Parenting Practices, Bedtime Routines, and Consistency: Associations with Pediatric Sleep Problems.

OBJECTIVES: Investigate the direct and moderating effects of daytime parenting practices on the relationship between bedtime routines and pediatric sleep problems. METHODS: A community sample of 407 parents with children 2-10 years old completed measures of parenting practices (i.e., laxness and over-reactivity) and bedtime routines (i.e., consistency and reactivity to changes in routines). Sleep problems (i.e., severity and signaled night waking) were assessed by a parent-report questionnaire and sleep diaries. RESULTS: Higher parenting laxness (ß = .13) and less bedtime routine consistency (ß = -.34) significantly predicted sleep problem severity. Laxness moderated the relationship between bedtime reactivity and sleep problem severity: when bedtime reactivity was high, higher parental laxness was associated with more severe sleep problems. CONCLUSIONS: Daytime parenting practices are important to consider when children are reactive to changes in bedtime routines, as permissive or inconsistent daytime parenting practices were found to be associated with more severe sleep problems. Future research should examine the effects of parenting practices and bedtime routines on problematic signaled night waking in a clinical sample of children.

Complex skills are required for new primary health care researchers: a training program responds.

BACKGROUND: Current dimensions of the primary health care research (PHC) context, including the need for contextualized research methods to address complex questions, and the co-creation of knowledge through partnerships with stakeholders - require PHC researchers to have a comprehensive set of skills for engaging effectively in high impact research. MAIN BODY: In 2002 we developed a unique program to respond to these needs - Transdisciplinary Understanding and Training on Research - Primary Health Care (TUTOR-PHC). The program's goals are to train a cadre of PHC researchers, clinicians, and decision makers in interdisciplinary research to aid them in tackling current and future challenges in PHC and in leading collaborative interdisciplinary research teams. Seven essential educational approaches employed by TUTOR-PHC are described, as well as the principles underlying the curriculum. This program is unique because of its pan-Canadian nature, longevity, and the multiplicity of disciplines represented. Program evaluation results indicate: 1) overall program experiences are very positive; 2) TUTOR-PHC increases trainee interdisciplinary research understanding and activity; and 3) this training assists in developing their interdisciplinary research careers. Taken together, the structure of the program, its content, educational approaches, and principles, represent a complex whole. This complexity parallels that of the PHC research context - a context that requires researchers who are able to respond to multiple challenges. CONCLUSION: We present this description of ways to teach and learn the advanced complex skills necessary for successful PHC researchers with a view to supporting the potential uptake of program components in other settings.

Children's Sleep During COVID-19: How Sleep Influences Surviving and Thriving in Families.

OBJECTIVE: The COVID-19 pandemic has the potential to disrupt the lives of families and may have implications for children with existing sleep problems. As such, we aimed to: (1) characterize sleep changes during the COVID-19 pandemic in children who had previously been identified as having sleep problems, (2) identify factors contributing to sleep changes due to COVID-19 safety measures, and (3) understand parents' and children's needs to support sleep during the pandemic. METHODS: Eighty-five Canadian parents with children aged 4-14 years participated in this explanatory sequential, mixed-methods study using an online survey of children's and parents' sleep, with a subset of 16 parents, selected based on changes in their children's sleep, participating in semi-structured interviews. Families had previously participated in the Better Nights, Better Days (BNBD) randomized controlled trial. RESULTS: While some parents perceived their child's sleep quality improved during the COVID-19 pandemic (14.1%, n = 12), many parents perceived their child's sleep had worsened (40.0%, n = 34). Parents attributed children's worsened sleep to increased screen time, anxiety, and decreased exercise. Findings from semi-structured interviews highlighted the effect of disrupted routines on sleep and stress, and that stress reciprocally influenced children's and parents' sleep. CONCLUSIONS: The sleep of many Canadian children was affected by the first wave of the COVID-19 pandemic, with the disruption of routines influencing children's sleep. eHealth interventions, such as BNBD with modifications that address the COVID-19 context, could help families address these challenges.

Correction to: Predicting Dropout from Children's Mental Health Services: Using a Need-Based Defnition of Dropout.

The original version of this article was unfortunately published with an error in Table 2. The confidence intervals listed in Table 2 were published incorrectly. The correct version of confidence intervals in Table 2 should read as below.

Predicting Dropout from Children's Mental Health Services: Using a Need-Based Definition of Dropout.

Dropout from children's mental health services has negative impacts on children, families and service providers. To target interventions aimed to reduce dropout, it is essential to predict individuals who drop out. This study compares predictors of dropout using a novel need-based definition, to existing definitions of dropout. Children (N = 650; 61% male) aged 5-13 attended five children's mental health agencies in Ontario. A mixed effects logistic regression was used to model binary outcome variables (i.e., dropout or treatment completion), for each definition of dropout. Using the need-based definition, older child age, lower child problem presentation, higher child risk behaviors, higher caregiver needs, and more child strengths predicted an increased likelihood of dropout. The need-based definition results in different predictors of dropout than existing definitions in the literature. High caregiver needs was the only predictor of dropout across all definitions. Caregiver needs represent a prospective target when distributing interventions aimed to reduce dropout.

Area-Level Variation in Children's Unmet Need for Community-Based Mental Health Services: Findings from the 2014 Ontario Child Health Study.

There is limited empirical evidence documenting the magnitude and correlates of area-level variability in unmet need for children's mental health services. Research is needed that identifies area-level characteristics that can inform strategies for reducing unmet need in the population. The study purpose is to: (1) estimate area-level variation in children's unmet need for mental health services (using Service Areas as defined by the Ontario Ministry of Children and Youth Services), and (2) identify area-level service arrangements, and geographic and population characteristics associated with unmet need. Using individual-level general population data, area-level government administrative data and Census data from Ontario, Canada, we use multilevel regression models to analyze unmet need for mental health services among children (level 1) nested within Service Areas (level 2). The study finds that 1.64% of the reliable variance in unmet need for mental health services is attributable to between-area differences. Across areas, we find that Service Areas with more agencies had a lower likelihood of unmet need for mental health services. Compared to other Service Areas, Toronto had much lower likelihood of unmet need compared to the rest of Ontario. Rural areas, areas with unsatisfactory public transport, and areas with higher levels of socio-economic disadvantage had a higher likelihood of unmet need for mental health services. These findings identify challenges in service provision that researchers, policymakers and administrators in children's mental health services need to better understand. Policy implications and potential Service Area strategies that could address equitable access to mental health services are discussed.

Predicting patterns of service utilization within children's mental health agencies.

BACKGROUND: Some children with mental health (MH) problems have been found to receive ongoing care, either continuously or episodically. We sought to replicate patterns of MH service use over extended time periods, and test predictors of these patterns. METHODS: Latent class analyses were applied to 4 years of visit data from five MH agencies and nearly 6000 children, 4- to 13-years-old at their first visit. RESULTS: Five patterns of service use were identified, replicating previous findings. Overall, 14% of cases had two or more episodes of care and 23% were involved for more than 2 years. Most children (53%) were seen for just a few visits within a few months. Two patterns represented cases with two or more episodes of care spanning multiple years. In the two remaining patterns, children tended to have just one episode of care, but the number of sessions and length of involvement varied. Using discriminant function analyses, we were able to predict with just over 50% accuracy children's pattern of service use. Severe externalizing behaviors, high impairment, and high family burden predicted service use patterns with long durations of involvement and frequent visits. CONCLUSIONS: Optimal treatment approaches for children seen for repeated episodes of care or for care lasting multiple years need to be developed. Children with the highest level of need (severe pathology, impairment, and burden) are probably best served by providing high intensity services at the start of care.

An Exploratory Study of Children's Mental Health Providers' Perspectives on the Transition to Adult Care for Young Adolescents in the Canadian Context.

PURPOSE: Many youth who receive specialized children's mental health treatment might require additional treatment as young adults. Little is known about how to prepare these youth for transitions to adult care. DESIGN AND METHODS: This study gained perspectives from children's mental health providers (n = 10) about the process of caring for younger adolescents (aged 12-15) with mental health problems (e.g., depression, anxiety), who might require mental health services after age 18. Providers were asked about their clients' future mental health needs and the possibility of transition to adult care. RESULTS: Using Grounded Theory analysis, an over-arching theme was providers' reluctance to consider the transition process for their younger clients (<16 years old). This stemmed from uncertainty among providers about: (1) who [which youth] will need adult mental health services; (2) when this discussion would be appropriate; and (3) what adult services would be available. CONCLUSIONS AND PRACTICE IMPLICATIONS: Findings indicate a lack of treatment capacity within children's mental health to routinely monitor youth as they approach the age of transfer (18 years old). In the absence of routine monitoring (post-treatment), it may be difficult to predict who will need adult care. A comprehensive evaluation of existing follow-up practices, in children's mental health and beyond, is needed to identify strategies for ensuring adolescents with recurring conditions receive optimal transition care.

"I Think He Will Have It Throughout His Whole Life": Parent and Youth Perspectives About Childhood Mental Health Problems.

Children's mental health (CMH) problems can be long-lasting. Even among children and youth who receive specialized CMH treatment, recurrence of problems is common. It is unknown whether youth and their parents view the possibility of future mental health problems. This has important implications for how CMH services should be delivered. This grounded theory study gained perspectives from youth (aged 12-15 years) who received CMH treatment ( n = 10) and their parents ( n = 10) about the expected course of CMH problems. Three disorder trajectories emerged: (a) not chronic, (b) chronic and persistent, and (c) chronic and remitting, with the majority of youth falling in the third trajectory. A gap in available services between CMH and adult care was perceived by parents, leaving them either help hopeful or help hungry about their child's future care. Improving care for youth with ongoing mental health problems is needed to minimize costs to families and the system.

Modeling Parenting Programs as an Interim Service for Families Waiting for Children's Mental Health Treatment.

Using a discrete choice conjoint experiment, we explored the design of parenting programs as an interim strategy for families waiting for children's mental health treatment. Latent class analysis yielded 4 segments with different design preferences. Simulations predicted the Fast-Paced Personal Contact segment, 22.1% of the sample, would prefer weekly therapist-led parenting groups. The Moderate-Paced Personal Contact segment (24.7%) preferred twice-monthly therapist-led parenting groups with twice-monthly lessons. The Moderate-Paced E-Contact segment (36.3%), preferred weekly to twice-monthly contacts, e-mail networking, and a program combining therapist-led sessions with the support of a computerized telephone e-coach. The Slow-Paced E-Contact segment (16.9%) preferred an approach combining monthly therapist-led sessions, e-coaching, and e-mail networking with other parents. Simulations predicted 45.3% of parents would utilize an option combining 5 therapist coaching calls with 5 e-coaching calls, a model that could reduce costs and extend the availability of interim services. Although 41.0% preferred weekly pacing, 58% were predicted to choose an interim parenting service conducted at a twice-monthly to monthly pace. The results of this study suggest that developing interim services reflecting parental preferences requires a choice of formats that includes parenting groups, telephone-coached distance programs, and e-coaching options conducted at a flexible pace.

Continuity of Care in Children's Mental Health: Parent, Youth and Provider Perspectives.

Continuity of care, how individuals experience care over time as coherent and linked, is considered an ethical principle of care. While continuity has been examined extensively in the adult health literature, there is a paucity of studies examining continuity in children's mental health care. Using qualitative semi-structured interviews with parents, youth, and service providers, the current study found themes and issues unique to this healthcare context, such as coordination across sectors; risks to discontinuity, such as transitions; and consequences of discontinuity, such as parents acting as liaisons. Implications of these findings are discussed.

What do preschool-aged children do when they wake at night: toward an understanding of night-waking behaviors among community children.

Little is known about behaviors displayed by preschoolers during night-waking. Mothers (N = 203) of community preschoolers completed the Children's Night-waking Behavior Scale and measures of night-waking, co-sleeping, and daytime behavior. Approximately 1/2 of wakings involved calling out, getting out of bed, and requests for comfort; 1/4 involved activity, fear, or instrumental requests. Specific associations between night-waking behaviors, night-waking, and bedtime and daytime behaviors were observed; associations were not consistent across child gender and age. For example, comfort requests were associated with mothers' perceptions of sleep as problematic in 4- and 5-year-old children only (ρ = .42); activity requests were associated with hyperactivity for boys only (r = .36). Understanding night-waking requires consideration of factors beyond parenting, such as children's behavior, age, and gender.

Continuity of Care in Children's Mental Health: development of a measure.

A new measure, Continuity of Care in Children's Mental Health (C3MH), is presented. The study involved item generation, pre-testing, pilot testing, and validation. The C3MH was administered to 364 parents recruited from 13 children's mental health agencies in Ontario, Canada. The measure includes five scales supported by confirmatory factor analysis. Scale validity was supported through analyses of relationships with established measures of satisfaction, problem severity, and therapeutic alliance, as well as through known-group differences. The results of a pilot youth-report version (N = 57) are presented. The C3MH will be a useful tool for assessing improvements in system integration.

Early nap cessation in young children as a correlate of language and psychosocial outcomes: Evidence from a large Canadian sample.

OBJECTIVES: Most children stop napping between 2 and 5years old. We tested the association of early nap cessation (ie, children who stopped before their third birthday) and language, cognition functioning and psychosocial outcomes. METHODS: Data were from a national, longitudinal sample of Canadian children, with three timepoints. Children were 0-to-1 year old at T1, 2-to-3 years old at T2, and 4-to-5 years old at T3. Early nap cessation was tested as a correlate of children's psychosocial functioning (cross-sectionally and longitudinally), cognitive function (longitudinally), and language skills (longitudinally). There were 4923 children (50.9% male; 90.0% White) and their parents in this study who were included in the main analyses. Parents reported on demographics, perinatal and developmental variables, child functioning, and child sleep. Children completed direct assessments of receptive language and cognitive ability. Nap cessation, demographic, and developmental-control variables were tested as correlates of cross-sectional and longitudinal outcomes using linear regression (with a model-building approach). RESULTS: Early nap cessation correlated with higher receptive language ability (ß = 0.059 ± 0.028) and lower anxiety (ß = -0.039 ± 0.028) at T3, after controlling for known correlates of nap cessation, nighttime sleep, and other sociodemographic correlates of the outcomes. Cognitive ability, hyperactivity-inattention, and aggression were not correlated with nap cessation. CONCLUSIONS: Early nap cessation is related to specific benefits (ie, better receptive language and lower anxiety symptoms). These findings align with previous research. Future research should investigate differences associated with late nap cessation and in nap-encouraging cultures, and by ethnicity.

Cross-sectional and prospective associations between sleep health and multimorbidity in middle to older-aged adults: Results from the Canadian Longitudinal Study on Aging (CLSA).

OBJECTIVE: Middle-aged to older adults often exhibit the co-existence of poor sleep health and multimorbidity. We examined cross-sectional and prospective associations of pooled index of sleep health with prevalent and incident multimorbidity in the framework of an ongoing cohort study in Canada. METHODS: Data were from approximately 24,000 individuals from the Canadian Longitudinal Study on Aging (CLSA), an ongoing national study of community-dwelling adults aged 45-85 years at baseline. Multimorbidity was defined as two or more chronic conditions out of five major condition categories. Sleep variables included sleep duration, quality, initiation, maintenance, and excessive daytime sleepiness, which were combined into an index using pooled approaches. Weighted logistic regression models were computed for each index with additional age- and sex-stratified analyses. RESULTS: Higher sleep index scores, indicating poorer sleep health, were observed in females and younger age groups (ages 45-54 and 55-64). In cross-sectional analysis, the fully adjusted model showed that a 1-unit increase in pooled scores was significantly associated with 1.48 higher odds (95 % CI = 1.38, 1.58; p < 0.001) of prevalent multimorbidity at baseline. Similarly, the prospective analysis indicated significant changes in incident multimorbidity with pooled index scores in the fully adjusted model (OR = 1.33; 95 % CI = 1.20, 1.48; p < 0.001). CONCLUSION: The pooled sleep index introduced in this study may offer a novel, concise, and comprehensive approach to assessing sleep health among middle-aged and older adults. Those in these age groups experiencing poorer sleep health are at a greater risk of prevalent multimorbidity, as well as of developing multimorbidity over time.

Who sleeps well in Canada? The social determinants of sleep health among middle-aged and older adults in the Canadian Longitudinal Study on Aging.

OBJECTIVES: Sleep health inequities likely contribute to disparities in health outcomes. Our objective was to identify social determinants of sleep health among middle-aged/older adults in Canada, where prior evidence is limited. METHODS: We analyzed cross-sectional data from the Canadian Longitudinal Study on Aging, a survey of over 30,000 community-dwelling adults aged 45-85years. Self-reported measures included sleep duration, sleep satisfaction, and sleep efficiency. We explored associations between sleep measures and social determinants of health. We used modified Poisson regression to estimate prevalence ratios for sleep satisfaction and sleep efficiency, and linear regression for sleep duration. Estimates were adjusted for all social, lifestyle, and clinical covariates. We explored effect modification by sex. RESULTS: Of the 11 social determinants explored, all were significantly associated with at least one domain of sleep health. These associations were reduced to 9 variables with adjustment for all social variables, and 7 with further adjustment for lifestyle and clinical covariates, including differences by sex, age, education, marital status, employment, race/ethnicity, and sexual orientation. Better sleep health in >1 domain was observed among males, older age groups (65 and older), higher income groups, the retired group, and homeowners with adjustment for social variables, and only in males and older age groups with additional adjustment for lifestyle and clinical variables. Only sleep duration associations were modified by sex. CONCLUSIONS: Sleep health disparities among Canadian adults exist across socioeconomic gradients and racial/ethnic minority groups. Poor sleep health among disadvantaged groups warrants increased attention as a public health problem in Canada.

Randomized trial of distance-based treatment for young children with discipline problems seen in primary health care.

OBJECTIVE: Many parents of preschool-age children have concerns about how to discipline their child but few receive help. We examined the effects of a brief treatment along with usual care, compared with receiving usual care alone. Patients. Parents (N = 178) with concerns about their 2- to 5-year olds' discipline were recruited when they visited their family physician at 1 of 24 practices. METHODS: After completing mailed baseline measures, parents were randomly assigned to receive usual care or the Parenting Matters intervention along with usual care. Parenting Matters combined a self-help booklet with two calls from a telephone coach during a 6-week treatment period. Follow-up assessments were completed at 7 weeks post-randomization, and 3 and 6 months later. RESULTS: Behaviour problems (Eyberg Child Behaviour Inventory) decreased significantly more in the Parenting Matters condition compared with Usual Care alone, based on a significant time by treatment group effect in intent-to-treat, growth curve analyses (P = 0.033). The Parenting Matters group also demonstrated greater and more rapid improvement than in usual care alone in terms of overall psychopathology (Child Behaviour Checklist, P = 0.02), but there were no group differences in parenting. The overall magnitude of group differences was small (d = 0.15 or less). CONCLUSION: A brief early intervention combining a self-help booklet and telephone coaching is an effective way to treat mild behaviour problems among young children. This minimal-contact approach addresses the need for interventions in primary health care settings and may be a useful component in step-care models of mental health.