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Few studies have derived data-driven dietary patterns in youth in the USA. This study examined data-driven dietary patterns and their associations with BMI measures in predominantly low-income, racial/ethnic minority US youth. Data were from baseline assessments of the four Childhood Obesity Prevention and Treatment Research (COPTR) Consortium trials: NET-Works (534 2–4-year-olds), GROW (610 3–5-year-olds), GOALS (241 7–11-year-olds) and IMPACT (360 10–13-year-olds). Weight and height were measured. Children/adult proxies completed three 24-h dietary recalls. Dietary patterns were derived for each site from twenty-four food/beverage groups using k-means cluster analysis. Multivariable linear regression models examined associations of dietary patterns with BMI and percentage of the 95th BMI percentile. Healthy (produce and whole grains) and Unhealthy (fried food, savoury snacks and desserts) patterns were found in NET-Works and GROW. GROW additionally had a dairy- and sugar-sweetened beverage-based pattern. GOALS had a similar Healthy pattern and a pattern resembling a traditional Mexican diet. Associations between dietary patterns and BMI were only observed in IMPACT. In IMPACT, youth in the Sandwich (cold cuts, refined grains, cheese and miscellaneous) compared with Mixed (whole grains and desserts) cluster had significantly higher BMI (β= 0·99 (95 % CI 0·01, 1·97)) and percentage of the 95th BMI percentile (β= 4·17 (95 % CI 0·11, 8·24)). Healthy and Unhealthy patterns were the most common dietary patterns in COPTR youth, but diets may differ according to age, race/ethnicity or geographic location. Public health messages focused on healthy dietary substitutions may help youth mimic a dietary pattern associated with lower BMI.

The COVID-19 pandemic exacerbated the child mental health crisis and existing disparities. Child anxiety, depression, suicide attempts and completions, and mental-health-related emergency department visits significantly increased. In response to this crisis, the Administration for Strategic Preparedness and Response (ASPR) developed behavioral health task forces associated with funded pediatric centers of disaster excellence. The Health Resources and Services Administration (HRSA) funded the Pediatric Pandemic Network (PPN) to prepare for future endemics and pandemics, with behavioral health identified as a priority in mitigation, preparedness, response, and recovery. This commentary provides insights from pediatric disaster preparedness and response behavioral health subject matter experts. Our roles have been to identify how to build behavioral health professional competencies across disciplines and various medical settings and to strengthen emergency interdisciplinary behavioral health care capability regionally and at the national level. Specific examples of interdisciplinary training and demonstration projects are included as models for enhancing behavioral health situational awareness and developing curricula to support preparedness and response for the current ongoing pandemic and future natural and biological disasters. This commentary also includes a call to action for workforce development to move beyond a boots-on-the-ground mentality for pediatric behavioral health disaster preparedness and response toward a more inclusive role for behavioral health providers of varied specialties. This means that behavioral health providers should become more informed of federal programs in this area, seek further training, and find innovative ways to collaborate with their medical colleagues and community partners.

OBJECTIVE. The present study was a secondary data analysis of a randomized controlled trial (RCT) to examine change in depressive symptoms and eating-related cognitions in teens who participated in a non-clinic-based adolescent behavioral weight control treatment delivered by YMCA coaches. Differences in intervention effects were also examined by sex. METHODS. Adolescents (N=66; 13-17 years; 60.6% female) with overweight (10.6%) or obesity (53.0% with severe obesity) participated in an RCT comparing two versions of an evidence-based intervention. Adolescents completed measures of eating-related cognitions (Eating Disorder Examination Questionnaire) and depressive symptoms (Children’s Depressive Inventory-2) at baseline and end of active treatment (16 weeks). RESULTS. There were no significant effects of group, time, or group by time interaction for depressive symptoms, global eating-related cognitions, dietary restraint, or eating concerns (ps >.05). Shape concerns (p=.04) and weight concerns (p=.02) significantly decreased over the intervention. Significant interactions between sex and time on global eating-related cognitions (p

As a response to clinical observations that the pervasive stress and social/environmental disruptions from the 2020 COVID-19 pandemic have also impacted sleep, the Society of Behavioral Sleep Medicine (SBSM) convened the COVID-19 Task Force with goals to identify and disseminate information that could be useful in addressing sleep concerns during this crisis.

OBJECTIVE Weight-related quality of life (WRQOL) is a type of health-related QOL that may serve as a patient-reported outcome of the potential burden of overweight. The present study uses structural equation modeling path analysis methods to examine body mass index (BMI) and other potential predictors of WRQOL components among adolescents who were overweight/obese from predominantly low-income, urban households. METHODS Baseline data were obtained from 360 participants (10-13 year olds; 57.8% female; 76.7% black; average BMI of 27.12) and their parents/legal guardians from a randomized, controlled, treatment trial. Youth completed measures of WRQOL, depressive symptoms, and family/friend social support for healthy eating. Parents completed measures of demographics and child social problems. RESULTS The initial model included BMI, gender, parent education, family/friend social support for healthy eating, child social problems, body esteem and social life WRQOL, and depressive symptoms. The final model fit the data well (χ = 27.738; df = 16; p = .034). Higher BMI was indirectly related to lower social life and body esteem WRQOL through greater social problems. Physical comfort and family relations WRQOL were unrelated to BMI and were not included. Lower social life and body esteem related to more depressive symptoms. Family/friend discouragement for healthy eating was associated with lower body esteem; also, family discouragement was related to lower social life. CONCLUSION Body mass index may not directly relate to WRQOL but may be associated through other factors, including child social problems. Interventions should screen for and treat mood and social problems and address family/friend support for healthy eating.

Background Little is known about the feasibility and impact of lifestyle intervention, determined by change in diet and cardiovascular fitness (CRF), on glycemic control in youth who are overweight with type 2 diabetes. This was examined in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial cohort from across 15 US centers. Subjects TODAY enrolled 699 youth aged 10 to 17 years with type 2 diabetes

Difficulty falling asleep and frequent nocturnal awakenings are common sleep problems in young children. These are highly influenced by parent choices about sleep schedules, bedtime routines, and psychosocial factors but are usually very treatable with effective behavioral interventions. Parents may respond with actions that actually end up perpetuating sleep problems based on their beliefs about the nature of the sleep disturbances. Parents may misattribute the sleep disturbance to other medical problems or misinterpret benign sleep disturbances such as confusional arousals. Even if these conditions are ruled out or identified, the learned negative sleep-onset associations can be challenging to alter. Fortunately, children’s sleep habits are amenable to change when caregivers apply empirically supported behavioral sleep medicine strategies. Sleep physicians and psychologists specializing in behavioral sleep medicine can work collaboratively to solve the mystery of complex toddler sleep problems, tailoring parent guidance and behavioral treatments to the individual child and family dynamics.

Summary Background The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial documented that metformin plus rosiglitazone, but not metformin plus lifestyle intervention, provided superior durability of glycemic control relative to metformin monotherapy. Objectives We examined weight changes among TODAY participants that completed at least 6 months of treatment, evaluated predictors of lifestyle outcome, and examined whether weight changes were related to cardiometabolic outcomes across treatment arms. Methods The 595 youth with type 2 diabetes, (85.1% of randomized participants aged 11–17 years) completed assessments of weight-related and cardiometabolic measures at months 0, 6, 12 and 24. Repeated measures models were used to investigate associations over time. Results Lifestyle intervention did not enhance outcome relative to metformin alone and no predictors of response to lifestyle treatment were identified. However, changes in percent overweight across treatment arms were associated with changes in multiple cardiometabolic risk factors, and decreases of ≥ 7% in overweight were associated with significant benefits over 24 months. Conclusions Although adjunctive intensive lifestyle intervention did not improve weight-related outcomes, weight changes in the full TODAY sample were associated with small, but significant improvements in cardiometabolic status, highlighting the importance of optimizing weight management in youth with T2DM.

Adolescents who are obese are at risk for being teased about their appearance with the concomitant negative psychological sequelae. Identifying modifiable variables associated with teasing could inform pediatric weight-management interventions. Characterizing society&rsquo, s role in the victimization of these at-risk individuals could guide anti-bullying programs for schools and broader public health efforts. This study aims to examine novel societal and cognitive factors associated with weight-related teasing frequency. Participants were adolescents (N = 334) being evaluated for a hospital-affiliated weight-management program. The outcome was perceived weight-related teasing frequency. Predictors were sociocultural awareness and internalization of appearance-related attitudes, physical activity self-efficacy, and psychological functioning. Multivariate regressions controlled for demographics and body mass index (BMI) z-scores with separate regressions testing interactions of BMI z-scores with all predictors. In adjusted analyses, higher physical activity self-efficacy and fewer depressive symptoms related to lower teasing frequency. Interactions indicated that less awareness/internalization of sociocultural attitudes towards appearance, more positive body image, and higher self-esteem related to lower teasing frequency regardless of BMI. Targeted interventions and public health campaigns should be developed and tested for adolescents that improve body image with promotion of diverse views about attractiveness, bolster confidence in overcoming physical activity barriers, and identify and treat mood symptoms.

Behavioral management of diabetes leads to better health outcomes. This paper reviews the available literature on facilitators of behavior change in people with diabetes and highlights approaches and strategies diabetes care providers can utilize. The research and clinical evidence points to the critical nature of considering the content and structure of recommendations, and utilizing problem solving and teamwork approaches. Furthermore, close attention to individual and community factors will optimize behavior change. These factors include health literacy, community infrastructure, support within the family, and whether there are co-occurring eating and mood issues. Recommendations are provided to optimize communication and embed behavior change approaches in clinical and community encounters.

OBJECTIVE : To examine associations of sleep duration and regularity with dietary intake and eating-related cognitions among adolescents who are overweight/obese. METHODS : Participants were 315 adolescents being evaluated through Healthy Kids, Healthy Weight. Outcomes were reported sleep duration and regularity (bedtime shift, wake-time shift, sleep duration shift). Major predictors were dietary intake (e.g., consumption of calories and sugar-sweetened beverages) and eating-related cognitions (food preoccupation, eating self-efficacy). RESULTS : Findings were that staying up (i.e., bedtime shift) and sleeping in later (i.e., wake-time shift) on weekends compared with weekdays significantly relates to drinking more sugar-sweetened beverages, the latter for males. Sleeping in on weekends was related to greater food preoccupation. CONCLUSIONS : Sleep regularity was the most important variable in its relationships with dietary intake. Evaluating sleep patterns and improving them with behavioral interventions should be considered as an additional weight loss strategy to promote dietary adherence.

Potential alterations in sleep stages and disruptions during the night place children and adolescents with Type 1 diabetes (T1D) at risk for negative sequelae related to short sleep duration or suboptimal sleep. In this special report, research establishing the importance of sleep variables in diabetes care, including for improved adherence and glycemic control, is described. Also, emerging research is presented supporting the impact of sleep on academic performance, internalizing and externalizing symptoms, and parental functioning in children with adolescents with T1D. Given the various ways in which sleep relates to functional outcomes in children and adolescents with T1D, assessment suggestions for pediatric endocrinologists are discussed. Recommendations are also provided for intervention.

Behavioral management of diabetes leads to better health outcomes. This paper reviews the available literature on facilitators of behavior change in people with diabetes and highlights approaches and strategies diabetes care providers can utilize. The research and clinical evidence points to the critical nature of considering the content and structure of recommendations, and utilizing problem solving and teamwork approaches. Furthermore, close attention to individual and community factors will optimize behavior change. These factors include health literacy, community infrastructure, support within the family, and whether there are co-occurring eating and mood issues. Recommendations are provided to optimize communication and embed behavior change approaches in clinical and community encounters.

The recently developed competencies in pediatric psychology from the Society of Pediatric Psychology (SPP) Task Force on Competencies and Best Training Practices in Pediatric Psychology provide a benchmark to evaluate training program practices and student progress toward training in level-specific competency goals. Graduate-level training presents a unique challenge for addressing the breadth of competencies required in pediatric psychology while maintaining development of broader clinical psychology training goals. We describe a recurring graduate-level pediatric psychology seminar course that addresses training in a number of the competency cluster areas. The structure of the seminar, examples of classroom topics that correspond with competency cluster areas as well as benchmarks used to evaluate each student's development in the competency area are provided. Specific challenges in developing and maintaining the seminar in this format are identified, and possible solutions are offered. This training format could serve as a model for established pediatric psychology programs to expand their didactic training goals or for programs without formal pediatric psychology training to address competencies outside of clinical placements.

Tony is a 6-year-old multiracial boy diagnosed as having attention-deficit/hyperactivity disorder-combined type who is followed in your primary care practice and has started on a stimulant medication. Tony continues to have difficulty with emotion regulation and impulse control both at home and at school. He was asked to leave his private school soon after beginning first grade because of physical fighting, emotional outbursts, and arguing with teachers.His mother made the decision to enroll Tony in online virtual schooling for the remainder of the academic year, with the plan to transition back to traditional school for the next academic year. They have enrolled in a program that offers lessons online and sends materials to the home for the child to use to complete certain types of assignments (e.g., science experiments). Virtual schools are different from traditional home schooling because children receive their instruction from teachers online with parental assistance as opposed to parents being responsible for teaching all material. Tony's mother comes to your practice requesting assistance with setting up an appropriate school environment for her son at home, where she can monitor and support his academic progress.Tony is a bright child, with an Intelligence Quotient in the superior range. He has advanced academic skills, but he becomes dysregulated if he is told he is wrong or that he has answered a question incorrectly. For example, if he answered a question incorrectly in class, he would become verbally abusive toward his teacher and often have temper tantrums. This challenging behavior occurred daily at school and was one of the factors leading to his expulsion. The behavior had predated the introduction of stimulant medication and had remained consistent after he began medication.Tony's parents are highly educated, and both parents hold professional jobs with steady income. His parents have good command of typical behavior management strategies such as the use of rewards, time out, and behavioral contingencies to target noncompliance and temper tantrums. However, Tony's difficulty identifying and regulating his emotions leads to emotional outbursts and shutdowns that have thus far been unresponsive to standard behavior management techniques. Tony continued to have outbursts even when the behavior was ignored. His mother is concerned not only about his learning during the coming year but also about his social relationships and the family dynamic. Tony's outbursts cause significant disruption in the home and are a source of tension among parents and siblings.His mother is asking for advice on how to support his behavior better at home now that he will be spending his entire day there. How might you assist this child and his mother by helping to integrate therapeutic goals into the academic environment?

The relationship between depressive symptoms and glycemic control in youth with type 2 diabetes was assessed at baseline (n = 682), 6, and/or 24 months (n = 576). Neither baseline nor persistence of depressive symptoms was significantly associated with maintenance of glycemic control. Nevertheless, depressive symptoms were common, suggesting the importance of repeated screening.

Defining the proper geographic scale for built environment exposures continues to present challenges. In this study, size attributes and exposure calculations from two commonly used neighborhood boundaries were compared to those from neighborhoods that were self-defined by a sample of 145 urban minority adolescents living in subsidized housing estates. Associations between five built environment exposures and physical activity, overweight and obesity were also examined across the three neighborhood definitions. Limited spatial overlap was observed across the various neighborhood definitions. Further, many places where adolescents were active were not within the participants׳ neighborhoods. No statistically significant associations were found between counts of facilities and the outcomes based on exposure calculations using the self-defined boundaries; however, a few associations were evident for exposures using the 0.75 mile network buffer and census tract boundaries. Future investigation of the relationship between the built environment, physical activity and obesity will require practical and theoretically-based methods for capturing salient environmental exposures.

IMPACT (Ideas Moving Parents and Adolescents to Change Together) is a 3-group randomized, multi-level trial comparing the efficacy of two distinct behavioral interventions and a control condition on body mass index (BMI) in middle school urban youth who are overweight/obese. Interventions include: (1) SystemCHANGE (SC), a promising new behavior change approach that focuses on system redesign of the family environment and daily routines; (2) HealthyCHANGE (HC), a cognitive-behavioral and Motivational Interviewing (MI)-consistent approach to behavior change that focuses on increasing intrinsic motivation, self-monitoring, goal setting, and problem solving; and (3) diet and physical education counseling (attention control). In addition, about half of the participants are enrolled in a K-8 public school that offers an innovative community-sponsored fitness program, augmented by study-supported navigators. In addition to the primary interventions effects, the study assesses the moderating effect of the school environment on BMI, blood pressure, cardiovascular risk factors, and quality of life. The sample consists of 360 children entering 6th grade from a large urban school district in the Midwest, identified through an existing BMI screening program. The intervention period is 36 months, and measures are obtained at baseline, 12, 24, and 36 months. Using intent-to-treat analyses across the 36-month intervention window, we hypothesize that both SC and HC will have a greater impact on BMI and other health outcomes compared to health education alone, and that the enriched school environment will enhance these effects. This manuscript describes IMPACT's study design and methods.

Little is known regarding how dimensions of the family social environment relate to fitness levels and physical activity self-efficacy (PASE) among adolescents who are overweight or obese and whether these relationships are mediated by self-esteem.Potential associations were evaluated between relationship subdomains (cohesion, conflict, expressivity) of the Family Environment Scale (FES), self-esteem (Rosenberg Self-Esteem Scale, RSES), and PASE and fitness, using recovery heart rate [RHR, beats per minute (bpm)] from a 3-minute submaximal step test at baseline. Participants were 108 adolescents who were overweight or obese and were seeking weight-loss treatment as part of the Healthy Kids, Healthy Weight 12-week multidisciplinary pediatric weight management program. Structural equation modeling (SEM) was used to simultaneously evaluate paths between these variables and test for mediation.In multivariable models, higher FES cohesion (β = -2.18, s.e. = 0.98; p = 0.02), expressivity (β = -1.97, s.e. = 0.99; p 0.05), and PASE (β = -0.64, s.e. = 0.33; p 0.05) scores were associated with lower RHR, which represents higher fitness. Furthermore, higher FES conflict scores were associated with lower RSES scores (β = -0.83, s.e. = 0.29; p 0.01), and FES conflict (β = -0.63, s.e. = 0.22; p 0.01) and RSES (β = 0.33, s.e. = 0.07; p 0.01) were associated with PASE scores. In a good-fitting multivariate SEM [Comparative Fit Index (CFI) = 1.00; Standardized Root Mean Square Residual (SRMR) = 0.02; Tucker-Lewis index (TLI) = 1.22; Root Mean Squared Error of Approximation (RMSEA)0.01], RSES mediated the relationship between FES conflict and PASE (sum of indirect paths: β = -0.30, s.e. = 0.11; p 0.01) scores.Our results highlight the importance of the relationship domain of the family environment on self-esteem, PASE, and physical fitness in adolescents who are overweight or obese.

Aim: To explore associations between health-related quality of life (HRQOL) and comorbidities in youth with Type 2 diabetes. Patients & methods: Of 699 youth in the TODAY study, 685 (98%) had baseline HRQOL data, 649 (93%) at 6 months and 583 (83%) at 24 months. Comorbidities were defined by sustained abnormal values and treatment regimens. Results: At baseline, 22.2% of participants demonstrated impaired HRQOL. Only depressive symptoms distinguished those with versus without impaired HRQOL and were significantly related to later impaired HRQOL (p < 0.0001). A significant correspondence between impaired HRQOL and number of comorbidities (p = 0.0003) was noted, but was driven by the presence of depressive symptoms. Conclusion: Results emphasize the need for evaluation of depressive symptoms. Other comorbidities did not have a significant impact on HRQOL in this cohort.

Sleep disordered breathing (SDB) is associated with medical and psychological problems, including obesity and depression. Snoring is the most common complaint for SDB. We hypothesized that children and adolescents who are obese and snore would have more depressive symptoms than those who do not snore. Participants (ages 6–17) evaluated for a weight management program (n = 247) were divided into parent-reported habitual snorers (34%) and non-snorers (65%). Habitual snorers had significantly more self-reported symptoms of depression than did non-snorers (0.041); a trend remained after controlling for BMI z-scores (0.053). Clinicians should be aware of depressive symptoms in this high-risk population.

Insufficient sleep may be a significant contributing factor to the increase in pediatric obesity and thus may also contribute to adult obesity and chronic illness. Previous research has been based on large survey studies with consideration of demographics and lifestyle factors (e.g., snacking and TV watching) but not of child psychological/behavioral functioning and parenting factors.This study investigated the relationship of sleep duration to obesity status in 819 children ages 8 to 11 years old, with consideration of demographics, clinical elevations in child psychological/behavioral functioning, and parenting stress.In unadjusted and adjusted analyses, parent-reported child sleep duration was significantly associated with the odds of obesity with an increase of 41% for each 1-hour reduction in sleep duration. In addition to sleep duration, only median neighborhood income was significantly related to obesity status. Indices of child psychological/behavioral functioning and parenting stress were associated with sleep duration but not with obesity, and adjusting for these behavioral and parenting characteristics did not appreciably alter the relationship between sleep duration and obesity status. Exploratory gender-specific analyses found that mean sleep duration was significantly associated with the odds of obesity for boys but not for girls.These results show that the relationship of shorter sleep duration to a greater likelihood of being obese persists even after adjusting for potential confounders of child psychological/behavioral functioning and parenting stress. Gender-specific associations are similar to findings reported in samples that include adolescents.

Objectives Adherence to medical regimens for children and adolescents with chronic conditions is generally below 50% and is considered the single, greatest cause of treatment failure. As the prevalence of chronic illnesses in pediatric populations increases and awareness of the negative consequences of poor adherence become clearer, the need for reliable and valid measures of adherence has grown. Methods This review evaluated empirical evidence for 18 measures utilizing three assessment methods: (a) self-report or structured interviews, (b) daily diary methods, and (c) electronic monitors. Results Ten measures met the “well-established” evidence-based (EBA) criteria. Conclusions Several recommendations for improving adherence assessment were made. In particular, consideration should be given to the use of innovative technologies that provide a window into the “real time” behaviors of patients and families. Providing written treatment plans, identifying barriers to good adherence, and examining racial and ethnic differences in attitudes, beliefs and behaviors affecting adherence were strongly recommended.

Over the last 30 years, the prevalence of overweight across all pediatric age groups and ethnicities has increased substantially, with the current prevalence of overweight among adolescents estimated to be approximately 30%. Current evidence suggests that overweight is modestly associated with obstructive sleep apnea syndrome (OSAS) among young children, but strongly associated with OSAS in older children and adolescents. The rising incidence of pediatric overweight likely will impact the prevalence, presentation, and treatment of childhood OSAS. The subgroup of children who may be especially susceptible include ethnic minorities and those from households with caregivers from low socioeconomic groups. OSAS, by exposing children to recurrent intermittent hypoxemia or oxidative stress, may amplify the adverse effects of adiposity on systemic inflammation and metabolic perturbations associated with vascular disease and diabetes. When these conditions manifest early in life, they have the potential to alter physiology at critical developmental stages, or, if persistent, provide cumulative exposures that may powerfully alter long-term health profiles. An increased prevalence of overweight also may impact the response to adenotonsillectomy as a primary treatment for childhood OSAS. The high and anticipated increased prevalence of pediatric OSAS mandates assessment of optimal approaches for preventing and treating both OSAS and overweight across the pediatric age range. In this Pulmonary Perspective, the interrelationships between pediatric OSAS and overweight are reviewed, and the implications of the overweight epidemic on childhood OSAS are discussed.

Obesity is a major healthcare problem in youth and their social/electronic media (SEM) use has been described as a risk factor. Though much is known about the newer technologies youth use to communicate, little is known about what is used by those in weight management programs. The aim of this study was to determine what types of SEM, including sedentary and active video games, youth in weight management programs use and which they prefer for communicating with healthcare providers.This was a multisite study using a 24-question online SurveyMonkey® questionnaire. Youth, 12-17 years old, attending pediatric weight management programs at seven participating centers in the Childhood Obesity Multi Program Analysis and Study System network were eligible.There were 292 responders with a mean age of 14.2 years. Fifty-four percent were female, 36% Caucasian, 35% African American, and 33% were Hispanic. Ninety-four percent had access to a computer, 71% had Internet access, and 63% had smartphones. Whereas 87% had at least one gaming system at home, 50% reported they never played sedentary video games (71% of females vs. 25% males; p 0.0001) and 63% never played exercise video games during the week. The preferred method of communication with a healthcare provider was face to face (60%), with few indicating a preference for communication by texting (13%), phone (12%), or social media (6%).Face-to-face communication with healthcare providers is the preferred method for youth in pediatric weight management programs. They self-reported video game use less than previously described.

Purpose: To examine the roles of cognitive social maturity and life change events in a structural equation model (SEM) to explain adolescents' use of marijuana, tobacco, and alcohol. Methods: Data were derived from 1322 9th and 10th graders in a HIV prevention study. Students completed a survey of their cognitive social maturity, recent life events and substance use habits. A model from a study on the metabolic control of adolescents with diabetes was modified to apply to health risk behaviors. Results: A SEM was tested and fit the data well. Lower cognitive social maturity and greater life change events significantly predicted health risk behaviors. Life events partially mediated the relationship between cognitive social maturity and health risk behaviors. Conclusions: Adolescents' social thought processes are related to their recent life events, which in turn are related to their substance use behaviors. Suggestions are made for interventions to improve adolescents' cognitive social maturity.

A situational analysis was conducted to evaluate challenges with the treatment regimen (a low protein diet and special supplemental formula) for children and adolescents with phenylketonuria (PKU) and their caregivers. A semistructured interview was administered to 19 caregivers and 11 children with PKU to describe formula and dietary problems and their frequency, difficulty, and affective intensity. Information was also gathered on attempted solutions to problems and their perceived effectiveness. Caregivers who rated dietary problems as less frequent, difficult, and emotionally upsetting and strategies as more effective for solving problems had children with significantly lower phenylalanine (Phe) levels, a biological indicator of adherence (i.e., better adherence; all p values

To compare two different parenting practices (parental monitoring and negotiated unsupervised time) and perceived parental trust in the reporting of health risk behaviors among adolescents.Data were derived from 692 adolescents in 9th and 10th grades (x = 15.7 years) enrolled in health education classes in six urban high schools. Students completed a self-administered paper-based survey that assessed adolescents' perceptions of the degree to which their parents monitor their whereabouts, are permitted to negotiate unsupervised time with their friends and trust them to make decisions. Using gender-specific multivariate logistic regression analyses, we examined the relative importance of parental monitoring, negotiated unsupervised time with peers, and parental trust in predicting reported sexual activity, sex-related protective actions (e.g., condom use, carrying protection) and substance use (alcohol, tobacco, and marijuana).For males and females, increased negotiated unsupervised time was strongly associated with increased risk behavior (e.g., sexual activity, alcohol and marijuana use) but also sex-related protective actions. In males, high parental monitoring was associated with less alcohol use and consistent condom use. Parental monitoring had no affect on female behavior. Perceived parental trust served as a protective factor against sexual activity, tobacco, and marijuana use in females, and alcohol use in males.Although monitoring is an important practice for parents of older adolescents, managing their behavior through negotiation of unsupervised time may have mixed results leading to increased experimentation with sexuality and substances, but perhaps in a more responsible way. Trust established between an adolescent female and her parents continues to be a strong deterrent for risky behaviors but appears to have little effect on behaviors of adolescent males.

Objective To develop and test a model based on Bandura's social cognitive theory to predict healthy lifestyle behaviors for the prevention of osteoporosis. Methods Participants were 354 girls, ages 8-11 years, recruited from area Girl Scout troops. Baseline data from a randomized trial of behavioral interventions are presented. Measures of social support, knowledge, self-efficacy, dietary calcium intake, and weight-bearing physical activity (WBPA) were obtained via interviews and self-administered questionnaires. Results A structural equation model was tested and fit the data well. Family social support, perceived self-efficacy for eating a calcium-rich diet, and knowledge of WBPA significantly predicted calcium intake. Friend and family support for exercise predicted WBPA. Self-efficacy partially mediated the relationship between family support and calcium intake, as confirmed by Holmbeck's post-hoc probing strategy (2002). Conclusions Suggestions are made for primary prevention interventions such as parent and peer involvement, health education, and problem-solving training.

Postdoctoral training is a critical milestone in the training of pediatric psychologists. It facilitates the development of clinical specialization and expertise through clinical experiences with specific pediatric populations, equips researchers to be competitive for funding and to become independent researchers, provides continued clinical experiences necessary for licensure, and, on a practical level, can facilitate the transition to employment.

Objectives To characterize, during a 2-year period, the proportion of youth with type 2 diabetes (T2D) enrolled in the Treatment Options for Type 2 Diabetes in Adolescents and Youth study that reported ever at least trying smoking cigarettes and/or drinking alcohol. Study design Longitudinal data were examined for participants with T2D ages 10-18 years at baseline. Youth psychosocial, parent/family, environmental, and biological correlates of trying health risk behaviors were tested via cross-sectional multivariate models at each time point. Longitudinal models were explored for selected factors. Results Data were obtained from the Treatment Options for Type 2 Diabetes in Adolescents and Youth study's ethnically diverse participants at baseline (N = 644), 6-month (N = 616), and 24-month (N = 543) assessments. The percentage of youth ever trying only smoking remained stable at 4%; only drinking alcohol increased from 17% to 26%, and both smoking and drinking increased from 10% to 18% during the 2-year period. Factors related to trying health risk behaviors were older age, male sex, non-Hispanic white race-ethnicity, lower grades, more depressive symptoms, and stressful life events. Depressive symptoms, stressful life events, and body mass index Z-score (the latter with smoking only) were related to engagement in health risk behaviors over time. Conclusions Youth with T2D who are already at risk for health complications and who reported engaging in activities that further increase the likelihood of life-threatening morbidities were characterized. Although most correlates of trying these risk behaviors are nonmodifiable, intervention efforts may need to focus on potentially modifiable factors, such as depressive symptoms and lower grades.

Children with Prader–Willi syndrome (PWS) are at risk for autism spectrum disorder (ASD), including pervasive social deficits. While play impairments in ASD are well documented, play abilities in PWS have not been evaluated. Fourteen children with PWS and ten children with ASD were administered the Autism Diagnostic Observation Schedule (ADOS) (Lord et al. in Autism Diagnostic Observation Schedule manual. Western Psychological Services, Los Angeles, 2006) as part of a larger project. A modified Affect in Play Scale (APS; Russ in Play in child development and psychotherapy: toward empirically supported practice. Lawrence Erlbaum Associates Publishers, Mahwah, 2004; Pretend play in childhood: foundation of adult creativity. APA Books, Washington, 2014) was used to score ADOS play activities. Results indicate both groups scored below normative data on measures of imagination, organization, and affective expression during individual play. In addition, the inclusion of a play partner in both groups increased all scaled scores on the APS. These findings suggest children with PWS show impaired pretend play abilities similar to ASD. Further research is warranted and should focus on constructing and validating programs aimed at improving symbolic and functional play abilities within these populations.

A situational analysis of problematic situations was conducted for 37 caregivers of children with sickle cell disease (SCD) who ranged in age from 5 to 13 years. Participants responded to a semistructured interview related to caring for a child with SCD. The interview included the domains of medication adherence, nutrition, minimizing and coping with pain episodes, social problems, academic difficulties, and children's expression of negative feelings related to having SCD. Caregivers described a total of 356 problems. Almost all caregivers reported experiencing problems with their children's nutrition (n = 35), minimizing pain episodes (n = 34), and their children expressing feelings about having SCD (n = 33). Moderately challenging and emotionally upsetting problems were reported for coping with pain episodes. The total number of problems was significantly higher for boys than for girls. Nutrition issues were more frequently reported for younger children. Findings have salient clinical implications for the care of children with SCD.

Adherence to medical treatment is a significant problem for children and adolescents with chronic conditions, such as asthma, diabetes, and cystic fibrosis. The consequences of nonadherence can be serious, contributing to increased symptoms, unnecessary hospitalizations, and declines in physical functioning. The quality of data obtained from clinical trials can also be affected by poor adherence, leading to erroneous conclusions concerning the efficacy of drug treatments and the dosages that are needed to achieve those effects. Adherence problems in both clinical research and practice also lead to substantially higher health care costs. In order to further our understanding of the barriers that lead to poor adherence and identify strategies that are effective in addressing them, we need to develop reliable and valid measures of adherence behaviors. Using cystic fibrosis as a model of a serious, chronic disease that requires a difficult and time-consuming medical regimen, three different types of adherence measures are considered: self-report questionnaires, daily diary reports, and electronic monitors. The specific advantages and disadvantages of each type of measurement are reviewed, and specific recommendations are made for future research.

The objective of this article is to evaluate whether sleep patterns and quality differed between adolescents born preterm and term, and to further explore whether differences in sleep patterns were explained by differences in mediating factors such as mood, behavior, or socioeconomic status. Five hundred and one 16- to 19-year-old children in the longitudinal Cleveland Children's Sleep and Health Study cohort underwent overnight polysomnography (PSG), wore wrist actigraphs, and completed sleep logs for 1 week. The modified Epworth Sleepiness Scale, the Adolescent Sleep Hygiene Scale, and the Adolescent Sleep-Wake Scale were used to further assess sleep. Adolescents born preterm demonstrated significantly (p < .05) earlier bed and wake times and sleep midpoints (approximately 22 min after adjusting for demographic and psychosocial factors) by actigraphy. They also had significantly fewer arousals (by PSG), and reported being more rested and alert in the morning, as well as less sleepiness and fatigue. These findings support a growing body of evidence that perinatal factors may influence sleep phenotypes later in life. These factors may reflect developmental influences, as well as the influence of parenting styles on children's sleep.

Objective The objective of this study was to offer a practical demonstration of the use of bootstrapping in structural equation modeling (SEM) with smaller samples by evaluating family dinnertime rituals at the intersection between the family social environment and pediatric type 1 diabetes mellitus management. Method Participants were 77 children and adolescents aged 6 to 18 years and their mothers from a larger study of child and parental challenges related to managing the treatment regimen and correlates of adherence. SEM was used to test a model of maternal reports of the family social environment as exogenous variables with mealtime rituals and child hemoglobin A1c levels as endogenous variables. The bootstrapping procedure and the Bollen-Stine bootstrapped χ test were then applied to test the stability and appropriateness of this model. Results Using SEM, the final model had robust goodness-of-fit indicators and revealed that the family social environment characteristics of control and cohesion were related to mealtime rituals, which was associated with hemoglobin A1c levels. The bootstrapping procedure indicated that the parameter estimates were very stable, thus lending greater credence to the model. The Bollen-Stine approach provided evidence that the entire hypothesized model was not significantly different from the model derived from bootstrapping. Conclusions This investigation offers a practical demonstration of the bootstrapping technique and the Bollen-Stine approach for testing models on smaller samples in SEM. These techniques may be used with relatively small samples, which are common in developmental/behavioral pediatrics and pediatric psychology research.

OVER THE PAST 40 YEARS, INSUFFICIENT SLEEP DURATION AMONG ADOLESCENTS HAS MARKEDLY INCREASED, WHEREBY TODAY ONLY ABOUT 33% OF teens are getting the recommended 9 hours of sleep.1 Concurrent with this rise in short sleep duration is the epidemic of obesity.2 Obesity in children and adolescents is a growing health concern because of its adverse impact on metabolism, blood pressure, respiratory disease, and quality of life,3 as well as its association with adult obesity and chronic illnesses, including cardiovascular diseases, cancer, musculoskeletal disease, and gastrointestinal disease.4,5,6 A number of studies have suggested that there is a link between sleep loss and weight gain in adults.7–9 For children, this finding has been consistent across large samples studied in various countries10,11 and in prospective studies.12 Studies with older children or adolescents have found the relationship between short sleep duration and obesity for males but not for females.13–15 Physiologic studies have shown that sleep deprivation may influence weight through effects on appetite, physical activity, and/or thermoregulation.16,17 Experimental reductions in sleep duration have been hypothesized to alter metabolic rate or to affect the levels of appetite regulatory hormones, leptin and ghrelin.16–21 An association between insufficient sleep and increased caloric intake has been demonstrated in some,22 but not other,23 studies. Differences in the literature may relate to differences in experiment design. Understanding the association between insufficient sleep and obesity in the population has been limited by a paucity of research that has quantified both energy intake and sleep duration in individuals studied in their native environments. Thus, it is unclear whether the mechanisms that mediate sleep loss and energy balance are through appetitive pathways, changes in energy expenditure, or altered metabolism. In this study, we examined the association between weekday sleep duration and energy consumption in adolescents aged 16 to 19 years studied in their natural environment. Using rigorously collected multiple-pass 24-hour food recalls and objectively measured sleep duration from wrist actigraphy, we tested the hypothesis that shorter sleep is associated with altered nutrient intake, including altered proportions of caloric intake from fats, carbohydrates, and snacks.

Objective To examine the association between observer ratings of physical attractiveness and weight preoccupation for female adolescents, and to explore any ethnic differences between Caucasian, African-American, and Hispanic females. Methods Normal-weight female adolescents who had participated in the National Longitudinal Study of Adolescent Health in-home Wave II survey were included (n = 4,324). Physical attractiveness ratings were made in vivo by interviewers. Using logistic regression models stratified by ethnicity, the associations between observer-rated attractiveness and weight preoccupation were examined after controlling for demographics, measured body mass index (BMI) and psychosocial factors. Results Caucasian female adolescents perceived as being more attractive reported significantly greater weight preoccupation compared with those rated as being less attractive. Observed attractiveness did not relate to weight preoccupation among African-American or Hispanic youth when controlling for other factors. Conclusions For Caucasian female adolescents, being perceived by others as more attractive may be a risk factor for disordered eating.

Objective To provide 1-year outcomes for a randomized controlled trial of a behavioral-educational intervention for the primary prevention of osteoporosis among 247 preadolescent girls. Methods Girl Scout troops were randomly assigned to one of two intervention groups-a group comprising girls only (n = 73) and girls with their mothers (n = 94)-and a healthy-lifestyles control group (n = 80). Multilevel (hierarchical) models were employed to account for clustering of girls within troops. Results Among girls who met the recommended levels of Ca at baseline, those in the intervention were significantly more likely to maintain or improve their intake at follow-up compared to controls. No significant group differences were found for changes in WBPA. Conclusions A behavioral intervention for the primary prevention of osteoporosis holds promise for maintaining adequate Ca intake among preadolescent females.