Training students to become responsive therapists: implications from a sequential mixed-methods study on situations that therapists find challenging.

OBJECTIVE: To draw implications for training of therapist responsiveness from a sequential mixed-methods study on challenging clinical situations. METHOD: Study 1: online survey mapping frequency and perceived difficulty of 15 clinical situations in a representative sample of psychologists. Study 2: online survey mapping frequency and perceived difficulty of 19 clinical situations among therapists in child and adolescent psychiatry. Study 3: focus group study exploring the situations identified through study 1 and 2. RESULTS: Study 1 and 2 showed that ratings of each situation varied between individuals and context. Study 3 showed that the degree to which a situation was challenging was described as depending on the characteristics of the therapist and the context. Experientially, challenging situations were characterized by lacking access to necessary information, falling short, and disturbing arousal. Perceiving therapeutic opportunities despite the challenging nature of the situation, collegial support, self-knowledge, and engagement were important resources. CONCLUSION: Six implications of the results from the three studies for training of responsiveness are discussed: (1) building self-awareness and conceptualization skills; (2) personalizing training; (3) transforming disturbing arousal into engagement; (4) being exposed to a broad range of clinical situations; (5) training on commonly encountered situations; and (6) building tolerance for uncertainty and capacity to seek support.

Lifestyle intervention for children and adolescents with severe obesity - results after one year. / Livsstilsbehandling av barn og ungdom med alvorlig fedme ­ resultater etter ett år.

BACKGROUND: Lifestyle interventions for children and adolescents with severe obesity show moderate short-term effects on weight reduction internationally. We evaluated treatment results at two Norwegian specialist outpatient clinics. MATERIAL AND METHOD: We performed a retrospective analysis of data from children and adolescents between 3 and 18 years of age collected in 2012-2016. Children and adolescents with severe obesity who attended their one-year follow-up were included. We included in the analyses the following body weight measures: percentage overweight as defined by the International Obesity Task Force cut-off (% IOTF-25); BMI standard deviation score; waist circumference standard deviation score; and body fat percentage at the start of treatment and at one-year follow-up. RESULTS: Of 568 children and adolescents who started treatment, 416 (73 %) attended the one-year check-up. A total of 271 (65 %) patients achieved a reduction in %IOTF-25, while 228 patients (55 %) reduced their BMI standard deviation score. There was a statistically significant mean reduction of all four registered body weight measurements. Altogether 54 of 325 children (17 %) changed category from severe obesity to obesity, 8 (2 %) went from severe obesity to overweight, and 8 of 91 children (9 %) changed category from obesity to overweight or normal weight. The proportion of participants with a reduction of more than 5 % in %IOTF-25 was 43 % (177/416), and a reduction in BMI standard deviation score of more than 0.25 was observed in 23 % (95/416) of participants. Girls responded on average more poorly to the intervention than boys. There was no clinically significant difference in results between the treatment centres. INTERPRETATION: After one year of treatment of children and adolescents with severe obesity in two specialist healthcare centres, we found a moderate mean reduction in weight, waist circumference and body fat percentage, but with large interindividual variation.

Differences in sleep patterns between patients with anorexia nervosa and healthy controls: a cross-sectional study.

BACKGROUND: Sleep difficulties are common in patients with anorexia nervosa (AN), but objective assessments have mostly been performed in hospital and laboratory settings. We aimed to identify differences in sleep patterns between patients with AN and healthy controls (HC) in their free-living environments, and potential associations between sleep patterns and clinical symptoms in patients with AN. METHODS: This cross-sectional study analyzed 20 patients with AN prior to them starting outpatient treatment and 23 HC. Sleep patterns were measured objectively using an accelerometer (Philips Actiwatch 2) for 7 consecutive days. Average sleep onset, sleep offset, total sleep time, sleep efficiency, wake after sleep onset (WASO) and mid-sleep awakenings lasting ≥ 5 min were compared between patients with AN and HC using nonparametric statistical analyses. Associations of sleep patterns with body mass index, eating-disorder symptoms, eating-disorder-associated impairment, and symptoms of depression were assessed in the patient group. RESULTS: Compared with HC, patients with AN had shorter WASO [median (interquartile range(IQR)): 33 vs. 42 min], but a longer average duration of mid-sleep awakenings lasting ≥ 5 min [median (IQR): 9 vs. 6 min, p = 0.006] and had more nights with no sleep (six nights in four patients with AN vs. zero nights in HC). There were no differences between patients with AN and HC regarding other sleep parameters and no significant correlations between sleep patterns and clinical parameters in patients with AN. However, HC presented a Intraindividual variability pattern that was closer to a normal distribution, whereas patients with AN tended to either have very regular or large variability in sleep onset time (AN; n = 7 < 25th percentile and n = 8 > 75th percentile vs. HC; n = 4 < 25 percentile and n = 3 > 75th percentile) during the week of sleep recordings. CONCLUSION: Patients with AN seem to spend more time awake during the night and have more nights without sleep than do HC, even though their average weekly sleep duration did not differ from that in HC. The intraindividual variability in sleep pattern seems to be an important parameter that should be assessed when studying sleep in patients with AN. Trial registration ClinicalTroals.gov. Identifier: NCT02745067. Registered: April 20, 2016.

Sleep disturbances are common in patients with anorexia nervosa. However, most studies that have assessed sleep patterns in this patient group have used either sleep questionnaires or sleep-measuring instruments in surroundings different from where they usually sleep. This study compared sleep patterns between patients with anorexia nervosa and healthy individuals without an eating disorder in their home environments using an accelerometer over 1 week. The accelerometer used was a sleep-monitoring instrument that looks similar to a wristwatch and records sleep patterns using movement and light sensors, and is easy to use in the home environment. We observed that patients with anorexia nervosa on average had longer periods awake during the night, as well as more awake nights compared with healthy individuals. Nevertheless, the average sleep duration during the week of sleep recordings was similar in the two groups. However, we also observed considerable variations in sleep patterns among the patients with anorexia nervosa, ranging from very regular to very irregular sleep patterns. We therefore believe that variability in the sleep patterns among patients with anorexia nervosa is an important parameter that should be included when studying sleep in these patients.

Polysomnographic comparison of sleep in children with obesity and normal weight without suspected sleep-related breathing disorder.

Short sleep and obstructive apneas/hypopneas have been shown to be associated with childhood obesity. Still, few studies have compared sleep in children with obesity, without suspected sleep disordered breathing and normal weight peers by objective sleep measures and compared results with subjective parent assessment of sleep. Children with obesity aged 7-13 years (N = 44) and a matched group of normal weight children (N = 42) completed clinical polysomnography (Embla A10 Recording System). Parents scored their children's sleep on the Children's Sleep Habits Questionnaire (CSHQ). Mann-Whitney U tests were used to compare groups. There was a higher obstructive apnea/hypopnea index (AHI) (median obesity = 1.20 vs. median normal  = 0.66; z = -1.33, U = 560.50, p = 0.002) and number of oxygen desaturation events per hour (median obesity = 0.7 vs. median normal  = 0.2; z = -3.45, U = 402.50, p = 0.001) in the children with obesity compared to children with normal weight. The children with obesity had a significantly longer sleep duration (median obesity 8:50 h = vs. median normal = 8:32 h; z = -2.05, U = 687.00, p = 0.041), longer stage N2 sleep (median obesity = 87 min vs. median normal = 52 min; z = -2.87, U = 576.50, p = 0. 004) and shorter REM sleep (median obesity = 94 min vs. median normal = 121 min; z = 5.05, U = 1477.00, p ≤ .001). No differences were observed for time in sleep stage N1 and N3, wake time after sleep onset or the total arousal index . Further, no group differences were found on the CSHQ sleep-disordered breathing sub-scale (p = 0.399). The children with obesity demonstrated significantly more mild to moderate sleep disordered breathing than children with normal weight, although this was not corroborated by parent report.

Weekday time in bed and obesity risk in adolescence.

INTRODUCTION: Sleep curtailment is associated with obesity in children, but few studies have investigated this relationship in a longitudinal sample of adolescents. The aim of the present study was to examine the longitudinal association between weekday time in bed (TIB) at age 10-13 and overweight at age 16-19. METHODS: Adolescents and their parents (N = 3025 families), participating in a longitudinal population-based study, completed questionnaires assessing habitual bedtime and wake time on weekdays, weight and height, socioeconomic status (SES), internalizing mental health problems and disturbed eating. Two surveys were administered with a 6-year interval (T1 and T2). A one-way analysis of covariance (ANCOVA) was performed examining the association between TIB and weight category 6 years later, with SES, internalizing problems and disturbed eating at baseline entered as covariates. Hierarchical and logistic regression analyses were used to assess TIB at age 10-13 years to as a predictor of body mass index (BMI) standardized deviation scores (SDS) and overweight status at age 16-19 adjusting for the same confounders and baseline BMI. RESULTS: A linear inverse relationship between TIB at age 10-13 and BMI category at age 16-19 was demonstrated by the ANCOVA, p < 0.001. Shorter TIB was related to higher weight, but the effect size was small (partial eta squared = 0.01). When adjusting for the included baseline confounders in the hierarchical regression model TIB significantly predicted later BMI SDS (ß = -0.039, p = 0.02). The adjusted logistic regression model showed that for each hour reduction of TIB at T1 the odds of being overweight/obese at T2 increased with a factor of 1.6. CONCLUSION: Shorter TIB was found to be a significant, yet modest, independent predictor of later weight gain in adolescence. The findings implicate that establishing healthy sleep habits should be addressed in prevention and treatment strategies for adolescent obesity.

The challenge of keeping it off, a descriptive systematic review of high-quality, follow-up studies of obesity treatments.

The aim of this systematic review is to answer the question: Is substantial, stable, and long-term weight loss a viable goal for adults with obesity? To answer this question, we conducted a broad systematic search of non-surgical and non-pharmacological obesity treatment studies with the following strict criteria: (a) minimum 3-year follow-up, (b) 5% body mass lost, (c) no continued interventions in the follow-up-period, (d) prospective design, and (e) less than 30% attrition from the start of the follow-up period. While the search revealed a very large number of published articles, only eight studies met the inclusion criteria. Several of the nonincluded studies report a majority of participants achieving satisfactory weight loss and little regain, especially among studies with continued interventions during the follow-up period. In contrast, the eight high-quality studies included in this study demonstrate a trend of weight regain towards pretreatment baseline. This review concludes that the majority of high-quality follow-up treatment studies of individuals with obesity are not successful in maintaining weight loss over time. The results suggest that excess weight can be lost but is likely regained over time, for the majority of participants.

Factors associated with low self-esteem in children with overweight.

OBJECTIVE: Low self-esteem is one of the main psychosocial factors related to childhood overweight. Yet not all overweight children are affected. Little is known about what characterises the group of overweight children with the lowest self-esteem. Our aim was to identify factors related to low domain-specific self-esteem in children with overweight/obesity. METHODS: Children (aged 10-13; N = 5,185) and parents from a large population-based sample completed the Eating Disturbance Scale, the Self-Perception Profile for Children, and questions about bullying and socio-economic status (SES). Parents reported the child's weight and height. 545 children with overweight/obesity were identified in the overall sample and selected for the current analyses. Self-esteem scores from this group were compared to scores from children with normal weight. Factors examined in relation to self-esteem in children with overweight/obesity were: age, gender, SES, disturbed eating, bullying, parents' evaluation of weight status and degree of overweight. RESULTS: Children with overweight scored significantly lower than normal-weight children on all self-esteem domains. Athletic competence and physical appearance were most impaired. Disturbed eating and bullying were related to low physical appearance as well as scholastic, social and athletic self-esteem. Being female, a pre-teen, having a higher BMI and being evaluated as overweight by parents were associated with lower satisfaction with physical appearance. CONCLUSIONS: Disturbed eating and bullying are significantly related to low self-esteem in the overweight group.