Identifying implementation barriers and facilitators in an integrated behavioral health training program to improve workforce development.

Integrated behavioral health (IBH) in pediatric primary care settings can improve access to needed care and outcomes. Behavioral Health Workforce Education and Training (BHWET) programs can better prepare the workforce and support improved care access. This case study identified factors that impede and facilitate the implementation of practice-based training in a BHWET program using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Surveys were administered to BHWET trainees and primary care partners to assess stakeholder perspectives on field-based training processes. Qualitative data were extracted from surveys and trainee clinical logs. Providers reported high levels of satisfaction with IBH care training experiences. Data analysis identified several implementation facilitators and barriers. Implementation facilitators were associated with two EPIS outer context factors (leadership and collaboration) and one inner context factor (partner staffing). Identified barriers were associated with two inner context factors (organizational characteristics and data collection). Although the facilitators and barriers identified in this study were program specific, they have relevance for similar programs. Barriers identified at the organizational level reflect those identified in the research literature and provide insights for university programs regarding factors that must be considered when integrating IBH training components in primary care settings.

Federally funded Behavioral Health Workforce Education and Training (BHWET) programs can better prepare the workforce and support integrated behavioral health (IBH) care in primary care settings. Using evaluation data gathered from primary care providers and trainees at partner clinics, this case study identified barriers that posed challenges to increasing behavioral health care for patients with identified needs, as well as factors that facilitated care. Barriers identified at the organizational level within partner clinics reflect those identified in the research literature and provide insights for medical professionals on factors they should consider when integrating behavioral health in primary care settings.

Recruitment feasibility and dietary and behavioral patterns in toddlers with ASD: Preliminary results from the Autism Eats program.

BACKGROUND: Problematic mealtime behaviors and inadequate diet quality are pressing concerns for children with autism spectrum disorder (ASD). This study aimed to evaluate recruitment feasibility and baseline outcomes of the Autism Eats program for children under 3 years with ASD. METHODS: Recruitment feasibility was assessed through reach and participation rates. The Healthy Eating Index (HEI-2015) scores were calculated from 3-day food records. Problematic mealtime behaviors were assessed with the Brief Autism Mealtime Behavior Inventory. Parental feeding practices were assessed using the Child Feeding Questionnaire. Anthropometric measurements of children and parents were taken. Weight-for-length percentiles were calculated based on the CDC growth charts. Descriptive statistics, one-sample t-tests, and Spearman's rho correlations were used for data analysis. RESULTS: Of the contacted dyads, 74 % agreed to participate. All 51 enrolled dyads completed baseline survey (100 %), and 98 % completed 3-day food records and anthropometric measurements. Significantly higher problematic mealtime behaviors were observed, compared to the reference (e.g., Total score 55.7 vs. 32.5; p < .001). Children with ASD exhibited lower HEI-2015 scores than national data (e.g., Total score 59 vs. 62). A large proportion of the children (29 %) had a weight-for-length ≥ 95th percentile. Several significant associations were found among mealtime behaviors, diet quality, parental feeding practices, and weight status. CONCLUSION: Recruitment was highly feasible, and the findings suggest that early nutrition intervention may hold promise in addressing problematic mealtime behaviors and promoting healthier dietary habits in young children with ASD. CLINICAL TRIAL REGISTRATION: This trial has been registered at www. CLINICALTRIALS: gov (NCT05194345).

A Digital Cognitive-Physical Intervention for Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Pharmacotherapy has been the primary treatment for ADHD, supplemented by behavioral interventions. Digital and exercise interventions are promising nonpharmacologic approaches for enhancing the physical and psychological health of children with ADHD. However, the combined impact of digital and exercise therapies remains unclear. OBJECTIVE: The aim of this study was to determine whether BrainFit, a novel digital intervention combining gamified cognitive and exercise training, is efficacious in reducing ADHD symptoms and executive function (EF) among school-aged children with ADHD. METHODS: This 4-week prospective randomized controlled trial included 90 children (6-12 years old) who visited the ADHD outpatient clinic and met the diagnostic criteria for ADHD. The participants were randomized (1:1) to the BrainFit intervention (n=44) or a waitlist control (n=46) between March and August 2022. The intervention consisted of 12 30-minute sessions delivered on an iPad over 4 weeks with 3 sessions per week (Monday, Wednesday, and Friday after school) under the supervision of trained staff. The primary outcomes were parent-rated symptoms of attention and hyperactivity assessed according to the Swanson, Nolan, and Pelham questionnaire (SNAP-IV) rating scale and EF skills assessed by the Behavior Rating Inventory of Executive Function (BRIEF) scale, evaluated pre and post intervention. Intention-to-treat analysis was performed on 80 children after attrition. A nonparametric resampling-based permutation test was used for hypothesis testing of intervention effects. RESULTS: Among the 145 children who met the inclusion criteria, 90 consented and were randomized; ultimately, 80 (88.9%) children completed the study and were included in the analysis. The participants' average age was 8.4 (SD 1.3) years, including 63 (78.8%) male participants. The most common ADHD subtype was hyperactive/impulsive (54/80, 68%) and 23 (29%) children had severe symptoms. At the endpoint of the study, the BrainFit intervention group had a significantly larger improvement in total ADHD symptoms (SNAP-IV total score) as compared to those in the control group (ß=-12.203, 95% CI -17.882 to -6.523; P<.001), owing to lower scores on the subscales Inattention (ß=-3.966, 95% CI -6.285 to -1.647; P<.001), Hyperactivity/Impulsivity (ß=-5.735, 95% CI -8.334 to -3.137; P<.001), and Oppositional Defiant Disorder (ß=-2.995, 95% CI -4.857 to -1.132; P=.002). The intervention was associated with significant reduction in the Metacognition Index (ß=-6.312, 95% CI -10.973 to -1.650; P=.006) and Global Executive Composite (ß=-5.952, 95% CI -10.214 to -1.690; P=.003) on the BRIEF. No severe intervention-related adverse events were reported. CONCLUSIONS: This novel digital cognitive-physical intervention was efficacious in school-age children with ADHD. A larger multicenter effectiveness trial with longer follow-up is warranted to confirm these findings and to assess the durability of treatment effects. TRIAL REGISTRATION: Chinese Clinical Trial Register ChiCTR2300070521; https://www.chictr.org.cn/showproj.html?proj=177806.

Helping Our Toddlers, Developing Our Children's Skills: Innovative Behavioral Management Training for Pediatric Residents.

This article describes the implementation of a behavioral management training program into pediatric and combined medicine-pediatric residencies at a large urban academic medical center in southwest Florida. We describe 2 modalities for training residents in effective behavioral modification strategies immediately useable in pediatric practice. Results indicate that residents significantly increased their knowledge of effective, evidence-based strategies and continued to use them 6 to 12 months following completion of the training.

A nutrition education intervention to improve eating behaviors of children with autism spectrum disorder: Study protocol for a pilot randomized controlled trial.

Autism spectrum disorder (ASD) is a developmental disorder that affects communication and social behaviors. Children with ASD often experience mealtime behavior challenges and selective eating behaviors. They also tend to consume fewer fruits and vegetables and more high-energy dense foods, compared to neurotypical peers. A nutrition intervention was designed to prevent the development of feeding disorders and the long-term negative health impacts associated with poor dietary intake. This randomized controlled trial will evaluate the feasibility and preliminary efficacy of the nutrition education intervention for children with ASD and their parents through the Early Intervention (EI) services. We will recruit EI providers and parent-child dyads (n = 48) from EI programs, and randomly assign them into Autism Eats intervention (n = 24) or enhance usual care (EUC) comparison group (n = 24). The Autism Eats is 10 weekly sessions delivered individually as part of EI, while the EUC group will receive only 1 nutrition education session and then weekly parent handouts. The Autism Eats integrates ASD-specific feeding strategies and behaviorally-focused intervention strategies such as goal setting. Feasibility indicators include reach/participation, attrition, completion, fidelity, compatibility, and qualitative participant feedback. Outcome measures include dietary intakes and mealtime behaviors of children with ASD using 3-day food records and a validated questionnaire, the Brief Autism Mealtime Behavior Inventory (BAMBI). We will examine whether there are differences in children's food intakes, variety, diet quality, and mealtime behaviors between Autism Eats and EUC groups at post-intervention and 5-month follow-up assessment. This study will provide critical data to inform a full-scale randomized controlled trial.

Pandemic parenting: A pilot study of in-person versus internet-DOCS K-5 for caregivers of school-age children with disruptive behaviors.

Behavioral parent training (BPT) programs are needed to address disruptive behavior disorders among school-aged children. Given the prolonged COVID-19 pandemic and associated mental health consequences, adapting BPTs to telehealth modalities is necessary to ensure continued services to children and families. This pilot study evaluated the use of a telehealth vs in-person modality to deliver the Developing Our Children's Skills K-5 (DOCS K-5) BPT. Participants were caregivers of children enrolled in elementary school exhibiting disruptive behaviors who participated in either in-person DOCS K-5 (n = 21) or internet-DOCS K-5 (i-DOCS K-5; n = 34). Pre- and post-intervention outcome measures were collected for child disruptive behavior, parenting stress, and caregiver symptoms of depression while consumer satisfaction was assessed at post-test only. Multiple linear and Poisson regression models were performed to assess the effect of session modality on the outcomes. Child disruptive behavior, parenting stress and depression, and consumer satisfaction scores were not significantly different across groups, even after adjusting for baseline characteristics. The results of this study provide preliminary evidence that the i-DOCS K-5 modality is as effective as the in-person program. Study findings may be beneficial to practitioners treating school-age children and utilizing telehealth interventions during the COVID-19 pandemic and onward.

COVID-19 Adaptations for Health Service Psychology Internship Training in a Medical School.

Health service psychology internship directors confronted a myriad of training challenges in response to the COVID-19 pandemic. Specifically, internship training directors were tasked with ensuring that interns received appropriate training in each of the nine profession-wide competency (PWCs) areas while also ensuring the physical and emotional well-being of staff and trainees. The purpose of this paper is to describe one internship's approach to adapting the nine PWCs during COVID-19 in the context of an academic medical setting. Successes and challenges associated with training adaptations in the context of each of the nine PWCs will be shared along with considerations for improving academic medical training programs' ability to support interns' educational goals and training requirements throughout and following the COVID-19 pandemic.

A nonrandomized trial of a behavioral parent training intervention for parents with children with challenging behaviors: In-person versus internet-HOT DOCS.

Behavioral parent training (BPT) programs are the first-line interventions for childhood disruptive behaviors. In light of the COVID-19 pandemic, adapting these programs to telehealth modalities is necessary to ensure continued services to children and families. This study evaluates the use of telehealth versus in-person modality to deliver the Helping Our Toddlers, Developing Our Children's Skills (HOT DOCS) BPT. The study design was quasi-experimental with two nonequivalent groups: in-person HOT DOCS (n = 152) and internet-HOT DOCS (n = 46). Participants were caregivers of children ages 2-5 exhibiting disruptive behaviors. Pre- and post-intervention outcome measures were collected for child disruptive behavior and parenting stress and post-test only for consumer satisfaction. Multiple linear and Poisson regression models were performed to assess the effect of class modality on the outcomes. Child disruptive behavior and parenting stress post-test scores for in-person and telehealth groups were not significantly different, even after adjusting for baseline characteristics. Consumer satisfaction scores were significantly more positive for the in-person group. The results of this study provide preliminary evidence for the i-HOT DOCS modality as being as effective as the in-person program. Study findings may be beneficial to practitioners utilizing telehealth interventions during the COVID-19 pandemic and onward.

Diet quality in an ethnically diverse sample of children and adolescents with autism spectrum disorder compared with nationally representative data.

BACKGROUND: Children with developmental disabilities are at an increased risk of unhealthy eating habits, which may contribute to compromised growth and development. Children with autism spectrum disorder (ASD) exhibit unique risk factors for unhealthy dietary patterns, including sensory issues and cognitive rigidity at mealtimes. OBJECTIVE: This cross-sectional study examined diet quality in a sample of children with ASD in Florida compared to nationally representative National Health and Nutrition Examination Survey (NHANES) 2009-2014/2013-2014 data using the Healthy Eating Index-2015 (HEI-2015). METHODS: A 24-h food record was completed by 41 parents of children with ASD aged 2-17 years, and food and beverage items consumed by each child were reported per standardized 24-h recall protocol. Two models were used to compare mean total and component HEI-2015 scores to NHANES means: (1) comparing means for our full sample to published NHANES means for children aged 2-18 years and (2) a matched model with subjects matched 1:1 by age, gender, race/ethnicity, and parent education level. RESULTS: HEI component scores were significantly lower (poorer) in children with ASD for whole fruit, total vegetables, dairy, total protein foods, and seafood and plant protein. Whole grains, fatty acids, added sugars, and refined grains scores were higher (better) in our sample. However, total HEI scores and HEI scores for all 13 components were similar among children with ASD and the matched cases from the NHANES data. CONCLUSIONS: There are potential discrepancies in diet quality between children with ASD and general population. Further research with a larger sample size, reporting both total and component HEI scores, is needed.

Early History, Mealtime Environment, and Parental Views on Mealtime and Eating Behaviors among Children with ASD in Florida.

This study was a cross-sectional study to examine problematic mealtime behaviors among children with autism spectrum disorder (ASD) in Florida. Forty-one parents completed a 48-item survey. The mean age of their children was 8.1 years and 73% were male. The data were divided and compared by age group: Ages 2⁻6, 7⁻11, and 12⁻17. Data from the 3- to 6-year-old children were extracted and compared with the references from Provost et al. (2010). There were age differences in eating difficulties at home (p = 0.013), fast food restaurants (p = 0.005), and at regular restaurants (p = 0.016). The total mealtime behavior score was significantly higher in early childhood (p < 0.001) and mid-childhood (p = 0.005) than adolescents. More parents of ages 3⁻6 with ASD reported difficulties with breastfeeding (p < 0.01); concerns about eating (p < 0.001); difficulties related to mealtime locations (p < 0.05), craving certain food (p < 0.05), and being picky eaters (p < 0.01) compared to typically developing children. The total mealtime behavior score was significantly higher in children with ASD than typically developing children (p < 0.001). The results indicate that early childhood interventions are warranted and further research in adolescents is needed.

Attendance and implementation of strategies in a behavioral parent-training program: comparisons between English and Español programs.

Low levels of attendance and implementation of strategies in behavioral parent-training programs may limit their impact. The purpose of this study was to examine attendance and implementation across a behavioral parent-training program delivered in English and Español. Participants included parents (n = 739) of young children who attended a behavioral parent-training program. The mean number of sessions attended for the entire sample was 4.46 (SD = 1.66, range = 1-6) of six sessions, and the mean number of strategies implemented was 17.66 (SD = 11.43, range = 0-35) of a possible 35. There were no significant differences across the number of sessions attended among the participants in the English (M = 4.45) and Español versions (M = 4.48) of the course, t(737) = -0.20, p = .85. There also were no significant differences between the English (M = 17.97) and Español (M = 16.87) versions for the number of Tip Trackers completed, t(737) = 1.18, p = .24. Only child diagnosis predicted parent attendance in the English group. Implications for research and practice are discussed.

BMI and physical activity among at-risk sixth- and ninth-grade students, Hillsborough County, Florida, 2005-2006.

INTRODUCTION: During the past 3 decades, the number of overweight adolescents increased while adolescent engagement in physical activity decreased. We investigated the prevalence of overweight and physical activity levels among economically disadvantaged and minority middle- and high-school students in a school district in Florida. In particular, data on physical activity levels of middle-school students are limited and needed for prevention and intervention planning. In addition, because of state education policies, students in Florida are less likely than students nationally to enroll in physical education, placing them at a higher risk for decreased physical activity levels. METHODS: We used multivariate methodology to analyze physical activity levels among 526 students from 3 middle and 2 high schools in southwest Florida. RESULTS: Forty percent of students met criteria for overweight or obesity. Overall, less than 45% of students reported engaging in daily physical activity. Boys reported higher levels of physical activity than did girls, and a decline in physical activity levels was observed between grades 6 and 9, especially among minority girls (ie, African American and Latino). Lack of time was identified as the greatest barrier to engaging in physical activity. CONCLUSION: This study documents health disparities among minority students from economically disadvantaged backgrounds in an urban school district. Participation in daily physical activity was below recommended guidelines across grades. We found numerous barriers to engaging in physical activity, which will enable local education agencies to evaluate their current physical activity policies and identify alternative physical activities for these youth.

Adaptation of a behavioral parent-training curriculum for Hispanic caregivers: HOT DOCS Español.

This article presents the process utilized to adapt a behavioral parent-training curriculum for Hispanic caregivers from a program currently available in English. Throughout this process, a number of cultural and language elements were identified as needing to be modified to meet the needs of the Hispanic population served. Fidelity and fit were balanced to develop a curriculum acceptable to diverse Hispanic caregivers while also incorporating all the essential elements of a theory-based approach to training caregivers. The lessons learned from this adaptation may assist others in their attempts to meet the needs of Hispanic families.