prevention study.

METHODS

Data were evaluated from 328 youth (ages 8-17). Childhood and Adolescent Migraine Prevention study participants completed headache diaries during a 28-day baseline period and a 168-day active treatment period during which youth took amitriptyline, topiramate, or placebo. Daily headache occurrence trajectories were established across baseline and active treatment periods using longitudinal hierarchical linear modeling. We tested potential treatment group differences. We also compared final models to trajectory findings from a clinical trial of cognitive behavioral therapy plus amitriptyline for youth with chronic migraine to test for reproducibility.

RESULTS

Daily headache occurrence showed stability across baseline. Active treatment models revealed decreases in headache frequency that were most notable early in the trial period. Baseline and active treatment models did not differ by treatment group and replicated trajectory cognitive behavioral therapy plus amitriptyline trial findings.

CONCLUSIONS

Replicating headache frequency trajectories across clinical trials provides strong evidence that youth can improve quickly. Given no effect for medication, we need to better understand what drives this clinically meaningful improvement. Results also suggest an expected trajectory of treatment response for use in designing and determining endpoints for future clinical trials.Trial Registration. ClinicalTrials.gov Identifier: NCT01581281.

Relationship Between Caregiver Uncertainty, Problem-Solving, and Psychological Adjustment in Pediatric Cancer

OBJECTIVE

The current study examined the roles of constructive and dysfunctional problem-solving strategies in the relationships between illness uncertainty and adjustment outcomes (i.e., anxious, depressive, and posttraumatic stress symptoms) in caregivers of children newly diagnosed with cancer.

METHODS

Two hundred thirty-eight caregivers of children (0-19 years of age) newly diagnosed with cancer (2-14 weeks since diagnosis) completed measures of illness uncertainty, problem-solving strategies, and symptoms of anxiety, depression, and posttraumatic stress.

RESULTS

A mediation model path analysis assessed constructive and dysfunctional problem-solving strategies as mediators between illness uncertainty and caregiver anxious, depressive, and posttraumatic stress symptoms. Dysfunctional problem-solving scores partially mediated the relationships between illness uncertainty and anxious, depressive, and posttraumatic stress symptoms. Constructive problem-solving scores did not mediate these relationships.

CONCLUSIONS

The current findings suggest that illness uncertainty and dysfunctional problem-solving strategies, but not constructive problem-solving strategies, may play a key role in the adjustment of caregivers of children newly diagnosed with cancer. Interventions aimed at managing illness uncertainty and mitigating the impact of dysfunctional problem-solving strategies may promote psychological adjustment.

Engaging Caregivers and Providers of Children With Sickle Cell Anemia in Shared Decision Making for Hydroxyurea: Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

Sickle cell anemia (SCA) is a genetic blood disorder that puts children at a risk of serious medical complications, early morbidity and mortality, and high health care utilization. Until recently, hydroxyurea was the only disease-modifying treatment for this life-threatening disease and has remained the only option for children younger than 5 years. Evidence-based guidelines recommend using a shared decision-making (SDM) approach for offering hydroxyurea to children with SCA (HbSS or HbS/β0 thalassemia) aged as early as 9 months. However, the uptake remains suboptimal, likely because caregivers lack information about hydroxyurea and have concerns about its safety and potential long-term side effects. Moreover, clinicians do not routinely receive training or tools, especially those that provide medical evidence and consider caregivers' preferences and values, to facilitate a shared discussion with caregivers.

OBJECTIVE

The aim of this study is to understand how best to help parents of young children with sickle cell disease and their clinicians have a shared discussion about hydroxyurea (one that considers medical evidence and parent values and preferences).

METHODS

We designed our study to compare the effectiveness of two methods for disseminating hydroxyurea guidelines to facilitate SDM: a clinician pocket guide (ie, usual care) and a clinician hydroxyurea SDM toolkit (H-SDM toolkit). Our primary outcomes are caregiver reports of decisional uncertainty and knowledge of hydroxyurea. The study also assesses the number of children (aged 0-5 years) who were offered and prescribed hydroxyurea and the resultant health outcomes.

RESULTS

The Ethics Committee of the Cincinnati Children's Hospital Medical Center approved this study in November 2017. As of February 2021, we have enrolled 120 caregiver participants.

CONCLUSIONS

The long-term objective of this study is to improve the quality of care for children with SCA. Using multicomponent dissemination methods developed in partnership with key stakeholders and designed to address barriers to high-quality care, caregivers of patients with SCA can make informed and shared decisions about their health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03442114; https://clinicaltrials.gov/ct2/show/NCT03442114.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27650.

Randomized clinical trial of Fibromyalgia Integrative Training (FIT teens) for adolescents with juvenile fibromyalgia - Study design and protocol

OBJECTIVE

Juvenile-onset fibromyalgia (JFM) is a chronic debilitating pain condition that negatively impacts physical, social and academic functioning. Cognitive-behavioral therapy (CBT) is beneficial in reducing functional disability among adolescents with JFM but has only a modest impact on pain reduction and does not improve physical exercise participation. This randomized controlled trial (RCT) aims to test whether a novel intervention that combines CBT with specialized neuromuscular exercise training (the Fibromyalgia Integrative Training program for Teens "FIT Teens") is superior to CBT alone or a graded aerobic exercise (GAE) program.

DESIGN/METHODS

This 3-arm multi-site RCT will examine the efficacy of the FIT Teens intervention in reducing functional disability (primary outcome) and pain intensity (secondary outcome), relative to CBT or GAE. All interventions are 8-weeks (16 sessions) in duration and are delivered in small groups of 4-6 adolescents with JFM. A total of 420 participants are anticipated to be enrolled across seven sites with approximately equal allocation to each treatment arm. Functional disability and average pain intensity in the past week will be assessed at baseline, post-treatment and at 3-, 6-, 9- and 12-month follow-up. The 3-month follow-up is the primary endpoint to evaluate treatment efficacy; longitudinal assessments will determine maintenance of treatment gains. Changes in coping, fear of movement, biomechanical changes and physical fitness will also be evaluated.

CONCLUSIONS

This multi-site RCT is designed to evaluate whether the combined FIT Teens intervention will have significantly greater effects on disability and pain reduction than CBT or GAE alone for youth with JFM. Clinical trials.gov registration: NCT03268421.

The Association of Executive Functioning With Academic, Behavior, and Social Performance Ratings in Children With ADHD

This study investigated the association of a performance-based measure of executive functioning (EF) with academic, social, and behavioral performance ratings in a convenience sample of 153 children aged 5 to 12 (78% male, 83% Caucasian) diagnosed with attention-deficit/hyperactivity disorder (ADHD). Multivariate regression showed that above and beyond age and ADHD severity, poorer EF performance was uniquely associated with more impairment in reading, written expression, and math by teacher report, and more impairment in the overall school and reading domains by parent report. ADHD symptoms were more strongly associated with ratings of impairment in social relationships, organized peer activities, and classroom behaviors than EF performance. Age did not moderate the findings, but younger children were rated as having more trouble with participation in organized activities by parents, as more likely to disrupt class by teachers, and to have problematic relationships with peers by parents and teachers. EF and academic performance appeared worst in the groups seen as highly symptomatic and impaired by both parents and teachers, and by teachers only. EF deficits may be a specific risk factor for academic impairment in children with ADHD.

Cognitive Behavior Therapy Tailored to Anxiety Symptoms Improves Pediatric Functional Abdominal Pain Outcomes: A Randomized Clinical Trial

OBJECTIVES

To evaluate the feasibility of a stepped care model, and establish the effect of a tailored cognitive behavioral therapy, the Aim to Decrease Anxiety and Pain Treatment (ADAPT), compared with standard medical treatment as usual on pain-related outcomes and anxiety.

STUDY DESIGN

Eligible patients between the ages of 9 and 14 years with functional abdominal pain disorders (n = 139) received enhanced usual care during their medical visit to a gastroenterologist. Those that failed to respond to enhanced usual care were randomized to receive either a tailored cognitive behavioral therapy (ADAPT) plus medical treatment as usual, or medical treatment as usual only. ADAPT dose (4 sessions of pain management or 6 sessions of pain and anxiety management) was based on presence of clinically significant anxiety. Outcomes included feasibility, based on recruitment and retention rates. Response to ADAPT plus medical treatment as usual vs medical treatment as usual on pain-related outcomes and anxiety measures was also investigated using a structural equation modeling equivalent of a MANCOVA. Anxiety levels and ADAPT dose as moderators of treatment effects were also explored.

RESULTS

Based on recruitment and retention rates, stepped care was feasible. Enhanced usual care was effective for only 8% of youth. Participants randomized to ADAPT plus medical treatment as usual showed significantly greater improvements in pain-related disability, but not pain levels, and greater improvements in anxiety symptoms compared with those randomized to medical treatment as usual only. Anxiety and ADAPT treatment dose did not moderate the effect of treatment on disability nor pain.

CONCLUSIONS

Tailoring care based on patient need may be optimal for maximizing the use of limited psychotherapeutic resources while enhancing care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03134950.

"How Well Does Your Structural Equation Model Fit Your Data?": Is Marcoulides and Yuan's Equivalence Test the Answer?

Structural equation modeling is an ideal data analytical tool for testing complex relationships among many analytical variables. It can simultaneously test multiple mediating and moderating relationships, estimate latent variables on the basis of related measures, and address practical issues such as nonnormality and missing data. To test the extent to which a hypothesized model provides an appropriate characterization of the collective relationships among its variables, researchers must assess the "fit" between the model and the sample's data. However, interpreting estimates of model fit is a problematic process. The traditional inferential test of model fit, the chi-square test, is biased due to sample size. Fit indices provide descriptive (i.e., noninferential) values of model fit (e.g., comparative fit index, root-mean-square error of approximation), but are unable to provide a definitive "acceptable" or "unacceptable" fit determination. Marcoulides and Yuan have introduced an equivalence-testing technique for assessing model fit that combines traditional descriptive fit indices with an inferential testing strategy in the form of confidence intervals to facilitate more definitive fit conclusions. In this paper, we explain this technique and demonstrate its application, highlighting the substantial advantages it offers the life sciences education community for drawing robust conclusions from structural equation models. A structural equation model and data set (N = 1902) drawn from previously published research are used to illustrate how to perform and interpret an equivalence test of model fit using Marcoulides and Yuan's approach.

Early brain abnormalities in infants born very preterm predict under-reactive temperament

BACKGROUND

Early temperament may mediate the association between brain abnormalities following preterm birth and neurodevelopmental outcomes.

AIMS

This exploratory study investigated whether brain abnormalities in infants born very preterm predicted temperament.

STUDY DESIGN

Infants born prematurely underwent structural MRI at term. Mother self-reported depression symptoms at the scanning visit, and the Infant Behavior Questionnaire-Revised-Short (IBQ-R-S) about their infant at 3-months corrected age.

SUBJECTS

Infants (n = 214) born at ≤32 weeks gestation (M = 29.29, SD = 2.60). Average post-menstrual age at the MRI scan was 42.72 weeks (SD = 1.30). The majority of the infants were male (n = 115), and Caucasian (n = 145) or African American (n = 58). The average birthweight in grams was 1289.75 (SD = 448.5).

OUTCOME MEASURES

Infant Behavior Questionnaire-Revised-Short (IBQ-R-S) subscales.

RESULTS

Multivariate regression showed white matter abnormalities predicted lower ratings on High Intensity Pleasure and Vocal Reactivity, grey matter abnormalities predicted lower ratings on High Intensity Pleasure and Cuddliness, and cerebellar abnormalities predicted lower ratings on Fear and Sadness IBQ-R-S subscales adjusting for gestational age and sex. The pattern of results was essentially unchanged when maternal depression and socioeconomic status were included in the model.

CONCLUSIONS

Early MRI-diagnosed brain abnormalities in infants born very preterm were associated less vocalization and engagement during cuddling, decreased ability to take pleasure in stimulating activities, and lower emotionality in fear and sadness domains. Although replication is warranted, an under-reactive temperament in infants born preterm may have a neurobiological basis.

Digital Therapeutic Self-Management Intervention in Adolescents With Migraine: Feasibility and Preliminary Efficacy of "Migraine Manager"

OBJECTIVE

The objective of this study was to design, code, and pilot test the feasibility and preliminary efficacy of a self-management digital therapeutic tool for adolescents with migraine.

BACKGROUND

Self-management of migraine in adolescents is complex and has important implications for health outcomes. A comprehensive and accessible approach to self-management is needed for youth with migraine, their parents, and clinicians.

METHODS

An iterative co-design process was used to develop and optimize the Migraine Manager's digital therapeutic self-management tool. Subsequently, 40 adolescents, age 11-18 years, were enrolled in an 8-week single-arm open label trial (N = 36 analyzed). The primary outcome was headache days.

RESULTS

Usage data for Migraine Manager were similar to other health app usage data and feedback from participants was uniformly positive, indicating acceptable feasibility. Preliminary efficacy was demonstrated by a reduction in headache days from 17.2 ± 8.5 at baseline to 7.9 ± 7.2 at 8 weeks (95% CI, -13.0 to -7.8; P < .001). There was also statistically significant improvement in patient physical functioning quality of life reported by both patients (baseline = 55.7 ± 20.4; 8 weeks = 69.7 ± 21.9, P = .005) and parents (baseline = 58.5 ± 22.8; 8 weeks = 74.3 ± 18.1, P = .002), and in parent-reported ingestion issues subscale of the adherence barriers scale from baseline to 8 weeks (baseline = 6.0 ± 2.6; 8 weeks = 5.2 ± 3.0, P = .020).

CONCLUSIONS

A self-management digital therapeutic tool for adolescents with migraine can offer care to patients who might not otherwise receive such services. Migraine Manager demonstrated the feasibility and preliminary efficacy in this pilot trial, highlighting the potential beneficial impact of this tool. Larger controlled trials with long-term follow-up are needed to definitively determine the clinical efficacy of Migraine Manager.

Allocation of Treatment Responsibility in Adolescents With Epilepsy: Associations With Cognitive Skills and Medication Adherence

Objectives

To describe allocation of treatment responsibility (ATR) in adolescents with epilepsy, investigate associations between cognitive skills and ATR, and examine whether ATR for antiepileptic drugs (AEDs) predicted electronically monitored adherence.

Method

Sixty adolescents with epilepsy and their caregivers completed the Allocation of Treatment Responsibility Scale and a battery of self-report measures. Medical chart review data and electronically monitored AED adherence were collected for 1 year. Descriptive data assessed ATR for caregivers and adolescents; multivariate hierarchical regressions tested associations between variables.

Results

ATR for labs and clinic appointments was greatest for caregivers, while ATR for AEDs was more likely to be shared between caregiver and adolescent. Poorer attention was associated with greater caregiver responsibility for AEDs. Greater caregiver responsibility for AEDs was associated with higher electronically monitored adherence over 12 months.

Conclusions

In adolescents with epilepsy, caregivers are responsible for most treatment tasks, although responsibility for taking medication was shared with the adolescent. Greater caregiver responsibility for medication results in better long-term AED adherence. ATR is an important construct that warrants further attention in research and clinical practice, especially in the context of transition and health outcomes in pediatric epilepsy.

Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings

OBJECTIVES

To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in a community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, race other than white) and clinical (eg, comorbid conditions) characteristics as well as physician characteristics (eg, older age, more years since completing training).

STUDY DESIGN

A retrospective cohort study was conducted with 577 children (mean age, 7.8 years; 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations.

RESULTS

Sixty-nine percent of children were prescribed ADHD medication in the year after initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (P < .05) bivariate relationship with medication prescription. In the multivariable model, being male (OR, 1.34; 95% CI, 1.01-1.78; P = .02), living in a neighborhood with higher medical expenditures (OR, 1.11 for every $100 increase; 95% CI, 1.03-1.21; P = .005), and higher scores on parent inattention ratings (OR, 1.06; 95% CI, 1.03-1.10; P < .0001) increased the likelihood of ADHD medication prescription.

CONCLUSIONS

We found that some children, based on sociodemographic and clinical characteristics, are less likely to receive an ADHD medication prescription. An important next step will be to examine the source and reasons for these disparities in an effort to develop strategies for minimizing treatment barriers.

Health behaviours reported by adults with congenital heart disease across 15 countries

Background

Health behaviours are essential to maintain optimal health and reduce the risk of cardiovascular complications in adults with congenital heart disease. This study aimed to describe health behaviours in adults with congenital heart disease in 15 countries and to identify patient characteristics associated with optimal health behaviours in the international sample.

Design

This was a cross-sectional observational study.

Methods

Adults with congenital heart disease ( n = 4028, median age = 32 years, interquartile range 25–42 years) completed self-report measures as part of the Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study (APPROACH-IS). Participants reported on seven health behaviours using the Health Behaviors Scale-Congenital Heart Disease. Demographic and medical characteristics were assessed via medical chart review and self-report. Multivariate path analyses with inverse sampling weights were used to investigate study aims.

Results

Health behaviour rates for the full sample were 10% binge drinking, 12% cigarette smoking, 6% recreational drug use, 72% annual dental visit, 69% twice daily tooth brushing, 27% daily dental flossing and 43% sport participation. Pairwise comparisons indicated that rates differed between countries. Rates of substance use behaviours were higher in younger, male participants. Optimal dental health behaviours were more common among older, female participants with higher educational attainment while sports participation was more frequent among participants who were younger, male, married, employed/students, with higher educational attainment, less complex anatomical defects and better functional status.

Conclusions

Health behaviour rates vary by country. Predictors of health behaviours may reflect larger geographic trends. Our findings have implications for the development and implementation of programmes for the assessment and promotion of optimal health behaviours in adults with congenital heart disease.

Assessing psychosocial risk in pediatric cystic fibrosis

BACKGROUND

Psychosocial risk factors are known to impact quality of life, treatment adherence, and health outcomes. No standardized comprehensive psychosocial risk screener is routinely utilized in cystic fibrosis (CF) care. The objectives of the study were to describe the range and severity of psychosocial risk within this CF population, investigate the reliability of a comprehensive psychosocial screener in pediatric CF clinical care, and explore relationships between psychosocial risk and key factors affecting health outcomes. It was hypothesized that the PAT-CF total and subscale α coefficients would be similar to those found in other pediatric medical populations.

METHOD

Parents of 154 children with CF completed a CF-specific version of the Psychosocial Assessment Tool_All-lit (PAT-CF), an empirically-based psychosocial risk assessment, during routine CF clinical care.

RESULTS

The internal consistency of the PAT-CF Total score was 0.71. Total score and subscale reliabilities reflect findings in other pediatric populations. Total risk scores fell in the following categories: 7% (Clinical-highest risk), 41% (Targeted), and 52% (Universal-lowest risk), respectively. Increased psychosocial risk was associated with Medicaid status and lower parent education, whereas having private insurance was associated with decreased psychosocial risk.

CONCLUSIONS

The PAT-CF can feasibly be used as an empirically-based comprehensive psychosocial risk tool in routine CF care and is acceptable by parents. In addition to providing universal anticipatory guidance regarding child and family wellness, early identification of risk factors allows care teams to proactively provide targeted support and intervention for specific psychosocial risk factors to promote improved quality of life and ability to sustain daily care.

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.

Long-term outcomes of adolescents with juvenile-onset fibromyalgia into adulthood and impact of depressive symptoms on functioning over time

Juvenile-onset fibromyalgia (JFM) is typically diagnosed in adolescence and characterized by widespread pain and marked functional impairment. The long-term impact of JFM into adulthood is poorly understood. The objectives of this study were to describe physical and psychosocial outcomes of youth diagnosed with JFM in early adulthood (∼8-year follow-up), examine longitudinal trajectories of pain and depressive symptoms from adolescence to young adulthood, and examine the impact of pain and depressive symptoms on physical functioning over time. Participants were 97 youth with JFM enrolled in a prospective longitudinal study in which pain symptoms, and physical and psychosocial functioning were assessed at 4 time points over approximately 8 years. At the time 4 follow-up (Mage = 24.2 years), the majority continued to suffer from pain and impairment in physical, social, and psychological domains. However, trajectories of pain and emotional symptoms showed varying patterns. Longitudinal analysis using growth mixture modeling revealed 2 pain trajectories (Steady Improvement and Rapid Rebounding Improvement), whereas depressive symptoms followed 3 distinct trajectories (Low-Stable, Improving, and Worsening). Membership in the Worsening Depressive symptoms group was associated with poorer physical functioning over time (P < 0.001) compared with the Low-Stable and Improving groups. This study offers evidence that although JFM symptoms persist for most individuals, pain severity tends to decrease over time. However, depressive symptoms follow distinct trajectories that indicate subgroups of JFM. In particular, JFM patients with worsening depressive symptoms showed decreasing physical functioning and may require more intensive and consistent intervention to prevent long-term disability.

Attention-Deficit/Hyperactivity Disorder-Related Deficits and Psychostimulant Medication Effects on Comprehension of Audiovisually Presented Educational Material in Children

Objective: We aimed to (1) examine differences in observed visual attention and motor activity, as well as comprehension of a science video between children with and without attention-deficit/hyperactivity disorder (ADHD) and (2) explore if psychostimulant medication improves ADHD behaviors and comprehension of a science video in children with ADHD. Method: Children aged 7-11 with (n = 91) and without (n = 45) ADHD watched a science video and then completed a comprehension test. Then, children with ADHD began a 4-week within-subject, randomized, double-blind crossover trial of methylphenidate (MPH). At post-testing, children were randomized to receive placebo or their optimal dosage, watched another science film, and completed a comprehension test. Results: Children with ADHD exhibited higher rates of motor activity during, and worse comprehension of material discussed within, the science video. Mediation models revealed that increased motor activity suppressed between-group differences in comprehension. MPH improved comprehension and visual attention, but not motor activity during the science video. Conclusion: Children with ADHD may benefit from MPH to improve comprehension of and sustained attention during audiovisually presented learning material.

An intensive family-based treatment guided intervention for medically hospitalized youth with anorexia nervosa: Parental self-efficacy and weight-related outcomes

Recent studies suggest the efficacy of family-based treatment (FBT) among youth with anorexia nervosa (AN) in intensive treatment settings. This study aimed to assess weight outcomes in youth who received an FBT intervention while hospitalized for medical complications of AN. Parental self-efficacy among participating caregivers was also measured. Post-discharge weights of 49 participants were compared with weights of 44 youth who were hospitalized prior to the provision of the FBT intervention. Youth who received the FBT intervention gained significantly more weight than youth in the retrospective treatment as usual group at 3 and 6 months following discharge. FBT youth were 2.84 times more likely than retrospective treatment as usual youth to achieve at least 95% of treatment goal weight at 6 months post-discharge. Finally, parental self-efficacy significantly increased in caregivers who participated in the FBT intervention. Findings provided preliminary support for the provision of FBT to medically hospitalized youth with AN.

Predictors of Exclusive Breastfeeding for 6 Months in a National Sample of US Children

PURPOSE

To explore predictors of breastfeeding behavior and seek to replicate prior findings using a recent nationally representative United States (US) sample, which has not been done previously.

DESIGN

Secondary data analysis using the National Survey of Children's Health 2011 to 2012.

SETTING

Households in the 50 US states, the District of Columbia, and the US Virgin Islands.

PARTICIPANTS

Caregivers with a child between 6 months and 6 years of age (n = 26 552).

MEASURES

Caregiver-reported child breastfeeding behavior, child birth weight, child/maternal/family demographics, maternal physical and mental health, and household tobacco exposure.

ANALYSIS

A multinomial logistic regression explored whether child, maternal, and family characteristics predicted exclusive breastfeeding for 6 months or breastfeeding for a suboptimal duration.

RESULTS

Approximately 79% and 17% of the sample-initiated breastfeeding and exclusively breastfed for 6 months, respectively. Child ethnicity/race, maternal education, household tobacco exposure, family composition, and family income predicted odds of both exclusive breastfeeding for 6 months and breastfeeding for a suboptimal duration or not exclusively. Normal or high child birth weight and better maternal physical health predicted greater odds of exclusive breastfeeding for 6 months.

CONCLUSION

Rates of exclusive breastfeeding for 6 months remain low in the United States. Single-parent and step-families, lower income families, non-Hispanic black children, children with exposure to tobacco, and children of mothers with lower education are at greatest risk.

Caregiver burden and illness perceptions in caregivers of medically hospitalized youth with anorexia nervosa

Caregiver burden is common in caregivers of youth with anorexia nervosa (AN) and could impede the successful implementation of family-based therapy (FBT). Thus, it is important to better understand mechanisms by which caregiver burden is developed and maintained. This study aimed to examine the relation between caregiver illness perceptions about AN, symptom severity indicators, and caregiver burden in a sample of medically hospitalized youth with AN. Fifty-one youth with AN (N = 34) or Atypical AN (AAN; N = 17; mean age = 14.85, SD = 1.41; 76% female) and their primary caregivers (N = 47 mothers and N = 4 fathers) completed self-report questionnaires at hospital admission. Collected data included caregiver and youth illness perceptions about AN, caregiver burden, and youth self-reports of psychological symptoms. Physiological data regarding symptom severity included admitting percent of expected body weight (%EBW) and minimum heart rate during admission. Findings indicated that caregiver beliefs about negative consequences of AN were associated with caregiver burden, independent of youth age, sex, illness duration, and diagnosis. Youth reports of symptom severity, %EBW, and low heart rate were not associated with increased caregiver burden. Findings suggest that the subjective experience of having a youth with AN are a greater determinant of caregiver burden than objective indicators of illness severity. Further, these findings provide support for the FBT clinician to strike a balance between providing information about the potential consequences of AN, while instilling hope for recovery and bolstering parent self-efficacy.

Recovery Trajectories of Executive Functioning After Pediatric TBI: A Latent Class Growth Modeling Analysis

OBJECTIVE

To identify latent trajectories of executive functioning (EF) recovery overtime after childhood traumatic brain injury (TBI) and examine the predictive value of known risk factors within and across recovery trajectories using latent class growth modeling (LCGM).

METHOD

A total of 206 children between the ages of 3 and 7 years with a moderate to severe TBI or orthopedic injury (OI) were included. LCGM was applied to identify longitudinal trajectories of postinjury EF as assessed by the Behavior Rating Inventory of Executive Functioning General Executive Composite (GEC). Separate models were estimated for the TBI and OI groups.

RESULTS

Two TBI trajectories-normal limits (70.8%) and clinically elevated (29.2%)-and 3 OI trajectories-normal limits (20.9%), subclinical (49.0%), and clinically elevated (30.17%)-were identified. Baseline GEC was the only predictor of class membership for all models. Both TBI trajectories demonstrated an increase in GEC over time, whereas only 1 of the 3 OI classes demonstrated this pattern. Family variables were associated with GEC across trajectories.

CONCLUSION

The lack of association of injury characteristics with trajectory class membership highlights the heterogeneity in recovery after pediatric TBI. Associations of EF trajectories with family factors underscore the importance of involving the family in interventions for children with traumatic injuries.

Sluggish Cognitive Tempo as a Possible Predictor of Methylphenidate Response in Children With ADHD: A Randomized Controlled Trial

OBJECTIVE

To examine whether sluggish cognitive tempo (SCT) symptomatology moderates dose response to methylphenidate and whether the impact of SCT on medication response is distinct from attention-deficit/hyperactivity disorder (ADHD) subtype effects.

METHODS

Stimulant-naive children with ADHD predominantly inattentive type (ADHD-I; n = 126) or ADHD combined type (ADHD-C; n = 45) aged 7-11 years were recruited from the community from September 2006 to June 2013 to participate in a prospective, randomized, double-blind, 4-week crossover trial of long-acting methylphenidate. ADHD diagnosis and subtype were established according to DSM-IV criteria using a structured interview and teacher ADHD symptom ratings. SCT symptoms were assessed using a teacher-rated scale with 2 factors (Sluggish/Sleepy and Daydreamy). Primary outcomes included (1) categorization of children as methylphenidate responders, methylphenidate nonresponders, or placebo responders by 2 blinded physicians and (2) parent and teacher ratings of child behavior on the Vanderbilt ADHD Diagnostic Rating Scales while subjects were on treatment with placebo or 1 of 3 methylphenidate dosages (low, medium, high).

RESULTS

Increased SCT Sluggish/Sleepy factor scores were associated with being a methylphenidate nonresponder or placebo responder rather than a methylphenidate responder (P = .04). Sluggish/Sleepy factor scores were also linked to diminished methylphenidate dose response for parent- and teacher-rated inattention symptoms (Sluggish/Sleepy factor × dose P = .004). SCT Daydreamy symptoms and ADHD subtype (ADHD-I vs ADHD-C) were not associated with methylphenidate responder status and did not moderate methylphenidate dose response for inattention symptoms.

CONCLUSIONS

SCT Sluggish/Sleepy symptoms, but not SCT Daydreamy symptoms or ADHD subtype, predicted methylphenidate nonresponse. This novel finding, if replicated, may have important implications for assessing SCT as part of ADHD care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01727414.

Validation of a Brief Insomnia Severity Measure in Youth Clinically Referred for Sleep Evaluation

Objectives

Evaluate psychometric properties of the Pediatric Insomnia Severity Index (PISI), a brief measure of insomnia severity.

Methods

Clinically referred youth ( n = 462; 283 males, 179 females, mean age = 7.28 ± 2.05 years) and their caregiver(s) completed sleep evaluation including the PISI, Children's Sleep Habits Questionnaire, and sleep disorders inventory for students. Tests of reliability and validity and confirmatory factor analysis (CFA) were conducted to assess PISI psychometric properties. Exploratory analyses were conducted to examine insomnia severity by insomnia diagnosis.

Results

Measures of internal consistency for the PISI factor scores varied. CFA indicated that a two-factor model had optimal fit relative to a single-factor solution. Overall, convergent and discriminant validity of PISI factors were supported. Insomnia severity varied by diagnosis.

Conclusions

Findings provide preliminary support for the reliability and validity of the PISI within a large pediatric sample and for its clinical utility as a brief measure of insomnia severity.

Romantic, sexual, and sexual risk behaviours of adolescent females with severe obesity

BACKGROUND

There is an increasing adolescent population with severe obesity with impairments in social and romantic relationships that are seeking clinical weight management, including weight loss surgery (WLS).

OBJECTIVE

To document romantic, sexual and sexual risk behaviours in a clinical sample of adolescent females with severe obesity (BMI > 40 kg/m² ) compared to those of healthy weight (HW).

METHODS

This multi-site study-an ancillary to a prospective longitudinal observational study documenting health in adolescents having WLS-presents pre-operative/baseline data from 108 females undergoing WLS, 68 severely obese seeking lifestyle intervention and 118 of HW. Romantic and sexual risk behaviour and birth control information sources were assessed using the Sexual Activities and Attitudes Questionnaire (SAAQ).

RESULTS

Severely obese females reported engaging in fewer romantic and sexual behaviours compared to HW. Similar to HW, a subgroup (25%) of severely females were engaging in higher rates of sexual risk behaviours and reported pregnancies and sexually transmitted infections (STIs). A considerable number (28-44%) reported receiving no birth control information from physicians.

CONCLUSIONS

Discussion topics with the adolescent patient should extend beyond reproductive health needs (e.g. contraception, unintended pregnancies) to include guidance around navigating romantic and sexual health behaviours that are precursors to these outcomes.

Treatment Adherence in Child and Adolescent Chronic Migraine Patients: Results From the Cognitive-Behavioral Therapy and Amitriptyline Trial

OBJECTIVES

To examine treatment adherence among children and adolescents with chronic migraine who volunteered to be in a clinical trial using 3 measures: treatment session attendance, therapy homework completion, and preventive medication use by daily diary.

MATERIALS AND METHODS

Analyses are secondary from a trial of 135 youth aged 10 to 17 years diagnosed with chronic migraine and with a Pediatric Migraine Disability Score over 20. Participants were randomly assigned to cognitive-behavioral therapy plus amitriptyline (CBT+A, N=64) or headache education plus amitriptyline (HE+A, N=71). Therapists recorded session attendance. Completion of homework/practice between sessions was reported to therapists by patients. Patients reported preventive medication adherence using a daily headache diary.

RESULTS

Mean session attendance adherence out of 10 treatment sessions was 95% for CBT+A and 99% for HE+A. CBT+A participants reported completing a mean of 90% of home practice of CBT skills between the 10 sessions. Participants reported taking amitriptyline daily at a mean level of 90% when missing diaries were excluded and 79% when missing diaries were considered as missed doses of medication.

DISCUSSION

Our findings demonstrate that youth with chronic migraine who agree to be a part of a clinical trial do quite well at attending therapy sessions, and report that they are adherent to completing home/practice between sessions and taking medication. These results lend further support to consideration of CBT+A as a first-line treatment for youth with chronic migraine and suggest that measurement of adherence when this treatment is provided in practice will be important.

Clinical Profiles of Young Adults With Juvenile-Onset Fibromyalgia With and Without a History of Trauma

OBJECTIVE

To examine the differential presentation(s) of psychological and health-related outcomes in young adults with juvenile-onset fibromyalgia (FM) with and without a history of trauma, compared to healthy controls.

METHODS

In total, 110 participants (86 with juvenile-onset FM and 24 healthy controls, with a mean age of 23.4 years) completed a structured clinical interview to assess for trauma and psychological comorbidities, as well as self-report questionnaires on pain, physical functioning, and health care utilization.

RESULTS

Of the juvenile-onset FM participants, 37% (n = 32) reported a history of trauma. Three group comparisons (i.e., juvenile-onset FM with trauma versus juvenile-onset FM with no trauma versus healthy controls) revealed that juvenile-onset FM participants significantly differed from healthy controls on all psychological and health-related outcomes. Further, although juvenile-onset FM participants with and without a history of trauma did not significantly differ on pain and physical functioning, juvenile-onset FM participants with a history of trauma were significantly more likely to have psychological comorbidities.

CONCLUSION

This is the first controlled study to examine the differential outcomes between juvenile-onset FM participants with and without a history of trauma. Group comparisons between juvenile-onset FM participants and healthy controls were consistent with previous research. Further, our findings indicate that juvenile-onset FM participants with a history of trauma experience greater psychological, but not physical, impairment than juvenile-onset FM participants without a history of trauma.

Null effects of boot camps and short-format training for PhD students in life sciences

Many PhD programs incorporate boot camps and summer bridge programs to accelerate the development of doctoral students' research skills and acculturation into their respective disciplines. These brief, high-intensity experiences span no more than several weeks and are typically designed to expose graduate students to data analysis techniques, to develop scientific writing skills, and to better embed incoming students into the scholarly community. However, there is no previous study that directly measures the outcomes of PhD students who participate in such programs and compares them to the outcomes of students who did not participate. Likewise, no previous study has used a longitudinal design to assess these outcomes over time. Here we show that participation in such programs is not associated with detectable benefits related to skill development, socialization into the academic community, or scholarly productivity for students in our sample. Analyzing data from 294 PhD students in the life sciences from 53 US institutions, we found no statistically significant differences in outcomes between participants and nonparticipants across 115 variables. These results stand in contrast to prior studies presenting boot camps as effective interventions based on participant satisfaction and perceived value. Many universities and government agencies (e.g., National Institutes of Health and National Science Foundation) invest substantial resources in boot camp and summer bridge activities in the hopes of better supporting scientific workforce development. Our findings do not reveal any measurable benefits to students, indicating that an allocation of limited resources to alternative strategies with stronger empirical foundations warrants consideration.

Does Sluggish Cognitive Tempo Fit Within a Bi-Factor Model of ADHD?

OBJECTIVE

Studies demonstrate sluggish cognitive tempo (SCT) symptoms to be distinct from inattentive and hyperactive-impulsive dimensions of ADHD. No study has examined SCT within a bi-factor model of ADHD, whereby SCT may form a specific factor distinct from inattention and hyperactivity/impulsivity while still fitting within a general ADHD factor, which was the purpose of the current study.

METHOD

A total of 168 children were recruited from an ADHD clinic. Most (92%) met diagnostic criteria for ADHD. Parents and teachers completed measures of ADHD and SCT.

RESULTS

Although SCT symptoms were strongly associated with inattention, they loaded onto a factor independent of ADHD g. Results were consistent across parent and teacher ratings.

CONCLUSION

SCT is structurally distinct from inattention as well as from the general ADHD latent symptom structure. Findings support a growing body of research suggesting SCT to be distinct and separate from ADHD.

Adolescent flourishing in relation to having asthma: Results from a population-based cross-sectional study

OBJECTIVE

This study investigated parent report of adolescent behaviors and flourishing of adolescents with asthma from a nationwide sample.

METHODS

A secondary analysis of the 2011-2012 National Survey of Children's Health was conducted. There were 2,880 youth with asthma in our sample and 25,841 without asthma between 13 and 17 years of age. Analyses examined flourishing among adolescents with and without asthma and the impact of adolescent arguing, bullying, and mood difficulties on adolescent flourishing for adolescents with asthma, while controlling for sex, age, and race.

RESULTS

Findings indicated lower flourishing for youth with asthma compared to youth without asthma. Moreover, adolescents with asthma who experienced negative behaviors, such as arguing and bullying, and adolescents who were experiencing sad feelings had lower flourishing.

CONCLUSIONS

The results were consistent with literature, indicating that relatively poorer behavioral and emotional functioning is related to lower flourishing in adolescents with asthma. The results highlight the importance of screening for emotional functioning in adolescents and the need for further research to understand characteristics of adolescents related to their positive functioning.

Generating Attention, Inhibition, and Memory: A Pilot Randomized Trial for Preschoolers With Executive Functioning Deficits

This goal of this study was to assess the initial feasibility and efficacy of a play-based intervention targeting executive functions (EF) and parent-child relationships in preschoolers compared with an active control group. Preschoolers with EF deficits (M age = 3.7 ± 0.47, predominantly White boys) and their parents were randomized to intervention (n = 36) or active control (n = 32) conditions. Child performance on EF tasks, parent and masked teacher ratings of EF and behavior, and masked clinician ratings of severity were collected at baseline and at 3 and 6 months postbaseline. Partial eta-squared effect sizes at .02 or higher comparing performance across the two groups was considered evidence of meaningful, albeit small, intervention effects. Intervention effects were observed for parent ratings of inattention, hyperactivity/impulsivity, and number/severity of problems experienced in various home situations, teacher ratings of severity of problems in various school situations, parent and teacher ratings of overall impairment, and clinician ratings of impairment. Intervention effects for functional improvements were maintained at the 6-month follow-up. No effect of the intervention was observed on the objective EF measures, although parent ratings of emotional control were improved for children in the intervention group. An intervention utilizing play-based activities targeting EF, when administered in a structured way by parents, is a promising approach for improving behavior in preschoolers with self-regulation deficits. More work is needed to investigate potential impact on EF and to disentangle mechanisms of action. It may be that the intervention's focus on the structure and quality of parent-child interactions is a mediator of outcomes, rather than improved EFs.