The Feasibility of Screening for Sleep Problems in Early Childhood Education Programs.

OBJECTIVES: Assess the feasibility and staff experience of screening for behavioral sleep problems (BSP) and sleep disordered breathing (SDB) in early childhood education (ECE) settings; examine BSP/SDB prevalence and caregivers' knowledge/attitudes, perception of child sleep problems, and sleep health engagement in this sample. METHOD: Eight staff representatives from four ECE sites involved with sleep problem screening procedures within a larger RCT on ECE sleep health, discussed their experiences in a focus group; transcript content reviewed. A random subset of caregiver-child dyads (n = 59) from the four ECE sites completed sleep problem measures (BSP: Children's Sleep Habits Questionnaire, Short form [SF-CSHQ], Tayside Children's Sleep Questionnaire [TCSQ-sleep disturbance and difficulty] and SDB: Pediatric Sleep Questionnaire [PSQ], in addition to RCT measures (Parent Knowledge/Attitude/Self-efficacy/Beliefs survey and sleep health goals). Caregiver sleep health engagement was measured by the sleep health goals set. RESULTS: ECE staff reported sleep problem screening as self-explanatory and doable but sometimes administratively burdensome. BSPs were identified in 44% (SF-CSHQ) to 63% (TCSQ-sleep disturbance) of children; SDBs in 13%. Only 11% of caregivers endorsed their child having a sleep "difficulty" (TCSQ). Sleep health goals were set by 85% of caregivers; 63% employed educational materials' language. CONCLUSION: Sleep problem screening in ECE is feasible, and problems are elicited. While caregivers readily engage in setting healthy sleep goals, few endorse sleep as difficult. ECE education could improve caregiver understanding/recognition of sleep problems.

Emotion regulation as a complex system: A multi-contextual and multi- level approach to understanding emotion expression and cortisol reactivity among Chinese and US preschoolers.

Are children from "Eastern" cultures less emotionally expressive and reactive than children from "Western" cultures? To answer this, we used a multi-level and multi-contextual approach to understand variations in emotion displays and cortisol reactivity among preschoolers living in China and the United States. One hundred two preschoolers from China (N = 58; 55% males) and the United States (N = 44, 48% males) completed three (i.e., control, interpersonal-related, and achievement-related) emotion-challenging paradigms over 3 days. Behavioral emotion expressions were coded, and salivary cortisol was sampled 30 minutes before and across 90 minutes post-task. Without considering context, Chinese preschoolers displayed fewer levels of positive and negative emotion expressions relative to their United States counterparts. However, Chinese preschoolers displayed similar levels of expressions as their United States counterparts during an achievement-related challenge that is more salient to their sociocultural emphases and showed higher negative emotion expressions in this challenge, relative to other contexts. Moreover, only the achievement-related challenge elicited increased cortisol levels among Chinese preschoolers, and this was correlated with higher levels of negative expressions. For US preschoolers, no cortisol increase was observed in any challenging paradigms, nor was cortisol associated with emotional expressions. Findings counter prior notions that East Asian children are generally less emotionally expressive. Instead, an achievement-related challenge elicited higher emotion expression and cortisol reactivity among Chinese preschoolers, suggesting that children's emotion expression and biological reactivity may be most responsive to contexts salient to their socio-cultural environments. We discuss the importance of considering cultural contexts when studying emotion regulation. RESEARCH HIGHLIGHTS: Chinese preschoolers displayed lower overall positive and negative expressions relative to their US counterparts without considering situational contexts. Chinese preschoolers displayed similar levels of emotion expressions as their US counterparts during an achievement-related challenge salient to their social-cultural environment. Chinese preschoolers are particularly responsive to achievement-related challenges, relative to other emotion-challenging situations that are less culturally salient. No cortisol increase was observed in any of the emotion-challenging paradigms among US preschoolers. Children's emotion expression and biological reactivity may be most responsive to challenges relevant to their socio-cultural environments.

Are Preschoolers' Neurobiological Stress Systems Responsive to Culturally Relevant Contexts?

Adults are biologically responsive to context, and their responses to particular situations may differ across cultures. However, are preschoolers' biological systems also responsive to situational contexts and cultures? Here, we show that children's neurobiological stress responses, as indexed by salivary cortisol, are activated and responsive to psychosocial stressors relevant to their sociocultural emphases. By examining cortisol changes across different contexts among 138 preschoolers living in the United States, China, and Japan, we found that an achievement-related stressor elicited an increased cortisol response among Chinese preschoolers, whereas interpersonal-related stressors elicited an increased cortisol response among Japanese preschoolers. By contrast, U.S. preschoolers showed decreased cortisol responses after these stressors but consistently higher levels of anticipatory responses to separation at the beginning of each session. Our findings suggest that children's neurobiological stress systems may be a critical biological mechanism allowing societal-level cultural phenomena to be embodied in individual-level responses, even among preschoolers.

Early-Life Iron Deficiency Alters Glucose Transporter-1 Expression in the Adult Rodent Hippocampus.

BACKGROUND: Early-life iron deficiency (ID) impairs hippocampal energy production. Whether there are changes in glucose transporter (GLUT) expression is not known. OBJECTIVE: The aim of this study was to investigate whether early-life ID and the treatment iron dose alter brain regional GLUT expression in adult rats and mice. METHODS: In Study 1, ID was induced in male and female Sprague Dawley rat pups by feeding dams a 3-mg/kg iron diet during gestation and the first postnatal week, followed by treatment using low-iron [3-10 mg/kg; formerly iron-deficient (FID)-10 group], standard-iron (40-mg/kg; FID-40 group), or high-iron (400-mg/kg; FID-400 group) diets until weaning. The control group received the 40 mg/kg iron diet. GLUT1, GLUT3, hypoxia-inducible factor (HIF)-1α, and prolyl-hydroxylase-2 (PHD2) mRNA and protein expression in the cerebral cortex, hippocampus, striatum, cerebellum, and hypothalamus were determined at adulthood. In Study 2, the role of hippocampal ID in GLUT expression was examined by comparing the Glut1, Glut3, Hif1α, and Phd2 mRNA expression in adult male and female wild-type (WT) and nonanemic hippocampal iron-deficient and iron-replete dominant negative transferrin receptor 1 (DNTfR1-/-) transgenic mice. RESULTS: In Study 1, Glut1, Glut3, and Hif1α mRNA, and GLUT1 55-kDa protein expression was upregulated 20-33% in the hippocampus of the FID-10 group but not the FID-40 group, relative to the control group. Hippocampal Glut1 mRNA (-39%) and GLUT1 protein (-30%) expression was suppressed in the FID-400 group, relative to the control group. Glut1 and Glut3 mRNA expression was not altered in the other brain regions in the 3 FID groups. In Study 2, hippocampal Glut1 (+14%) and Hif1α (+147%) expression was upregulated in the iron-deficient DNTfR1-/- mice, but not in the iron-replete DNTfR1-/- mice, relative to the WT mice (P < 0.05, all). CONCLUSIONS: Early-life ID is associated with altered hippocampal GLUT1 expression in adult rodents. The mouse study suggests that tissue ID is potentially responsible.

Consequences of 'tiger' parenting: a cross-cultural study of maternal psychological control and children's cortisol stress response.

Parenting strategies involving psychological control are associated with increased adjustment problems in children. However, no research has examined the extent to which culture and psychological control predict children's stress physiology. We examine cultural differences in maternal psychological control and its associations with children's cortisol. Chinese (N = 59) and American (N = 45) mother-child dyads participated in the study. Mothers reported on psychological control. Children's cortisol was collected during a stressor and two indices of Area Under the Curve (AUC) were computed: AUCg which accounts for total output, and AUCi, which captures reactivity. Results indicate that Chinese mothers reported higher levels of psychological control and Chinese children had higher levels of AUCg than their American counterparts. Across both cultures, psychological control was significantly associated with increased cortisol levels as indexed by AUCg. There were no associations for AUCi. Finally, mediation analyses demonstrated that psychological control fully explained cultural differences in children's cortisol stress response as indexed by AUCg.

Promoting Sleep Health Among Families of Young Children in Head Start: Protocol for a Social-Ecological Approach.

Inadequate or poor quality sleep in early childhood impairs social-emotional and cognitive function via effects on the developing brain and increases obesity risk via hormonal and endocrine effects. The prevalence of short sleep duration, behavioral sleep problems, and sleep-disordered breathing among children aged 3 to 5 years is 20% to 50%. Healthy sleep habits increase sleep duration and prevent behavioral sleep problems. Awareness of sleep-disordered breathing symptoms leads to its timely treatment. We designed a study that aims to empower families whose children are in early childhood programs with the knowledge and skills needed to obtain healthy sleep and to recognize a sleep problem. We used the social-ecological framework to guide individual, interpersonal, organizational, community, and policy interventions. This study builds on the Sweet Dreamzzz, Inc, Early Childhood Sleep Education Program (ECSEP) in Head Start. A stepped-wedge-cluster randomized trial will test effects on child, parent, and classroom outcomes; a policy evaluation will assess the impact of knowledge-translation strategies. The study has 3 aims. The first is to adapt educational materials into multimedia formats and build the capacity of Head Start agencies to implement the study. The second aim is to enroll 540 parent-child dyads in a primary prevention trial of sleep health promotion in Head Start and to analyze effects on children's sleep duration (primary outcome); parents' knowledge, attitudes, self-efficacy, and behavior; and children's sleep difficulties. The third aim is to conduct a secondary prevention feasibility study of screening and guidance for sleep problems. Secondary outcomes are changes in classroom behaviors and policies. Integrating sleep health literacy into early childhood programs could affect the life-course development of millions of children.

The impact of culture on physiological processes of emotion regulation: a comparison of US and Chinese preschoolers.

Cognitive determinants of emotion regulation, such as effortful control, have been hypothesized to modulate young children's physiological response to emotional stress. It is unknown, however, whether this model of emotion regulation generalizes across Western and non-Western cultures. The current study examined the relation between both behavioral and questionnaire measures of effortful control and densely sampled, stress-induced cortisol trajectories in U.S. and Chinese preschoolers. Participants were 3- to 5- year-old children recruited from the United States (N = 57) and Beijing, China (N = 60). Consistent with our hypothesis, U.S. children showed a significant negative relation between maternal-rated inhibitory control and both cortisol reactivity and recovery. However, this was not replicated in the Chinese sample. Children in China showed a significant positive relation between maternal-rated attentional focusing and cortisol reactivity that was not seen in the U.S. Results suggest that children who reside in Western and non-Western cultures have different predictors of their emotion-related stress response.

Rectal prolapse in older children associated with behavioral and psychiatric disorders.

PURPOSE: Rectal prolapse (RP) beyond infancy is challenging, and despite surgical correction, recurrences are not uncommon, suggesting that underlying contributing processes may have a role. This study highlights a previously poorly recognized relationship between RP in older children and behavioral/psychiatric disorders (BPD). We describe the incidence of recurrence and use of behavioral, psychological and physical therapeutic tactics in a multidisciplinary approach to pediatric RP. METHODS: A retrospective 20-year review of RP in children >3 years of age was adopted. Charts were reviewed for gastrointestinal, connective tissue, and BPD conditions, incidence of recurrence, and therapies employed including surgery, behavioral, and physical therapy. RESULTS: 45 patients were included, ranging from 3 to 18 years of age; 29 males. Thirty-seven underwent surgery. Six of the 45 were excluded as they had gastrointestinal or connective tissue conditions placing them at risk for prolapse. Over half (21/39, 53%) had BPD. Slightly more than half of patients had a recurrence, but there was no increased risk in those with associated BPD. While all 21 underwent some therapy for their BPD, over the past 5 years we have enrolled eight of these patients into a program of behavioral and/or physical therapy with all reporting reductions in frequency and severity of prolapse after initiating pelvic floor strengthening, behavior modification, and biofeedback, and avoidance of surgery in three. CONCLUSIONS: This study highlights an important group of pediatric patients with RP that may well benefit from a combination of behavioral therapy, physical therapy as well as surgical intervention to obtain the most optimal outcome.

Diagnosis and management of ADHD in children.

Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder in children, and the prevalence is increasing. Physicians should evaluate for ADHD in children with behavioral concerns (e.g., inattention, hyperactivity, impulsivity, oppositionality) or poor academic progress using validated assessment tools with observers from several settings (home, school, community) and self-observation, if possible. Physicians who inherit a patient with a previous ADHD diagnosis should review the diagnostic process, and current symptoms and treatment needs. Coexisting conditions (e.g., anxiety, learning, mood, or sleep disorders) should be identified and treated. Behavioral treatments are recommended for preschool-aged children and may be helpful at older ages. Effective behavioral therapies include parent training, classroom management, and peer interventions. Medications are recommended as first-line therapy for older children. Psychostimulants, such as methylphenidate and dextroamphetamine, are most effective for the treatment of core ADHD symptoms and have generally acceptable adverse effect profiles. There are fewer supporting studies for atomoxetine, guanfacine, and clonidine, and they are less effective than the psychostimulants. Height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence should be recorded at follow-up visits.

Iron Deficiency and Sleep/Wake Behaviors: A Scoping Review of Clinical Practice Guidelines-How to Overcome the Current Conundrum?

Current evidence suggests that iron deficiency (ID) plays a key role in the pathogenesis of conditions presenting with restlessness such as attention deficit hyperactivity disorder (ADHD) and restless legs syndrome (RLS). In clinical practice, ID and iron supplementation are not routinely considered in the diagnostic work-up and/or as a treatment option in such conditions. Therefore, we conducted a scoping literature review of ID guidelines. Of the 58 guidelines included, only 9 included RLS, and 3 included ADHD. Ferritin was the most frequently cited biomarker, though cutoff values varied between guidelines and depending on additional factors such as age, sex, and comorbidities. Recommendations surrounding measurable iron biomarkers and cutoff values varied between guidelines; moreover, despite capturing the role of inflammation as a concept, most guidelines often did not include recommendations for how to assess this. This lack of harmonization on the interpretation of iron and inflammation biomarkers raises questions about the applicability of current guidelines in clinical practice. Further, the majority of ID guidelines in this review did not include the ID-associated disorders, ADHD and RLS. As ID can be associated with altered movement patterns, a novel consensus is needed for investigating and interpreting iron status in the context of different clinical phenotypes.

Iron supplementation dose for perinatal iron deficiency differentially alters the neurochemistry of the frontal cortex and hippocampus in adult rats.

BACKGROUND: Long-term prefrontal cortex (PFC)- and hippocampus-based cognitive deficits are the sequelae of perinatal iron deficiency, despite iron supplementation starting in the newborn period. Whether high-dose iron supplementation prevents these deficits is yet to be determined. METHODS: Perinatal iron deficiency was induced in rat pups using a low-iron (3 mg/kg diet) diet during gestation until postnatal day (P)8. Iron was supplemented using a standard (40 mg/kg diet) or a 10-fold higher (400 mg/kg diet) iron-containing diet until P21. PFC and hippocampal neurochemistry was determined using in vivo (1)H nuclear magnetic resonance (NMR) spectroscopy at 9.4 Tesla on P90. RESULTS: Both standard and 10-fold higher iron supplementation doses corrected anemia and brain iron deficiency by P21. The neurochemical profile of the PFC in both supplementation groups was comparable with the control group. In the hippocampus, standard-dose iron supplementation resulted in lower concentrations of N-acetylaspartate (NAA) and phosphoethanolamine (PE) and higher concentrations of N-acetylaspartylglutamate (NAAG) and glycerophosphocholine + phosphocholine (GPC + PC). High-dose iron supplementation resulted in lower PE and higher GPC + PC concentrations. CONCLUSION: The iron supplementation dose for perinatal iron deficiency differentially alters the neurochemical profile of the PFC and hippocampus in adults. The neurochemical changes suggest altered glutamatergic neurotransmission, hypomyelination, and abnormal phospholipid metabolism in the formerly iron-deficient (FID) hippocampus.

Behavior and monoamine deficits in prenatal and perinatal iron deficiency are not corrected by early postnatal moderate-iron or high-iron diets in rats.

Developmental iron deficiency anemia (IDA) causes brain and behavioral deficits in rodent models, which cannot be reversed when treated at periods equivalent to later infancy in humans. This study sought to determine whether earlier iron treatment can normalize deficits of IDA in rats and what iron dose is optimal. The offspring of dams with IDA during gestation were cross-fostered at postnatal d (P) 8 to dams receiving diets with 1 of 3 iron concentrations until weaning (P21): 0.003-0.01 g/kg [totally iron deficient (TID)]; 0.04 g/kg [formerly iron deficient (FID-40)]; or 0.4 g/kg (FID-400). Always iron-sufficient control dams (CN-40) received a 0.04-g/kg iron diet. At P21, TID pups received a 0.01 g iron/kg diet; all others received a 0.04 g iron/kg diet. Hematocrit and brain iron and monoamine concentrations were assessed at P21 and P100. Pup growth, development, activity, object recognition, hesitancy, and watermaze performance were evaluated. Regional brain iron was restored by iron treatment. Regional monoamine and metabolite concentrations were elevated in FID-40 rats and reduced in FID-400 and TID rats compared with CN-40 rats. FID-40 offspring had motor delays similar to TID during lactation and FID-400 rats had elevated thigmotaxis similar to TID rats at P25 and P100 in the spatial watermaze. In conclusion, iron treatment at P8 in rats did not normalize all monoamine or behavioral measures after early IDA. Moderate iron treatment improved adult behavior, but higher iron treatment caused brain and behavioral patterns similar to TID in the short and long term.

Maternal serum ferritin concentration is positively associated with newborn iron stores in women with low ferritin status in late pregnancy.

Iron deficiency (ID) is common in pregnant women and infants, particularly in developing countries. The relation between maternal and neonatal iron status remains unclear. This study considered the issue in a large sample of mother-newborn pairs in rural southeastern China. Hemoglobin (Hb) and serum ferritin (SF) were measured in 3702 pregnant women at ≥37 wk gestation and in cord blood of their infants born at term (37-42 wk gestation). Maternal anemia (Hb <110 g/L) was present in 27.5% and associated with maternal SF <20 µg/L in 86.9%. Only 5.6% of neonates were anemic (Hb <130 g/L) and 9.5% had cord-blood SF <75 µg/L. There were low-order correlations between maternal and newborn iron measures (r = 0.07-0.10 for both Hb and SF; P ≤ 0.0001 due to the large number). We excluded 430 neonates with suggestion of inflammation [cord SF >370 µg/L, n = 208 and/or C-reactive protein (CRP) >5 mg/L, n = 233]. Piecewise linear regression analyses identified a threshold for maternal SF at which cord-blood SF was affected. For maternal SF below the threshold of 13.6 µg/L (ß = 2.4; P = 0.001), cord SF was 0.17 SD lower than in neonates whose mothers had SF above the threshold (167 ± 75 vs. 179 ± 80 µg/L). The study confirmed that ID anemia remains common during pregnancy in rural southeastern China. Despite widespread maternal ID, however, iron nutrition seemed to meet fetal needs except when mothers were very iron deficient. The impact of somewhat lower cord SF on iron status later in infancy warrants further study.

Long-term neuroendocrine effects of iron-deficiency anemia in infancy.

INTRODUCTION: Iron-deficiency anemia (IDA) is recognized to have long-lasting effects on neurodevelopment, but there is little research on neuroendocrine systems. METHODS: This study examined the effects of IDA in early or later infancy on plasma cortisol and prolactin stress-response patterns for 1 h after a venipuncture and catheter placement in 10-y-old healthy Chilean children. Children identified with IDA at 6 mo (IDA-6; n = 13) or 12 mo (IDA-12; n = 24) and who were iron sufficient (IS) at other infancy time points were compared to children who were IS at all time points during infancy (n = 23). All children received at least 6 mo of oral iron treatment in infancy. RESULTS: At 10 y of age, IDA-6 and IDA-12 children demonstrated altered cortisol response patterns; both showed a more immediate decline and IDA-12 children showed a blunted curvature as compared to IS children. IDA-12 children showed significantly lower cortisol levels at 30 and 45 min after venipuncture and catheter placement than did IS children. There were no significant differences for stress-responsive plasma prolactin patterns between groups. DISCUSSION: The results indicate that having IDA during infancy is associated with long-term neuroendocrine effects on stress-responsive cortisol patterns.

Effects of a Sleep Health Education Program for Children and Parents on Child Sleep Duration and Difficulties: A Stepped-Wedge Cluster Randomized Clinical Trial.

Importance: Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration. Objective: To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program. Design, Setting, and Participants: This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data. Interventions: A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school. Main Outcomes and Measures: Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used. Results: The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months. Conclusions and Relevance: The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects. Trial Registration: ClinicalTrials.gov Identifier: NCT03556462.

Altered dopaminergic profile in the putamen and substantia nigra in restless leg syndrome.

Restless leg syndrome (RLS) is a sensorimotor disorder. Clinical studies have implicated the dopaminergic system in RLS, while others have suggested that it is associated with insufficient levels of brain iron. To date, alterations in brain iron status have been demonstrated but, despite suggestions from the clinical literature, there have been no consistent findings documenting a dopaminergic abnormality in RLS brain tissue. In this study, the substantia nigra and putamen were obtained at autopsy from individuals with primary RLS and a neurologically normal control group. A quantitative profile of the dopaminergic system was obtained. Additional assays were performed on a catecholaminergic cell line and animal models of iron deficiency. RLS tissue, compared with controls, showed a significant decrease in D2R in the putamen that correlated with severity of the RLS. RLS also showed significant increases in tyrosine hydroxylase (TH) in the substantia nigra, compared with the controls, but not in the putamen. Both TH and phosphorylated (active) TH were significantly increased in both the substantia nigra and putamen. There were no significant differences in either the putamen or nigra for dopamine receptor 1, dopamine transporters or for VMAT. Significant increases in TH and phosphorylated TH were also seen in both the animal and cell models of iron insufficiency similar to that from the RLS autopsy data. For the first time, a clear indication of dopamine pathology in RLS is revealed in this autopsy study. The results suggest cellular regulation of dopamine production that closely matches the data from cellular and animal iron insufficiency models. The results are consistent with the hypothesis that a primary iron insufficiency produces a dopaminergic abnormality characterized as an overly activated dopaminergic system as part of the RLS pathology.

Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis.

OBJECTIVE: To examine the efficacy of an enhanced intervention (EI) compared to standard care (SC) in increasing daily water intake and fluid goal adherence in children seeking treatment for retentive encopresis. METHODS: Changes in beverage intake patterns and fluid adherence were examined by comparing 7-week diet diary data collected during participation in the EI to achieved data for families who had previously completed the SC. RESULTS: Compared to children in SC (n = 19), children in the EI (n = 18) demonstrated a significantly greater increase in daily water intake from baseline to the conclusion of treatment ( p ≤ .001), and were four and six times more likely to meet fluid targets in Phases 1 (Weeks 3-4) and 2 (Weeks 5-6) of fluid intervention, respectively (both p ≤ .001). CONCLUSIONS: Enhanced education and behavioral strategies were efficacious in increasing children's intake of water and improving fluid adherence. Future research should replicate the findings in a prospective randomized clinical trial to discern their effectiveness.

Brief report: Adherence to fluid recommendations in children receiving treatment for retentive encopresis.

OBJECTIVE: Limited data are available regarding whether children being treated for retentive encopresis are adherent to recommendations to increase their daily fluid intake. The purpose of this study was to examine fluid adherence in children who received treatment for retentive encopresis. METHODS: A retrospective chart review was performed using diet diary data for 26 children (ages 3-12) who completed a group behavioral intervention for retentive encopresis. RESULTS: Mean daily intake of clear fluid increased significantly during treatment and children relied primarily on water and juice to make this dietary change. However, adherence rates to clear fluid goals were <50%. CONCLUSIONS: Children's increased clear fluid intake did not equate to high fluid adherence. Children's high juice consumption is concerning as it could place them at risk for other negative health consequences. Future research should examine whether enhanced fluid education and use of behavior change strategies yield higher fluid adherence.

Individual differences in cortisol responses to fear and frustration during middle childhood.

The purpose of this study was to examine individual differences in the activation and regulation of the hypothalamic-pituitary-adrenal (HPA) axis in prepubertal children after exposure to two different stress modalities and to evaluate the utility of an individual differences approach to the examination of HPA axis functioning. After a 30-min controlled baseline period, 73 7-year-olds (40 boys and 33 girls) were randomly assigned to a validity check condition or one of two experimental tasks designed to elicit fear or frustration. This was followed by a 60-min controlled regulation phase. A total of 17 saliva samples were collected, including 12 poststress samples at 5-min intervals. There was a significant stress modality effect, with children exposed to the fear condition reaching peak cortisol levels at 25min poststress and those exposed to the frustration condition reaching peak levels at 45min poststress. There was no difference in peak cortisol levels between the stress modalities. Individual variability across conditions was significant, with participants reaching peak levels as early as 10min poststress and as late as 60min poststress. Our data suggest that analysis of individual curves prior to making group-level comparisons may improve the explanatory power of HPA axis behavior models.