Parents' Obesity-Related Behavior and Confidence to Support Behavioral Change in Their Obese Child: Data From the STAR Study

ObjectiveSuccessful childhood obesity interventions frequently focus on behavioral modification and involve parents or family members. Parental confidence in supporting behavior change may be an element of successful family-based prevention efforts. We aimed to determine whether parents' own obesity-related behaviors were related to their confidence in supporting their child's achievement of obesity-related behavioral goals.MethodsCross-sectional analyses of data collected at baseline of a randomized control trial testing a treatment intervention for obese children (n = 787) in primary care settings (n = 14). Five obesity-related behaviors (physical activity, screen time, sugar-sweetened beverage, sleep duration, fast food) were self-reported by parents for themselves and their child. Behaviors were dichotomized on the basis of achievement of behavioral goals. Five confidence questions asked how confident the parent was in helping their child achieve each goal. Logistic regression modeling high confidence was conducted with goal achievement and demographics as independent variables.ResultsParents achieving physical activity or sleep duration goals were significantly more likely to be highly confident in supporting their child's achievement of those goals (physical activity, odds ratio 1.76; 95% confidence interval 1.19–2.60; sleep, odds ratio 1.74; 95% confidence interval 1.09–2.79) independent of sociodemographic variables and child's current behavior. Parental achievements of TV watching and fast food goals were also associated with confidence, but significance was attenuated after child's behavior was included in models.ConclusionsParents' own obesity-related behaviors are factors that may affect their confidence to support their child's behavior change. Providers seeking to prevent childhood obesity should address parent/family behaviors as part of their obesity prevention strategies.     

Pediatric Caregiver Version of the Shared Decision Making Process Scale: Validity and Reliability for ADHD Treatment Decisions

ObjectiveShared decision making (SDM) is recommended for common pediatric conditions; however, there are limited data on measures of SDM in pediatrics. This study adapted the SDM Process scale and examined validity and reliability of the scale for attention-deficit/hyperactivity disorder (ADHD) treatment decisions.MethodsCross-sectional survey of caregivers (n = 498) of children (aged 5–13) diagnosed with ADHD, who had made a decision about ADHD medication in the last 2 years. Surveys included the adapted SDM Process scale (scores range 0–4, higher scores indicate more SDM), decisional conflict, decision regret, and decision involvement. Validity was assessed by testing hypothesized relationships between these constructs. A subset of participants was surveyed a week later to assess retest reliability.ResultsPediatric Caregiver version of the SDM Process scale (M = 2.8, SD = 1.05) showed no evidence of floor or ceiling effects. The scale was found to be acceptable (<1% missing data) and reliable (intraclass correlation coefficient = 0.74). Scores demonstrated convergent validity, as they were higher for those without decisional conflict than those with decisional conflict (2.93 vs 2.46, P < .001, d = 0.46), and higher for caregivers who stated they made the decision with the provider than those who made the decision themselves (3.0 vs 2.7; P = .003). Higher scores were related to less regret (r = ?0.15, P < .001), though the magnitude of the relationship was small.ConclusionsThe adapted Pediatric Caregiver version of the SDM Process scale demonstrated acceptability, validity and reliability in the context of ADHD medication decisions made by caregivers of children 5–13. Scores indicate pediatricians generally involve caregivers in decision making about ADHD medication.     

The patient-centered medical home, practice patterns, and functional outcomes for children with attention deficit/hyperactivity disorder

ObjectiveTo determine whether children with attention deficit/hyperactivity disorder (ADHD) receive care in a patient-centered medical home (PCMH) and how that relates to their ADHD treatment and functional outcomes.MethodsCross-sectional analysis of the 2007 National Survey for Children’s Health, a nationally representative survey of 91,642 parents. This analysis covers 5169 children with parent-reported ADHD ages 6–17. The independent variable is receiving care in a PCMH. Main outcome measures are receiving ADHD medication, mental health specialist involvement, and functional outcomes (difficulties with participation in activities, attending school, making friends; having problem behaviors; missed school days; and number of times parents contacted by school).ResultsOnly 44% of children with ADHD received care in a PCMH. Children with ADHD receiving care in a PCMH compared with those who did not were more likely to receive medication for ADHD (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1–1.9); less likely to have mental health specialist involvement (OR, 0.6; 95% CI, 0.4–0.7); less likely to have difficulties participating in activities (OR, 0.6; 95% CI 0.4–0.8), making friends (OR, 0.6; 95% CI, 0.5–0.9), and attending school (OR, 0.4; 95% CI, 0.3?06); less likely to have problem behaviors (OR 0.6; 95% CI 0.5–0.9); had fewer missed school days (β = ?1.5, 95% CI ?2.4 to ?0.5); and parents were contacted by school less frequently (β = ?0.2, 95% CI ?0.3 to ?0.1).ConclusionsFor children with ADHD, receiving care in a PCMH is associated with practice pattern change and better outcomes. The PCMH may represent a promising opportunity to improve quality of care and outcomes for children with ADHD.     

Examining the Unified Theory of Behavior Change Constructs Among Adolescents Taking Attention-Deficit/Hyperactivity Disorder Medicine: A Longitudinal Study

ObjectiveTo quantitatively validate the preintention factors, behavioral intentions, and implementation factors and examine the relationships theorized by the Unified Theory of Behavior Change (UTBC) model among adolescents with attention-deficit/hyperactivity disorder (ADHD).MethodsWe conducted longitudinal analyses of data from 40 adolescents with ADHD, aged 11 to 15 years old, and their parents, including self-report of UTBC constructs using standardized measures. We collected pharmacy dispensing records for adolescents for the 4 months that followed. We used bivariate correlations to examine relationships between medication continuity, behavioral intentions, preintention factors, and the implementation factors. We conducted paired sample t-tests to compare adolescent and parent responses on UTBC items.ResultsAdolescents (mean [standard deviation {SD}] age = 13.3 [1.2] years, 75% male, 77.5% non-Hispanic Black, 90% publicly insured) reported a mean total ADHD symptom score = 29.8/54 (SD = 10.94) and mean total impairment score = 18.7/52 (SD = 10.90) and had a mean percentage of days covered with medicine over 4 months = 0.21 (range = 0–0.97). Adolescent intention to take ADHD medicine every school day was significantly related to adolescents’ subsequent medication continuity (r = 0.37, P < .05). Adolescent self-concept/image and confidence taking ADHD medicine were the most important factors related to the intention to take ADHD medicine every school day. Adolescents reported less belief and intention to take ADHD medicine and more barriers to taking ADHD medicine compared to their parents.ConclusionThe UTBC model shed light on factors related to subsequent medication use, providing a plausible mechanism for additional research to intervene to promote future medication continuity.     

Disparities in Mental and Behavioral Health Treatment for Children and Youth in Immigrant Families

Background and ObjectiveChildren and youth in immigrant families (CIF)—children and youth with at least 1 foreign-born parent—face unique psychosocial stressors. Yet little is known about access to mental and behavioral health (MBH) services for CIF. Among US CIF and non-CIF with MBH problems, we assessed access to MBH treatment.MethodsWe used the National Survey of Children's Health-2016, a nationally representative survey of predominantly English- or Spanish-speaking US parents. The sample included 2- to 17-year-olds whose parent reported at least 1 MBH problem. The primary outcome was prior-year receipt of MBH treatment (counseling, medication, or both).ResultsOf 50,212 survey respondents, 7164 reported a current MBH problem (809 CIF and 6355 non-CIF). The majority of CIF were Hispanic/Latinx (56% CIF vs 13% non-CIF, P < .001). CIF were less likely than non-CIF to have an Attention Deficit Hyperactivity Disorder (ADHD) diagnosis (35% vs 59%, P < .001) and less likely to have received MBH medication and/or counseling (61% vs 71%, P = .02). This difference was pronounced for receiving medication (32% vs 50%, P < .001). When controlling for multiple covariates, differences in any MBH treatment were no longer statistically significant (adjusted odds ratios 0.76, 95% confidence interval 0.52–1.11), while the odds of receipt of medication remained significantly lower for CIF (adjusted odds ratios 0.61, 95% confidence interval 0.42–0.88).ConclusionsAmong children and youth with at least 1 parent-reported MBH problem, CIF, compared with non-CIF, were less likely to receive MBH treatment, specifically medication. This may be explained, in part, by differences in the proportion of CIF and non-CIF diagnosed with ADHD.     

Parents' Perception of Satisfaction With Care From Pediatric Nurse Practitioners Instrument

IntroductionThe purpose of this methodological study was to establish the psychometric properties of the newly developed Parents' Perceptions of Satisfaction with Care from Pediatric Nurse Practitioners (PPSC-PNP) instrument to measure parents' satisfaction with PNP care.MethodThe initial 37-item PPSC-PNP was sent to five expert judges for review. The 28 retained items yielded a content validity index of .81. The PPSC-PNP instrument was completed by two convenience samples of 25 and 91 parents of children younger than 18 years who were recruited from clinical practice settings in Southeastern Pennsylvania.ResultsItems on the PPSC-PNP were evaluated for content validity by Cronbach's α internal consistency reliability coefficients and item-to-total correlations. The final 28-item PPSC-PNP had a Cronbach's α of .98. The scores on the PPSC-PNP indicated that the parents were satisfied with PNP care.DiscussionAlthough several instruments designed to measure patients' satisfaction with nurse practitioner care are reported in the nursing literature, none were found to measure parents' perception of pediatric nurse practitioner care. The newly developed PPSC-PNP is a valid and reliable instrument that can be used as a quality indicator of PNP care.     

Concordancia entre padres e hijos en la calidad de vida relacionada con la salud en niños con trastorno por déficit de atención con hiperactividad: estudio longitudinal

ObjectivesTo assess parent-child agreement on changes over a short-term period of time in the HRQOL of children treated for ADHD over a short period of time, and to compare child and parent ratings of children with ADHD with general population norms.MethodsProspective study in children 6-12 years old with ADHD. Children and parents completed the Spanish versions of the Child Health and Illness Profile-Child Edition (CHIP-CE) before and after 8 weeks of treatment. CHIP-PE scores at both visits were compared using paired t tests and effect sizes (ES), intra-class correlation coefficients (ICC), and scatter plots. Child and parent ratings were compared with CHIP-CE scores for a general population sample.ResultsThirty-one children and parents were included in the analysis. The highest change between the first and the follow-up visit was on the Risk Avoidance domain both children and parents (effect size [ES]=0.24 and 0.40, respectively). The ICC ranged from 0.44 (Satisfaction) to 0.01 (Risk avoidance). Child self-ratings were close to general population values. All domains of the parent version presented standardized means below the reference values at the baseline visit and closer to the general population norm after treatment.ConclusionsThis study found poor parent-child agreement and suggests that both ratings should be collected in future studies on the impact of ADHD and treatment effectiveness.     

Nurse-Led Telephone Follow-Up to Improve Parent Promotion of Healthy Behaviors in Young Children With Motivational Interviewing Techniques

IntroductionThe American Academy of Pediatrics (AAP) recommends primary care–based health promotion for obesity prevention at all visits, focusing on nutrition and activity.MethodsIn this quality improvement project, a primary care innovation was developed to support parents in promoting healthy habits in their children ages 2 to 5 years old. Nurse-led telephone support using motivational interviewing was implemented during two follow-up phone calls aimed at helping parent–child dyads reach self-created activity or nutrition goals.ResultsParent-rated confidence and motivation related to meeting these goals showed significant increases. During the second call, 80% self-reported goal completion and high satisfaction with the visits. Registered nurses reported a significant increase in their self-efficacy of communication with parents.DiscussionThis project showed the feasibility of using nurse telephone visits in an urban low-income primary care setting to improve parental recognition and understanding of healthy habits that align with American Academy of Pediatrics recommendations for obesity prevention.     

Addressing Goals of Parents of Hospitalized Children: A Qualitative Analysis of Parents’ and Physicians’ Perspectives

ObjectiveGoals of care discussions are crucial in helping parents navigate complex medical decisions and shown to improve quality of care. Little is known about whether physicians elicit or address parents’ goals during a child's hospitalization. The purpose of this study was to understand the current practice of goal setting at the beginning of hospitalization by exploring the perspectives of parents of hospitalized children and their hospital physicians.MethodsA qualitative study with semi-structured interviews was conducted from 2018 to 2019 at a 361-bed quaternary suburban freestanding children's hospital. Twenty-seven parents of hospitalized children and 16 pediatric hospital medicine faculty were matched to participate. Data were analyzed using modified grounded theory, with themes identified through constant comparative approach.ResultsFive themes were identified: 1) Majority of hospitalized children's parents want to share their goals with physicians. 2) Parents and physicians share the same underlying goal of getting the child better to go home. 3) Parents of children with chronic diseases identified nonhospital goals that were not addressed. 4) Physicians do not explicitly elicit but rather assume what parents’ goals of care are. 5) Factors related to patient, parent, and physician were identified as barriers to goal setting.ConclusionsPhysicians may not consistently elicit parents’ goals of care for their hospitalized children at the start of hospitalization. Parents desire their physicians to explicitly ask about their goals and involve them in goal setting during hospitalization. Strategies were identified by parents and physicians to improve goal setting with parents of hospitalized children.     

Novel Immunization Reminder/Recall Approaches: Rural and Urban Differences in Parent Perceptions

ObjectiveTo assess the following among parents of young children: 1) preferences about the source of immunization reminder/recall (R/R) messages, 2) the degree of acceptability of different R/R modalities, and 3) factors that influence preferences, including rural and urban characteristics.MethodsWe conducted a survey among parents of children 19 to 35 months old who needed ≥1 immunization according to the Colorado Immunization Information System (CIIS). Equal numbers of urban and rural respondents were randomly selected. Up to 4 surveys were mailed to each parent who had a valid address.ResultsAfter removing invalid addresses, the response rate was 55% (334 of 607). Half of parents (49.7%) had no preference about whether the public health department or their child's doctor sent reminders. Urban parents were more likely to prefer R/R come from their child's doctor (46.7%) compared to rural parents (33.7%), P = .003. Mail was the preferred R/R method (57.7%), then telephone (17.0%), e-mail (12.7%), and text message (10.7%). Although not preferred, 60.1% reported it would be acceptable to receive R/R by e-mail and 46.2% by text message. Factors associated with preferring to receive R/R from their child's doctor were urban residence and educational level of college graduate or greater.ConclusionsA large portion of parents are willing to be reminded about vaccinations by their health department rather than their child's provider and via novel modalities, such as e-mail or text messaging. Urbanicity and higher educational level were associated with preferring that R/R come from a provider.     

Pediatrician Delivered Smoking Cessation Messages for Parents: A Latent Class Approach to Behavioral Phenotyping

ObjectiveMessage framing can be leveraged to motivate adult smokers to quit, but its value for parents in pediatric settings is unknown. Understanding parents’ preferences for smoking cessation messages may help clinicians tailor interventions to increase quitting.MethodsWe conducted a discrete choice experiment in which parent smokers of pediatric patients rated the relative importance of 26 messages designed to increase smoking cessation treatment. Messages varied on who the message featured (child, parent, and family), whether the message was gain- or loss-framed (emphasizing benefits of engaging or costs of failing to engage in treatment), and the specific outcome included (eg, general health, cancer, respiratory illnesses, and financial impact). Participants included 180 parent smokers at 4 pediatric primary care sites. We used latent class analysis of message ratings to identify groups of parents with similar preferences. Multinomial logistic regression described child and parent characteristics associated with group membership.ResultsWe identified 3 groups of parents with similar preferences for messages: Group 1 prioritized the impact of smoking on the child (n = 92, 51%), Group 2 favored gain-framed messages (n = 63, 35%), and Group 3 preferred messages emphasizing the financial impact of smoking (n = 25, 14%). Parents in Group 2 were more likely to have limited health literacy and have a child over age 6 and with asthma, compared to Group 1.ConclusionsWe identified 3 groups of parent smokers with different message preferences. This work may inform testing of tailored smoking cessation messages to different parent groups, a form of behavioral phenotyping supporting motivational precision medicine.     

Adverse Childhood Experiences: Translating Knowledge into Identification of Children at Risk for Poor Outcomes

ObjectiveTo pilot test a tool to screen for adverse childhood experiences (ACE), and to explore the ability of this tool to distinguish early child outcomes among lower- and higher-risk children.MethodsThis cross-sectional study used data collected of 102 children between the ages of 4 and 5 years presenting for well-child visits at an urban federally qualified health center. Logistic regression analyses adjusted for child sex, ethnicity, and birth weight were used to test the association between each dichotomized child outcome and risk exposure based on a 6-item (maltreatment suspected, domestic violence, substance use, mental illness, criminal behavior, single parent) and 7-item (plus maternal education) Child ACE tool.ResultsEffect sizes were generally similar for the 6-item and 7-item Child ACE tools, with the exception of 2 subscales measuring development. The adjusted odds of behavior problems was higher for children with a higher compared to a lower 7-item Child ACE score (adjusted odds ratio [aOR] 3.12, 95% confidence interval [CI] 1.34–7.22), as was the odds of developmental delay (aOR 3.66, 95% CI 1.10–12.17), and injury visits (aOR 5.65, 95% CI 1.13–28.24), but lower for obesity (aOR 0.32, 95% CI 0.11–0.92).ConclusionsBrief tools can be used to screen for ACE and identify specific early child outcomes associated with ACE. We suggest that follow-up studies test the incorporation of the 7-item Child ACE tool into practice and track rates of child behavior problems, developmental delays, and injuries.     

Suivi à long terme des effets d’un entraînement de la mémoire de travail (Cogmed) auprès d’enfants présentant un TDA/H

BackgroundAttention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder associated with working memory deficits. In that optic, new interventions designed to train working memory have been developed. Cogmed Working Memory Training (CWMT) is a popular online training program that is said to increase working memory (WM) and related skills in the ADHD population. However, follow-up measures are not systematically included, and long-term effects of CWMT are controversial. Also, the number of studies examining transfer of learning and controlling for medication or comorbidities are limited.ObjectivesThis study investigates the long-term effects of CWMT combined with psychostimulant medication on WM and related skills.MethodsThis study included 31 participants aged 7 to 13 years, diagnosed with ADHD (mixed subtype) associated with learning disorders, oppositional-defiant disorder and/or Tourette syndrome. Participants first completed CWMT and were evaluated at follow-up six months later. We used a randomized, double-blind, placebo-controlled design.ResultsThe results found no significant impact of CWMT at follow-up. There were no improvements of WM nor transfer effects on related skills, academic achievement or ADHD symptoms at six months’ follow-up.ConclusionLong-term efficacy of CWMT is not demonstrated. We can’t support CWMT as an effective complementary treatment for children with ADHD and associated comorbidities.     

Evidence-Based Milestones for Surveillance of Cognitive,Language, and Motor Development

ObjectiveFewer than half of the nation’s pediatricians conduct systematic surveillance of young children’s development. Because time and cost are among the barriers, our objective was to create a brief set of parent-report questions about cognitive, motor, and language milestones that is freely available and can be administered and scored quickly.MethodsA team of experts developed candidate items after reviewing existing instruments and prior research. We selected final items based on statistical fit to a graded item response model developed and replicated in separate samples enrolled from primary care settings (n = 469 and 308, respectively). We then developed a 10-item form for each visit on the pediatric periodicity schedule. Combining our initial samples with 395 families enrolled from referral clinics, we tested these forms’ concurrent validity with respect to the ASQ-3 and parent reports of developmental diagnoses.ResultsA final set of 54 items displayed adequate fit to our statistical model regardless of race/ethnicity, education level, and child gender. Beginning at 4 months, scores on 10-item forms displayed consistent associations with the ASQ-3, and all but the 60-month form detected parents’ reports of developmental delay with adequate sensitivity and specificity.ConclusionsThe Milestones is one element of the Survey of Well-being of Young Children (SWYC), a brief but comprehensive screening instrument for children under 5 years. The Milestones is a set of evidence-based items with individual normative data that are appropriate for pediatric surveillance. In addition, the scoring of 10-item Milestones forms may provide many advantages of a first level developmental screening instrument.     

Parental opinions regarding treatment for social anxiety disorder in youth

This study surveyed parents' opinions about treatment for childhood social anxiety disorder and assessed variables that may affect treatment acceptability. A 20-item survey assessing treatment attitudes and a semistructured interview were administered to 190 parents of children (8-17 years) who were randomly selected from a pediatric primary care setting. An exploratory factor analysis of the treatment attitudes survey yielded four factors: medication acceptability, counseling acceptability, counseling feasibility, and general beliefs about social anxiety treatment. Findings revealed that parents endorsed favorable attitudes toward counseling and somewhat neutral beliefs about medication. White parents were more accepting of medication and counseling and also perceived counseling as more feasible than nonwhite parents. Treatment acceptance was associated with past mental health utilization but not with severity of social anxiety. Further research is necessary to determine if clinical interventions for child anxiety disorders may be more efficacious if parents' attitudes and beliefs about prescribed treatments are addressed.     

Parent Readiness for Hospital Discharge Scale: Psychometrics and Association With Postdischarge Outcomes

IntroductionThe purpose of this study is to validate the Readiness for Hospital Discharge Scale (RHDS) for use with parents of hospitalized children. PedRHDS is a structured tool for a discharge readiness assessment before pediatric discharge.MethodsUsing combined data from four studies with 417 parents, psychometric testing and item reduction proceeded with principal component analysis for factor structure delineation, Cronbach's alpha for reliability estimation, and regression analysis for predictive validity.ResultsA 23-item PedRHDS retained the a priori factor structure. Reliability ranged from 0.73 to 0.85 for the 23-item and 10- and 8-item short scales. PedRHDS (all forms) was associated with postdischarge coping difficulty (explaining 12%–16% of variance) and readmission (odds ratio = 0.71−0.80).DiscussionThe PedRHDS and both short forms (PedRHDS-SF10 and PedRHDS-SF8) are reliable and valid measures of parental discharge readiness that can be used as outcome metrics of hospital care and risk indicators for postdischarge coping difficulty and readmission.     

The Transition Readiness Assessment Questionnaire (TRAQ): Its Factor Structure,Reliability, and Validity

ObjectiveNational consensus statements recommend that providers regularly assess the transition readiness skills of adolescent and young adults (AYA). In 2010 we developed a 29-item version of Transition Readiness Assessment Questionnaire (TRAQ). We reevaluated item performance and factor structure, and reassessed the TRAQ's reliability and validity.MethodsWe surveyed youth from 3 academic clinics in Jacksonville, Florida; Chapel Hill, North Carolina; and Boston, Massachusetts. Participants were AYA with special health care needs aged 14 to 21 years. From a convenience sample of 306 patients, we conducted item reduction strategies and exploratory factor analysis (EFA). On a second convenience sample of 221 patients, we conducted confirmatory factor analysis (CFA). Internal reliability was assessed by Cronbach's alpha and criterion validity. Analyses were conducted by the Wilcoxon rank sum test and mixed linear models.ResultsThe item reduction and EFA resulted in a 20-item scale with 5 identified subscales. The CFA conducted on a second sample provided a good fit to the data. The overall scale has high reliability overall (Cronbach's alpha = .94) and good reliability for 4 of the 5 subscales (Cronbach's alpha ranging from .90 to .77 in the pooled sample). Each of the 5 subscale scores were significantly higher for adolescents aged 18 years and older versus those younger than 18 (P < .0001) in both univariate and multivariate analyses.ConclusionsThe 20-item, 5-factor structure for the TRAQ is supported by EFA and CFA on independent samples and has good internal reliability and criterion validity. Additional work is needed to expand or revise the TRAQ subscales and test their predictive validity.