Variation in care for inpatients with avoidant restrictive food intake disorder leads to development of a novel inpatient clinical pathway to standardize care.

INTRODUCTION: There is limited evidence to guide management of patients with avoidant restrictive food intake disorder (ARFID) admitted for medical stabilization. We describe variations in inpatient care which led to the development of a multidisciplinary inpatient clinical pathway (ICP) to provide standardized management and examine differences after the ICP was implemented. METHODS: A retrospective review of patients with ARFID admitted to Adolescent Medicine, Gastroenterology, and General Pediatrics at a single academic center was conducted. We compare hospital utilization and use of consulting services during the pre-ICP (2015-2017) and post-ICP (2018-2020) periods. RESULTS: 110 patients were admitted with ARFID (n = 57 pre- vs. n = 53 post-ICP). Most presented with moderate/severe malnutrition (63% pre vs. 81% post; p = 0.11) and co-morbid anxiety and/or depression (74% pre vs. 92% post; p = 0.01). There was some variation in use of enteral tube feeding by service in both periods (p = 0.76 and p = 0.38, respectively), although overall use was consistent between periods (46% pre vs. 58% post; p = 0.18). Pre-ICP, use of the restrictive eating disorder protocol differed across services (p < 0.001), with only AM using it. Overall, utilization of the restrictive eating disorder protocol decreased from 16% pre-ICP to 2% post-ICP (p = 0.02). There was variation by service in psychiatry/psychology (range 82-100% by service; p = 0.09) and social work consultations (range 17-71% by service; p = 0.001) during the pre-ICP period, though variation was reduced in the post-ICP period (p = 0.99 and p = 0.05, respectively). Implementation of the ICP led to improvements in these consultative services, with all patients in the post-ICP period receiving psychiatry/psychology consultation (p = 0.05) and an increase in social work consults from 44 to 64% (p = 0.03). Nutrition consults were consistently utilized in both periods (98% pre vs. 100% post; p = 0.33). CONCLUSION: The ICP was developed to standardize inpatient medical stabilization for patients with ARFID. In this single center study, implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: there were improvements in the use of consulting services and a reduction in the use of the restrictive eating disorder protocol. The ICP demonstrates the potential to further standardize and improve care over time.

There is limited evidence to guide management of children and adolescents with Avoidant Restrictive Food Intake Disorder (ARFID) admitted for medical stabilization. The study describes the variation in inpatient care for ARFID, which led to the development of a multidisciplinary standardized inpatient clinical pathway (ICP). The ICP centers the experience of the patient and family with an emphasis on biopsychosocial support. Implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: There were improvements in the use of psychiatry/psychology and social work consulting services and a reduction in the use of the restrictive eating disorder protocol. Future research is needed to better understand the impact of the inpatient clinical pathway to improve care over time.

Pediatric hospital utilization for patients with avoidant restrictive food intake disorder.

BACKGROUND: Avoidant restrictive food intake disorder (ARFID) is a relatively new feeding and eating disorder added to the DSM-5 in 2013 and ICD-10 in 2018. Few studies have examined hospital utilization for patients with ARFID specifically, and none to date have used large administrative cohorts. We examined inpatient admission volume over time and hospital utilization and 30-day readmissions for patients with ARFID at pediatric hospitals in the United States. METHODS: Using data from the Pediatric Health Information System (PHIS), we identified inpatient admissions for patients with ARFID (by principal International Classification of Diseases, 10th Revision, ICD-10 diagnosis code) discharged October 2017-June 2022. We examined the change over time in ARFID volume and associations between patient-level factors (e.g., sociodemographic characteristics, co-morbid conditions including anxiety and depressive disorders and malnutrition), hospital ARFID volume, and hospital utilization including length of stay (LOS), costs, use of enteral tube feeding or GI imaging during admission, and 30-day readmissions. Adjusted regression models were used to examine associations between sociodemographic and clinical factors on LOS, costs, and 30-day readmissions. RESULTS: Inpatient ARFID volume across n = 44 pediatric hospitals has increased over time (ß = 0.36 per month; 95% CI 0.26-0.46; p < 0.001). Among N = 1288 inpatient admissions for patients with ARFID, median LOS was 7 days (IQR = 8) with median costs of $16,583 (IQR = $18,115). LOS and costs were highest in hospitals with higher volumes of ARFID patients. Younger age, co-morbid conditions, enteral feeding, and GI imaging were also associated with LOS. 8.5% of patients were readmitted within 30 days. In adjusted models, there were differences in the likelihood of readmission by age, insurance, malnutrition diagnosis at index visit, and GI imaging procedures during index visit. CONCLUSIONS: Our results indicate that the volume of inpatient admissions for patients with ARFID has increased at pediatric hospitals in the U.S. since ARFID was added to ICD-10. Inpatient stays for ARFID are long and costly and associated with readmissions. It is important to identify effective and efficient treatment strategies for ARFID in the future.

Recent studies indicate that Avoidant Restrictive Food Intake Disorder (ARFID) is a complex feeding and eating disorder often diagnosed in younger children. To date, there are no large studies using administrative data to examine hospital utilization or costs among patients with ARFID. In a geographically diverse cohort of pediatric hospitals in the United States, we found inpatient admissions for ARFID have increased over time and that ARFID is associated with long, costly stays and readmissions which has important implications for identifying efficient treatment strategies. Future studies are needed to explore effective and efficient treatment strategies and prevent readmissions in this patient population.

Factors affecting pediatric adherence to positive airway pressure: Patient- and caregiver-reported treatment barriers and sleep difficulties.

OBJECTIVE/BACKGROUND: Adherence to positive airway pressure (PAP) treatment among children and adolescents is often suboptimal. Little is understood about modifiable determinants of PAP adherence. We evaluated whether patient and caregiver-perceived treatment barriers (across behavioral, environmental, emotional, and physical domains), as well as insomnia severity, were associated with PAP adherence among youth with sleep disordered breathing (SDB). PATIENTS/METHODS: We conducted a retrospective review of 188 patients prescribed PAP, ages 2-19 years. At the clinical visit, PAP adherence was assessed via objective download/smartcard and patients and their caregivers completed validated standardized questionnaires on barriers to PAP adherence and sleep onset and maintenance difficulties. We tested predictors of PAP adherence using linear regression. RESULTS: On average, patients wore their PAP 2/3 of nights for 5.3 ± 3.4 h. Patients reported more barriers overall compared to caregivers, and specifically more behavioral and emotional barriers (e.g., over a third of patients reported they just want to forget about sleep apnea). After controlling for demographic/treatment characteristics, patient-reported barriers accounted for a significant proportion of the variance in percent nights used (51%) and average nightly use (42%). Greater difficulties with sleep maintenance predicted poorer PAP adherence (percent nights and nightly duration). CONCLUSIONS: Study findings suggest that assessment of both patient and caregiver-perceived barriers to PAP adherence, as well as evaluating for sleep maintenance concerns, may provide important treatment targets for promoting PAP adherence among youth. Results also support the potential benefit of a multi-disciplinary team-based approach to managing SDB and promoting PAP adherence.

Technology-Assisted Stepped-Care to Promote Adherence in Adolescents with Asthma: A Pilot Study.

To examine the feasibility, acceptability, and preliminary efficacy of a technology-assisted stepped-care behavioral intervention to improve adherence in adolescents with asthma. Thirty adolescents (Mage = 14.66, 53% male) with moderate to severe-persistent asthma completed daily adherence monitoring and medication reminders via a mobile app (Step 1). Participants with < 68% adherence during Step 1 received a telehealth behavioral intervention (Step 2). Twenty-six of 30 participants (87%) completed Step 1. Step 2 was indicated for 18 participants and was completed by 17. Participants favorably rated their experience in the study. Improvements in adherence (40-58%, p = .048) and decreases in asthma composite severity scores (CASI 6.08-5.08, p = .023) were observed for the full sample. Technology-assisted stepped-care is feasible and acceptable. Participants demonstrated improved adherence and asthma composite severity scores once they received the appropriate step of the intervention. Future studies should include a control group, a longer time-frame and an intermediate intervention step.

Youth safety perceptions of weight control behaviors: A moderated mediation study.

BACKGROUND: Youth may engage in healthy weight control behaviors (HWCBs) and unhealthy weight control behaviors (UWCBs) to lose or maintain weight. Youth observation of WCBs by supporter groups (parents/siblings/peers) and youth beliefs about the safety of WCBs may impact which WCBs youth use. The primary aim of this study was to examine the mediating role of youth safety perceptions of WCBs on the relationships between supporter group engagement in WCBs and youth engagement in WCBs. Youth BMI-z-score was analyzed as a moderator. METHODS: Participants were 219 youth (52.1% females), ages 10-17, attending an outpatient medical appointment. Participants completed questionnaires about their WCB use, whether they perceived WCBs as safe/unsafe, and whether they perceived parents, siblings and peers to use WCBs. A standardized formula including youth age, sex, height, and weight was used to calculate BMI-z-score. RESULTS: A moderated mediation model examining parental and youth engagement in UWCBs revealed that for youth in the healthy to overweight/obese (OV/OB) range, greater safety perception of UWCBs mediated the relationship between higher parent engagement in UWCBs and higher youth engagement in UWCBs. Furthermore, youth safety perception of HWCBs mediated the relationship between perceived parent, sibling, and peer engagement in HWCBs and youth engagement in HWCBs. CONCLUSION: This study identifies perceived parent, sibling, and peer WCBs and youth safety perceptions as mechanisms affecting youth WCB engagement, particularly for youth in the OV/OB range. Intervention effectiveness may increase if parent, sibling, and peer WCBs are targeted and education about safe/unsafe ways to control weight is provided.

The Impact of COVID-19 on Pediatric Adherence and Self-Management.

The COVID-19 pandemic has presented unique circumstances that have the potential to both positively and negatively affect pediatric adherence and self-management in youth with chronic medical conditions. The following paper discusses how these circumstances (e.g., stay-at-home orders, school closures, changes in pediatric healthcare delivery) impact disease management at the individual, family, community, and healthcare system levels. We also discuss how barriers to pediatric adherence and self-management exacerbated by the pandemic may disproportionately affect underserved and vulnerable populations, potentially resulting in greater health disparities. Given the potential for widespread challenges to pediatric disease management during the pandemic, ongoing monitoring and promotion of adherence and self-management is critical. Technology offers several opportunities for this via telemedicine, electronic monitoring, and mobile apps. Moreover, pediatric psychologists are uniquely equipped to develop and implement adherence-promotion efforts to support youth and their families in achieving and sustaining optimal disease management as the current public health situation continues to evolve. Research efforts addressing the short- and long-term impact of the pandemic on pediatric adherence and self-management are needed to identify both risk and resilience factors affecting disease management and subsequent health outcomes during this unprecedented time.

Validation and confirmatory factor analysis of the pediatric Adherence Barriers to Continuous Positive Airway Pressure Questionnaire.

OBJECTIVE: To evaluate and refine a newly proposed factor structure for the Adherence Barriers to Continuous Positive Airway Pressure Questionnaire (ABCQ) and to present psychometric data from a large, geographically diverse sample of children and young adults with sleep disordered breathing (SDB) treated with positive airway pressure (PAP). METHODS: A sample of 181 patients prescribed PAP for treatment of SDB, ages 8-21 years, and caregivers (n = 234) of patients ages 2-21 years, completed the ABCQ during routine sleep medicine clinic visits. Adherence data from participants' PAP machines were obtained via electronic download, providing objective data on PAP adherence immediately preceding the clinic visit during which the ABCQ was completed. RESULTS: A three-factor structure (1. Behavior, Beliefs, Environment, 2. Emotional Barriers, & 3. Physical Barriers) exhibited good model fit in confirmatory factor analysis. Results indicate that the ABCQ has strong psychometric properties, including good internal consistency among subscales and strong convergent validity with objectively measured PAP adherence. Analysis of the Receiver Operator Characteristic Curve (ROC) yielded an ABCQ total cut-off score of 46.5 for patient report and 53.5 for caregiver report. Scores above the cutpoint predicted nonadherence to PAP, defined as failure to use PAP for ≥4 h on 70% of nights. CONCLUSIONS: The three-factor ABCQ appears to be a useful patient- and caregiver-report instrument to measure barriers to PAP treatment in children and young adults with sleep disordered breathing.

Patient-Reported Outcomes for Pediatric Adherence and Self-Management: A Systematic Review.

OBJECTIVE: Treatment adherence is approximately 50% across pediatric conditions. Patient-reported outcomes (PROs) are the most common method of measuring adherence and self-management across research and clinical contexts. The aim of this systematic review is to evaluate adherence and self-management PROs, including measures of adherence behaviors, adherence barriers, disease management skills, and treatment responsibility. METHODS: Following PRISMA guidelines for systematic reviews, literature searches were performed. Measures meeting inclusion/exclusion criteria were evaluated using Hunsley and Mash's (2018) criteria for evidence-based assessment across several domains (e.g., internal consistency, interrater reliability, test-retest reliability, content validity, construct validity, validity generalization, treatment sensitivity, and clinical utility). Rating categories were adapted for the present study to include the original categories of adequate, good, and excellent, as well as an additional category of below adequate. RESULTS: After screening 172 articles, 50 PROs across a variety of pediatric conditions were reviewed and evaluated. Most measures demonstrated at least adequate content validity (n = 44), internal consistency (n = 34), and validity generalization (n = 45). Findings were mixed regarding interrater reliability, test-retest reliability, and treatment sensitivity. Less than half of the measures (n = 22) exhibited adequate, good, or excellent construct validity. CONCLUSIONS: Although use of adherence and self-management PROs is widespread across several pediatric conditions, few PROs achieved good or excellent ratings based on rigorous psychometric standards. Validation and replication studies with larger, more diverse samples are needed. Future research should consider the use of emerging technologies to enhance the feasibility of broad implementation.

Longitudinal non-adherence predicts treatment escalation in paediatric ulcerative colitis.

BACKGROUND: Medication non-adherence in paediatric ulcerative colitis (UC) has been associated with negative health outcomes including flares in disease activity. However, no studies to date have examined longitudinal adherence to maintenance medication in a prospective controlled trial. AIMS: To determine whether objectively measured adherence to standardised mesalazine (mesalamine) therapy over time was related to remission at 52 weeks and the need for treatment escalation in newly diagnosed paediatric patients with UC METHODS: PROTECT (NCT01536535) was a prospective, inception cohort, multi-site study of paediatric patients aged 4-17 years with newly diagnosed UC followed for 52 weeks. Patients received standardised mesalazine, with pre-established criteria for escalation to thiopurines or anti-TNFα inhibitors. Patients used pill bottles with electronic caps to monitor mesalazine adherence. We tested whether longitudinal adherence to mesalazine predicted steroid-free remission at week 52 (i.e. quiescent disease on mesalazine alone with no corticosteroids ≥4 weeks prior) and need for treatment escalation (i.e. introduction of immunomodulators, calcineurin-inhibitors or anti-TNFα inhibitors). RESULTS: Among 268 patients, average mesalazine adherence trajectories did not predict week 52 steroid-free remission. Declining adherence over time strongly predicted treatment escalation (ß = -.037, P = .001). By month 6, adherence rate ≤85.7% was associated with treatment escalation. CONCLUSIONS: Non-adherence may have affected therapeutic efficacy of standardised mesalazine, thereby contributing to need for treatment escalation. Routine adherence monitoring for at least 6 months following treatment initiation and addressing adherence difficulties early in the disease course are recommended.

Evaluation of a Novel Educational Tool in Adolescents With Inflammatory Bowel Disease: The NEAT Study.

OBJECTIVES: Among adolescents with inflammatory bowel disease (IBD), nonadherence rates are 50 to 88% across medications. Improving education in adults with IBD has been shown to improve coping and adherence to treatment in adults with IBD. Therapeutic patient education (TPE) has been used in patients with chronic diseases to train patients in skills to support treatment adaptation and condition management. This study tested the feasibility and preliminary efficacy of a novel TPE intervention in adolescents with IBD. METHODS: In this pilot, mixed-methods study, we evaluated the feasibility and preliminary efficacy of TPE with the IBD Pocket Guide on medication adherence, IBD knowledge, and transition readiness in adolescents ages 11 to 18 years. Medication adherence was monitored using a MedMinder Pill Dispensing system. Participants who were <90% adherent during a 4-week pre-intervention monitoring period were randomized to either a usual care group or an educational intervention (EI) group. Participants were followed for an additional 4 weeks after intervention. RESULTS: Trends were found in the EI group indicating improved medication adherence and IBD knowledge compared with the usual care group, though differences between groups did not reach statistical significance. Qualitative data showed that participants perceived that they had improved knowledge after the educational intervention. CONCLUSIONS: Therapeutic patient education may be beneficial for improving patient medication adherence and IBD knowledge. Future directions include testing the effects of the intervention with a larger sample.

Examination of the uses, needs, and preferences for health technology use in adolescents with asthma.

Objective: To examine the health technology uses and preferences of adolescents with asthma using a qualitative descriptive individual interview approach. Methods: Twenty adolescents were recruited from regularly scheduled asthma clinic appointments from February to July 2016. Patients were interviewed about their technology use and ways in which health technology could improve their asthma management using an open-ended semi-structured interview format. Interviews were audio recorded, transcribed, and coded into themes. Results: Social media (e.g. Snapchat, Instagram) and general communication (e.g. messaging) were the most common uses of technology while medical reminders (e.g. appointment, refill, medication) were the most common use of health technology. Adolescents identified ways in which health technology could improve their asthma management including (1) tracking symptoms and medication, (2) medical reminders, and (3) asthma and self-management knowledge specifically related to medications and individual action plans. Other themes that emerged included a desire to customize health technology to fit with individual schedules and medical routines and use of health technology data with medical providers. Conclusions: Adolescents and parents experience a number of challenges related to managing asthma, and health technology interventions should focus on ways to improve adherence and self-management. Future research considerations and potential interventions including ways to integrate adolescent preferences with evidence-based interventions are discussed.

Content and Usability Evaluation of Medication Adherence Mobile Applications for Use in Pediatrics.

OBJECTIVE: The objective of this study was to systematically evaluate commercially available medication adherence apps for the inclusion of behavior change techniques (BCTs) and to conduct a usability analysis on a subset of apps with adolescents and young adults living with a chronic illness. METHODS: Medication adherence apps were identified via a search of iTunes app store in August 2016. Seventy-five apps meeting initial inclusion criteria were independently coded by two researchers for the presence/absence of 26 BCTs. Twenty adolescents and young adults (ages: 13-20 years) with inflammatory bowel disease conducted usability testing on a subset of apps (n = 4). RESULTS: Across 75 apps coded for presence/absence of 26 BCTs, only 7 unique BCTs were identified. The number of BCTs per app ranged from 2 to 6, with an average of 3.3 BCTs. In usability testing, quality ratings varied across apps. Medisafe received the highest average scores on engagement, functionality, aesthetics, and information subscales. Medisafe and MyTherapy ranked first and second, respectively, on overall quality and perceived impact ratings. CONCLUSION: Content evaluation revealed only a limited number of BCTs that have been translated to medication adherence apps. Among apps with comparable content, clear user preferences emerged based on perceived quality and usability. Greater collaboration is needed between psychologists and health technologists to incorporate more evidence-based BCTs in apps. Findings also indicate a need for app developers to consider and incorporate the preferences of younger end users to improve app quality and engagement for pediatric populations.

The Role of Child and Adolescent Adjustment Problems and Sleep Disturbance in Parent Psychological Distress.

The goal of this study was to examine the moderating role of youth sleep disturbance on the relationship between youth internalizing and externalizing symptoms and parent psychological distress. Participants were 225 youth (ages 8-17) and parent dyads attending a primary care clinic appointment. Participants completed questionnaires that assessed parent psychological distress, youth internalizing symptoms, youth externalizing symptoms, and youth sleep disturbance. Moderation analyses were conducted to examine whether youth sleep disturbance moderated the relationship between youth internalizing and externalizing symptoms and parent psychological distress. The interaction between youth internalizing symptoms and youth sleep disturbance was significantly related to parent psychological distress, such that having increased sleep disturbance amplified the positive relationship between internalizing symptoms and parent psychological distress. The moderation model explained 52% of the variance in parent psychological distress. The interaction between youth externalizing symptoms and youth sleep disturbance was also significantly related to parent psychological distress, such that increased sleep disturbance amplified the positive relationship between externalizing symptoms and parent psychological distress. This model accounted for 53% of the variance in parent psychological distress. Greater youth sleep disturbance strengthens the positive relationship between youth internalizing/externalizing symptoms and parent psychological distress. Accordingly, reducing youth sleep disturbance may serve as an appropriate intervention target in families experiencing increased parent psychological distress.

Behavioral and Pharmacological Adherence in Pediatric Sickle Cell Disease: Parent-Child Agreement and Family Factors Associated With Adherence.

Objective: This study aimed to evaluate agreement between children and parents on a measure of behavioral and pharmacological adherence in children with sickle cell disease (SCD), and the associations among family factors (i.e., problem-solving skills, routines, communication) and adherence behaviors. Methods: In all, 85 children (aged 8-18 years) with SCD and their parents completed questionnaires assessing individual and family factors. Results: Overall parent-child agreement on an adherence measure was poor, particularly for boys and older children. Greater use of child routines was associated with better overall child-reported adherence. Open family communication was associated with higher overall parent-reported adherence. Conclusions: While further research is needed before definitive conclusions can be drawn, results suggest the need to assess child adherence behaviors via both child and parent reports. Findings also suggest that more daily family routines and open family communication may be protective factors for better disease management.

Topical Review: Adherence Interventions for Youth on Gluten-Free Diets.

Objective: To summarize gluten-free diet (GFD) nonadherence risk factors, nonadherence rates, and current intervention research within an integrative framework and to develop a research agenda for the development and implementation of evidence-based GFD adherence interventions. Methods: Topical review of literature published since 2008 investigating GFD adherence in pediatric samples. Results: Reviews of pediatric studies indicate GFD nonadherence rates ranging from 19 to 56%. There are few evidence-based, published pediatric GFD adherence interventions. Novel assessments of GFD adherence are promising but require further study. Nonmodifiable and modifiable factors within individual, family, community, and health systems domains must be considered when developing future interventions. Clinical implications are discussed. Conclusions: Avenues for future research include development and refinement of adherence assessment tools and development of evidence-based GFD adherence interventions. Novel technologies (e.g., GFD mobile applications) require empirical study but present exciting opportunities for adherence intervention.

Youth internalizing symptoms, sleep-related problems, and disordered eating attitudes and behaviors: A moderated mediation analysis.

PURPOSE: Internalizing symptoms increase the risk for disordered eating; however, the mechanism through which this relationship occurs remains unclear. Sleep-related problems may be a potential link as they are associated with both emotional functioning and disordered eating. The present study aims to evaluate the mediating roles of two sleep-related problems (sleep disturbance and daytime sleepiness) in the relationship between youth internalizing symptoms and disordered eating, and to explore if age moderates these relations. METHODS: Participants were 225 youth (8-17years) attending a primary care appointment. Youth and legal guardians completed questionnaires about youth disordered eating attitudes and behaviors, internalizing symptoms, sleep disturbance, and daytime sleepiness. Mediation and moderated mediation analyses were utilized. RESULTS: The mediation model revealed both youth sleep disturbance and daytime sleepiness independently mediated the association between internalizing symptoms and disordered eating attitudes and behaviors, and explained 18% of the variance in disordered eating. The moderated mediation model including youth age accounted for 21% of the variance in disordered eating; youth age significantly interacted with sleep disturbance, but not with daytime sleepiness, to predict disordered eating. Sleep disturbance only mediated the relationship between internalizing symptoms and disordered eating in youth 12years old and younger, while daytime sleepiness was a significant mediator regardless of age. CONCLUSION: As sleep-related problems are frequently improved with the adoption of health behaviors conducive to good sleep, these results may suggest a relatively modifiable and cost-effective target to reduce youth risk for disordered eating.

Youth Safety Perceptions of Weight Control Behaviors.

OBJECTIVE: Youth attempting to lose weight may engage in a variety of weight control behaviors (WCBs), some of which are viewed as healthy WCBs (HWCBs), whereas others are viewed as unhealthy WCBs (UWCBs). This study sought to examine youth perceptions of which WCBs are safe versus unsafe ways to lose weight. Furthermore, youth safety perceptions of WCBs and body mass index (BMI) z-scores were examined in relation to how often youth engage in these WCBs. METHOD: Participants were 219 youth (aged 10-17 years) attending a primary care clinic appointment. Participants completed questionnaires about the frequency of their own WCB use and whether they perceived each WCB as a safe way to lose weight. RESULTS: Results revealed differences in safety perceptions across weight status groups for certain HWCBs and UWCBs. Youth perception of WCBs as safe ways to lose weight was associated with more frequent engagement in WCBs. Furthermore, an interaction between youth safety perception of HWCBs and youth BMI z-scores was related to greater engagement in HWCBs, such that the relationship between safety perception and engagement was only significant for youth who are overweight/obese. The moderation model explained 36.95% of the variance in engagement in HWCBs. The moderation model was also significant for UWCBs (r = .35). CONCLUSION: This study identifies youth safety perception of WCBs as a mechanism that may lead to increased youth engagement in WCBs. Health care providers should educate both youth and family members about safe versus unsafe WCBs.

Systematic review and meta-analysis of comprehensive behavioral family lifestyle interventions addressing pediatric obesity.

PURPOSE: To conduct a meta-analysis of randomized controlled trials examining the efficacy of comprehensive behavioral family lifestyle interventions (CBFLI) for pediatric obesity. METHOD: Common research databases were searched for articles through April 1, 2013. 20 different studies (42 effect sizes and 1,671 participants) met inclusion criteria. Risk of bias assessment and rating of quality of the evidence were conducted. RESULTS: The overall effect size for CBFLIs as compared with passive control groups over all time points was statistically significant (Hedge's g = 0.473, 95% confidence interval [.362, .584]) and suggestive of a small effect size. Duration of treatment, number of treatment sessions, the amount of time in treatment, child age, format of therapy (individual vs. group), form of contact, and study use of intent to treat analysis were all statistically significant moderators of effect size. CONCLUSION: CBFLIs demonstrated efficacy for improving weight outcomes in youths who are overweight or obese.

Predictors of maternal encouragement to diet: a moderated mediation analysis.

Maternal encouragement to diet has been linked to child disordered eating, overweight and obesity, and negative psychosocial outcomes. A limited amount of research has examined variables that may contribute to maternal encouragement to diet. The current study examined the relationship between child BMI, parent BMI, maternal concern about child weight status, and maternal encouragement to diet. 80 youths, aged 8-17, and their mothers were administered questionnaires to assess maternal weight concern and child perception of maternal encouragement to diet. Data were analyzed using a bootstrapped moderated mediation model. Higher child BMI predicted increased maternal weight concern, which in turn was related to increased encouragement to diet. Mothers of overweight and obese youth were more likely to be concerned about their child's weight if mothers themselves were overweight or obese. Overweight or obese girls (but not boys) with an overweight or obese mother were more likely to be encouraged to diet. The model accounted for 48% of the variance in maternal encouragement to diet. Results indicate a potential mechanism by which encouragement to diet occurs and highlight the relevance of maternal weight and child gender in the prediction of encouragement to diet.