Management of Childhood Obesity-Time to Shift from Generalized to Personalized Intervention Strategies.

As a major public health concern, childhood obesity is a multifaceted and multilevel metabolic disorder influenced by genetic and behavioral aspects. While genetic risk factors contribute to and interact with the onset and development of excess body weight, available evidence indicates that several modifiable obesogenic behaviors play a crucial role in the etiology of childhood obesity. Although a variety of systematic reviews and meta-analyses have reported the effectiveness of several interventions in community-based, school-based, and home-based programs regarding childhood obesity, the prevalence of children with excess body weight remains high. Additionally, researchers and pediatric clinicians are often encountering several challenges and the characteristics of an optimal weight management strategy remain controversial. Strategies involving a combination of physical activity, nutritional, and educational interventions are likely to yield better outcomes compared to single-component strategies but various prohibitory limitations have been reported in practice. This review seeks to (i) provide a brief overview of the current preventative and therapeutic approaches towards childhood obesity, (ii) discuss the complexity and limitations of research in the childhood obesity area, and (iii) suggest an Etiology-Based Personalized Intervention Strategy Targeting Childhood Obesity (EPISTCO). This purposeful approach includes prioritized nutritional, educational, behavioral, and physical activity intervention strategies directly based on the etiology of obesity and interpretation of individual characteristics.

Integrating Behavioral and Primary Health Care in Rural Clinics: What Does Culture Have to Do with It?

Successful integration of health care in rural and underserved communities requires attention to power structures, trust, and disciplinary boundaries that inhibit team-based integration of behavioral and primary health care. This paper reports on perceived successes and ongoing challenges of integrating primary and behavioral health care from the perspectives of providers, community leaders, and community members. Data collection consisted of semi-structured qualitative interviews and focus groups conducted as part of a regional health equity assessment in northern Arizona. The authors explore barriers and successes in integrating health care in rural clinics using the perspective of a social ecological framework and the mediating role of culture. Differing expectations, differing professional areas, and interpersonal interactions were primary factors challenging movement toward integrated health care. Results suggest that providers and policymakers working toward health care integration should consider culture and interpersonal interaction as dynamic mediators, particularly in underserved and rural health care contexts.

Defining Optimal Care for Functional Gut Disorders - Multi-Disciplinary Versus Standard Care: A Randomized Controlled Trial Protocol.

BACKGROUND: Functional gastrointestinal disorders (FGIDs) are the commonest reason for gastroenterological consultation, with patients usually seen by a specialist working in isolation. There is a wealth of evidence testifying to the benefit provided by dieticians, behavioral therapists, hypnotherapists and psychotherapists in treating these conditions, yet they rarely form a part of the therapeutic team, and these treatment modalities are rarely offered as part of the therapeutic management. There has been little examination of different models of care for FGIDs. We hypothesize that multi-disciplinary integrated care is superior to standard specialist-based care in the treatment of functional gut disorders. METHODS: The "MANTRA" (Multidisciplinary Treatment for Functional Gut Disorders) study compares comprehensive multi-disciplinary outpatient care with standard hospital outpatient care. Consecutive new referrals to the gastroenterology and colorectal outpatient clinics of a single secondary and tertiary care hospital of patients with an FGID, defined by the Rome IV criteria, will be included. Patients will be prospectively randomized 2:1 to multi-disciplinary (gastroenterologist, gut-hypnotherapist, psychiatrist, behavioral therapist ('biofeedback') and dietician) or standard care (gastroenterologist or colorectal surgeon). Patients are assessed up to 12 months after completing treatment. The primary outcome is an improvement on a global assessment scale at the end of treatment. Symptoms, quality of life, psychological well-being, and healthcare costs are secondary outcome measures. DISCUSSION: There have been few studies examining how best to deliver care for functional gut disorders. The MANTRA study will define the clinical and cost benefits of two different models of care for these highly prevalent disorders. TRIAL REGISTRATION NUMBER: Clinicaltrials.govNCT03078634 Registered on Clinicaltrials.gov, completed recruitment, registered on March 13th 2017. Ethics and Dissemination: Ethical approval has been received by the St Vincent's Hospital Melbourne human research ethics committee (HREC-A 138/16). The results will be disseminated in peer-reviewed journals and presented at international conferences. Protocol version 1.2.

Collaborative Care of Attention Deficit Hyperactivity Disorder: An Innovative Partnership to Serve Rural Pediatric Patients.

Attention deficit hyperactivity disorder (ADHD) is a common behavioral health disorder in childhood that causes significant impairments in quality of life, home relationships, and school success. Despite a substantial evidence base and corresponding practice guidelines established by the American Academy of Pediatrics that support use of behavioral therapy to treat ADHD, affected patients infrequently receive therapy. This article will review the causes of underuse of behavioral therapy and methods to overcome these barriers such as integrating behavioral health care, thereby creating a pediatric patient-centered medical home. Additionally, a novel practice model of a behavioral health care collaboration being piloted in a rural pediatric office will be presented, including methods to screen, assess, and treat ADHD patients and families within the comfort of the primary care office.

Stories and Music for Adolescent/Young Adult Resilience During Transplant Partnerships: Strategies to Support Academic-Clinical Nurse Collaborations in Behavioral Intervention Studies.

Evidence-based nursing is in the forefront of healthcare delivery systems. Federal and state agencies, academic institutions, and healthcare delivery systems recognize the importance of nursing research. This article describes the mechanisms that facilitate nursing partnerships yielding high-level research outcomes in a clinical setting. A phase-II multicenter behavioral intervention study with pediatric stem cell transplant patients was the context of this academic/clinical research partnership. Strategies to develop and maintain this partnership involved a thorough understanding of each nurse's focus and barriers. A variety of communication plans and training events maximized preexisting professional networks. Academic/clinical nurses' discussions identified barriers to the research process, the most significant being role conflict. Communication and validation of benefits to each individual and institution facilitated the research process during challenging times. Establishing strong academic/clinical partnerships should lead to evidence-based research outcomes for the nursing profession, healthcare delivery systems, and patients and families.

Honoring the Past and Looking to the Future: Updates on Seminal Behavior Therapy Publications on Etiology and Mechanisms of Change.

This is the introduction to the first of two special issues in honor of the 50th anniversary of the Association for Behavioral and Cognitive Therapies. The goal of this issue is to pay tribute to prior seminal Behavior Therapy publications on etiology and mechanisms of change, to provide an updated review of important topics covered by these papers, and to make recommendations for the future. Each invited paper highlights a particular Behavior Therapy publication's contribution to our understanding and also provides an updated review or meta-analysis on the topic of the original paper. The topics covered here include mechanisms of etiology such as preparedness, reinforcement, and control. In terms of papers on mechanisms of change, we cover mechanisms related to extinction including fear activation, within- and between-session extinction, safety behaviors, and variables related to imagery. In addition, we examine principles related to generalization of learning and optimizing the impact of homework. With the two special issues of Behavior Therapy, we hope to inspire additional research and discussion.

Finding harmony so the music plays on: pragmatic trial design considerations to promote organizational sustainment of an empirically-supported behavior therapy.

BACKGROUND: Pragmatic trials of empirically-supported behavior therapies may inform clinical and policy decisions concerning therapy sustainment. This retrospective trial design paper describes and discusses pragmatic features of a hybrid type III implementation/effectiveness trial of a contingency management (CM) intervention at an opioid treatment program. Prior reporting (Hartzler et al., J Subst Abuse Treat 46:429-438, 2014; Hartzler, Subst Abuse Treat Prev Policy 10:30, 2015) notes success in recruiting program staff for voluntary participation, durable impacts of CM training on staff-level outcomes, provisional setting implementation of the intervention, documentation of clinical effectiveness, and post-trial sustainment of CM. METHODS/DESIGN: Six pragmatic design features, and both scientific and practical bases for their inclusion in the trial, are presented: (1) a collaborative intervention design process, (2) voluntary recruitment of program staff for therapy training and implementation, (3) serial training outcome assessments, with quasi-experimental staff randomization to either single or multiple baseline assessment conditions, (4) designation of a 90-day period immediately after training in which the setting implemented the intervention on a provisional basis, (5) inclusive patient eligibility for receipt of the CM intervention, and (6) designation of two staff as local implementation leaders to oversee clinical/administrative issues in provisional implementation. DISCUSSION: Each pragmatic trial design feature is argued to have contributed to sustainment of CM. Contributions implicate the building of setting proprietorship for the CM intervention, culling of internal staff expertise in its delivery, iterative use of assessment methods that limited setting burden, documentation of setting-specific clinical effectiveness, expanded penetration of CM among staff during provisional implementation, and promotion of setting self-reliance in the oversight of sustainable implementation procedures. It is hoped this discussion offers ideas for how to impact local clinical and policy decisions via effective behavior therapy dissemination.

Behavioral interventions for office-based care: interventions in the family medicine setting.

The practice of family medicine includes the care of many patients with mental health or behavior change needs. Patients in mild to moderate distress may benefit from brief interventions performed in the family physician's office. Patients in more extreme distress may be helped by referral to behavioral health clinicians for short-term or open-ended therapies. Electronic therapy programs and bibliotherapy are also useful resources. The transition to the patient-centered medical home model may allow for more widespread integration of behavioral health care clinicians into primary care, in person and through telemental health care. Integrated care holds the promise of improved access, greater effectiveness of behavioral health service provision, and enhanced efficiency of primary care for patients with behavioral health care needs.

A simple methodology for piloting and evaluating mass media interventions: an exploratory study.

To develop effective mass media health campaigns it is important to explore the behaviour-change techniques that make campaigns more or less effective. This exploratory study observed the behaviour-change techniques employed in two current healthy eating television programmes, and mapped these techniques onto key theoretical frameworks. Interviews were then conducted with six participants who watched the programmes, to identify which techniques were perceived to be more and less effective and to identify any disjunctures between the behaviour-change techniques used in the programmes and factors perceived by the participants to be particularly influential upon their healthy eating. The two programmes were found to use similar behaviour-change techniques, with a heavy reliance on providing general health motivation. Interviews revealed that participants perceived several specific barriers to eating healthily, felt the need for more specific guidance and emphasised the importance of identifying with the role models used in the programmes. Recommendations for future mass media health campaigns include the need to educate individuals about how to overcome specific barriers that they might face when trying to eat a healthy diet and to include a wider range of role models to encourage the audience to identify with the programme participants.

Practical strategies for treating postsurgical bowel dysfunction.

Postsurgical bowel dysfunction is a potential complication for patients undergoing ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis. In our setting, these patients are referred to the Anorectal Physiology Clinic at the Townsville Hospital, Queensland, for comprehensive behavioral therapy. The goals of the therapy are as follows: improve stool consistency, improve control over stool elimination, decrease fecal frequency and rectal urgency, fecal continence without excessive restrictions on food and fluid intake, and increase quality of life. This article outlines our holistic approach and specific treatment strategies, including assessment, education, support and assistance with coping, individualized dietary and fluid modifications, medications, and exercise. Biofeedback is used to help patients improve anal sphincter and pelvic floor muscle function and bowel elimination habits. Information on the biofeedback component of the treatment program will be described in a subsequent article.

Adapted Couple Therapy (ACT) for pathological gamblers: a promising avenue.

The study of the effectiveness of treatment for pathological gambling constitutes a field that is still largely unexplored. To date, the models assessed primarily target the individual and include little or no involvement of the family circle. Yet, the deleterious effects of gambling on loved ones and especially spouses are well recognized. Further, the addition of a couple modality to individual treatment has been shown to be effective on many levels in the treatment of substances use disorders. This article therefore proposes a critical review of (1) the literature providing a better understanding of the complex interactions between the couple relationship and pathological gambling, (2) studies on the effects of couple therapies on gamblers and their partners. We then present the therapeutic model developed by our team of clinician-researchers in collaboration with actors from Québec clinical settings: Adapted Couple Therapy (ACT) for pathological gamblers. In the Québec context, this model will serve as a complement to an individual cognitive-behavioral treatment model that has been proven effective and is employed throughout the Canadian province. The assessment of couple therapies could reveal avenues of solutions to better assist pathological gamblers who tend to drop-out of treatment and relapse.

Behavioral therapies at the primary care level: the current state of knowledge.

Urinary incontinence, the complaint of any involuntary loss of urine, is a troubling symptom experienced by men and women of all ages. Options for treatment include a range of behavioral, pharmacologic, and surgical therapies. Behavioral therapies, such as dietary modification, pelvic floor muscle training, and bladder training, are noninvasive, with little risk of side effects, and experts agree they should represent the first line of treatment whenever possible. These therapies can be initiated and monitored at the primary care level, thereby enhancing the accessibility of care for those affected. The purpose of this article is to methodically review what is and is not known about behavioral therapies, with attention to research needs. Although there is clear evidence for pelvic floor muscle training in women with urinary incontinence and modest evidence in men for a short time after radical prostatectomy, less is known about bladder training, prompted voiding, habit retraining, and timed voiding. Additional research is required to enhance our understanding of the comparative efficacy of behavioral interventions in specific populations. This research must take an increasingly long-term focus, given the potentially chronic nature of urinary incontinence.

Modification of pathological type A as worksite stress management and disease prevention intervention.

The importance of helping an employee to better cope with occupational stress as the aim of stress management interventions is presented. It particularly concerns the employees who have the poorest temperamental and personality potential for effective coping and should be the target of primary stress intervention and prevention. According to evidence, Type A workers are at risk of occupational stress and disease, especially when some personality features of Type A are accompanied by high reactivity. The concept of pathological Type A is introduced. The already existing programs of modifying Type A and the framework of a program based on the elements that have been established to be the most therapeutic for pathological Type A are presented.