The Association of Quality of Life with Psychosocial Factors in Adolescents with Tourette Syndrome.

Individuals with Tourette syndrome (TS) have poorer quality of life (QoL) than their peers, yet factors contributing to poor QoL in this population remain unclear. Research to date has predominantly focused on the impact of tics and psychiatric symptoms on QoL in TS samples. The aim of this cross-sectional, multi-informant study was to identify psychosocial variables that may impact adolescent QoL in TS. Thirty-eight adolescents aged 13 to 17 with TS and 28 age-matched controls participated with a caregiver. No group differences were found on QoL, although the TS group reported reduced QoL compared to population normative data. In the TS group, reduced QoL was associated with lower self-esteem, poorer family functioning, higher stress, and greater depression and anxiety; QoL was unrelated to tic severity. In regression analyses, after adjusting for covariates, family functioning was the strongest predictor of QoL. These results emphasize the need to further explore the influence of psychosocial factors, particularly family functioning, on QoL in adolescents with TS.

A Brief Intervention in Primary Care to Improve Parents' Discipline Practices and Reach Other Caregivers.

Parents (N = 599) of 6-month-old to 10-year-old children were given a handbook intervention that educates about healthy discipline in a pediatric clinic serving low-income families in Nashville, Tennessee. A research assistant spent approximately 1 minute introducing the intervention. A total of 440 parents (73.4%) responded to a follow-up survey 2 to 4 months later. Most parents (88%) who completed the follow-up survey had read at least part of the handbook. Of parents who received the handbook, 63% reported that the handbook helped them discipline their children. Half of parents reported specific changes they made because of the handbook. The most frequently reported changes were more talking/explaining/communicating (25%), more redirecting (7.8%), more patience/listening (6.0%), less anger/yelling (10.8%), and less spanking (7.5%). 42% of parents reported that they shared the handbook with other caregivers, friends, relatives, and children. A brief clinic intervention improves parents' discipline practices and reaches other caregivers.

Translation, cross-cultural adaptation and validity study of the "Play Nicely Program: The Healthy Discipline Handbook" for use in Brazil.

OBJECTIVE: to describe the translation, cross-cultural adaptation and validity process of the "Play Nicely Program: The Healthy Discipline Handbook" for use in Brazil. METHODS: a methodological study that followed the translation, back-translation, expert committee assessment, and pre-test steps. The Content Validity Index (CVI) was calculated for both the judge population and the pre-test population. Four translators, seven expert judges in the field of child health and thirty participants in the pre-test, including parents, teachers and healthcare professionals, participated in the study. RESULTS: in experts' analysis (98.4%), a value of 100% of adequate assessments was obtained, and in the target population's analysis (89.5%), there were 100% of adequate assessments. In both analyses, suggested adaptations were made. CONCLUSIOS: cross-cultural adaptation and content validity into Brazilian Portuguese of the "Play Nicely Program: The Healthy Discipline Handbook" were considered adequate for application in the target population.

Bullying and School Violence.

Rates of traditional bullying have remained stable (30%) but rates of cyberbullying are increasing rapidly (46% of youth). There are significant long-term physical and mental health consequences of bullying especially for vulnerable youth. Multi-component school-based prevention programs that include caring adults, positive school climate, and supportive services for involved youth can effectively reduce bullying. While bullying has emerged as a legitimate concern, studies of surviving perpetrators to date suggest bullying is not the most significant risk factor of mass school shootings. Pediatricians play a critical role in identification, intervention, awareness, and advocacy.

Translation, cross-cultural adaptation and validity study of the "Play Nicely Program: The Healthy Discipline Handbook" for use in Brazil / Traducción, adaptación transcultural y estudio de validación del "Play Nicely Program: The Healthy Discipline Handbook" / Tradução, adaptação transcultural e estudo de validação do "Play Nicely Program: The Healthy Discipline Handbook"

ABSTRACT Objective: to describe the translation, cross-cultural adaptation and validity process of the "Play Nicely Program: The Healthy Discipline Handbook" for use in Brazil. Methods: a methodological study that followed the translation, back-translation, expert committee assessment, and pre-test steps. The Content Validity Index (CVI) was calculated for both the judge population and the pre-test population. Four translators, seven expert judges in the field of child health and thirty participants in the pre-test, including parents, teachers and healthcare professionals, participated in the study. Results: in experts' analysis (98.4%), a value of 100% of adequate assessments was obtained, and in the target population's analysis (89.5%), there were 100% of adequate assessments. In both analyses, suggested adaptations were made. Conclusios: cross-cultural adaptation and content validity into Brazilian Portuguese of the "Play Nicely Program: The Healthy Discipline Handbook" were considered adequate for application in the target population.

RESUMEN Objetivo: desarrollar el proceso de traducción, adaptación transcultural y validación del "Play Nicely Program: The Healthy Discipline Handbook" para uso en Brasil. Métodos: estudio metodológico, siguiendo las etapas de traducción, retrotraducción, evaluación por el comité de jueces y preprueba. Se calculó el Índice de Validez de Contenido (IVC) tanto para la población de jueces como para la población previa a la prueba. Población de estudio: cuatro traductores, siete jueces expertos en el área de salud infantil y treinta participantes en la preprueba con padres, docentes y profesionales de la salud. Resultados: en el análisis de los especialistas (98,4%), se obtuvo un valor de 100% de valoraciones adecuadas y, en el análisis de la población objetivo (89,5%), Se totalizó el 100% de las evaluaciones adecuadas. En ambos análisis, se realizaron adaptaciones sugeridas. Conclusiones: la adaptación transcultural y la validación de contenido para el portugués brasileño del "Play Nicely Program: The Healthy Discipline Handbook" se consideraron adecuadas para su aplicación en la población objetivo.

RESUMO Objetivo: desenvolver o processo de tradução, adaptação transcultural e validação do "Play Nicely Program: The Healthy Discipline Handbook" para uso no Brasil. Métodos: estudo metodológico, seguindo as etapas de tradução, retrotradução, avaliação do comitê de juízes e pré-teste. Foi calculado o Índice de Validade de Conteúdo (IVC) tanto para a população de juízes quanto para a população do pré-teste. População do estudo: quatro tradutores, sete juízes especialistas na área de saúde da criança e trinta participantes no pré-teste com pais, professores e profissionais da saúde. Resultados: na análise dos especialistas (98,4%), obteve-se valor de 100% de avaliações adequadas e, na análise da população-alvo (89,5%), totalizaram-se 100% de avaliações adequadas. Em ambas análises, foram realizadas adaptações sugeridas. Conclusão: a adaptação transcultural e a validação de conteúdo para o português do Brasil do "Play Nicely Program: The Healthy Discipline Handbook" foram consideradas adequadas para a aplicação na população-alvo.

The Development, Preliminary Validation, and Clinical Application of the Quick Parenting Assessment.

To prevent diseases, efforts are needed to determine how to address Adverse Childhood Experiences (ACEs), including parenting behaviors. The objective of this study, conducted in Nashville TN in 2017, was to initiate testing the psychometric properties of two new Adverse Childhood Experiences (ACEs) screening tools, the Quick Parenting Assessment (QPA) and Other Childhood Stressors (OCS). In a clinic serving low-income families, caregivers of children ages 2-10 completed assessments of parenting (QPA), other stressors (OCS), child behavior problems ((Strength and Difficulties Questionnaire (SDQ)), and Attitudes Toward Spanking (ATS). The QPA takes 1 min to complete and assesses for healthy and unhealthy parenting behaviors. Seventy-five percent of eligible participants completed the survey (N=558). A reduced 10-item QPA yielded a Cronbach's alpha of 0.79 and, in 4-10-year-olds, was associated with high SDQ conduct, hyperactivity, and total difficulties scores (r=0.44, 0.48, and 0.47; all p< 0.001). Children with QPAs of >4 were nine times more likely than those children with scores of ≤2 to have behavior problems (OR=8.93, 95% CI = 3.74-21.32). Elevated QPAs were associated with the ATS (r=0.47, p < .001). The OCS was also associated with high SDQ total difficulties scores (r=0.28, p< 0.001). Two pediatric ACEs screening tools, the QPA and the OCS, have promising psychometric properties. The findings suggest that parenting behaviors may play an outsized role in the pathogenesis of outcomes associated with ACEs. We discuss the clinical application of QPA at our institution and the theoretical potential for this instrument to reduce the rates of short- and long-term health problems.

Educating Parents About Corporal Punishment and Effective Discipline: Pediatricians' Preparedness, Motivation, and Barriers.

OBJECTIVE: To assess US pediatricians' preparedness, motivation, and barriers related to educating parents about corporal punishment (CP) and effective child discipline. METHODS: A random sample of 1500 pediatricians was drawn from a nationwide database in the United States. A self-administered questionnaire was sent via mail in 2016. The response rate (53%; n = 787) was maximized via repeated survey mailings and use of cash incentives. RESULTS: The majority of respondents were White (69%), female (59%) and were members of the American Academy of Pediatrics (85%). Most pediatricians felt somewhat prepared to advise parents about child discipline, particularly CP, and perceived their colleagues to be slightly less prepared than themselves. Although most (72%) respondents believed it was "extremely/very" likely that parents valued their advice about child discipline, only 36% believed parents were "extremely/very" likely to follow their advice. Most respondents were highly motivated to participate in activities designed to change norms regarding CP. The most common strategy pediatricians identified for improving child behavior was being consistent with rules (71%). Perceived barriers to providing child discipline advice to parents included lack of time (90%), lack of insurance reimbursement (48%), and lack of training and educational resources (47%). CONCLUSIONS: Pediatricians are a key source of professional advice for parents about how to discipline children safely. Given this, along with strong approval and use of CP in the United States and its harm for children, the current findings suggest a strong need for pediatricians to receive additional training on how to advise parents about child discipline along with removal of barriers to providing such advice.

Normative Trends in Physically Aggressive Behavior: Age-Aggression Curves from 6 to 24 Months.

OBJECTIVE: To investigate age-related trends in physically aggressive behaviors in children before age 2 years. STUDY DESIGN: A normative US sample of 477 mothers of 6- to 24-month-old children reported on the frequency of 9 interpersonally directed aggressive child behaviors, and hurting animals, in the past month. RESULTS: Almost all (94%) of the children were reported to have engaged in physically aggressive behavior in the past month. Based on 2-part regression models, the prevalences of kicking (OR, 1.70; P = .023), pushing (OR, 3.22; P < .001), and swiping (OR, 1.78; P = .018) increased with years of age, but the prevalence of hair pulling decreased with age (OR, 0.55; P = .020). The prevalences of hitting and throwing increased initially, then plateaued at age 18-20 months, and then decreased (quadratic aOR, 0.13 and 0.16; P < .001 and .010, respectively). The frequencies of hitting (R2 = .05; P < .001) and throwing (R2 = .03; P = .030) increased, and the frequencies of hair pulling (R2 = .07; P < .001) and scratching (R2 = .02; P = .042) decreased with age (P values adjusted for false discovery rate). CONCLUSIONS: Physically aggressive behavior in the 6- to 24-month age range appears to be nearly ubiquitous. Most, but not all, forms of physical aggression increase with age. These results can guide pediatricians as they educate and counsel parents about their child's behavior in the first 2 years of life.

US Pediatricians' Attitudes, Beliefs, and Perceived Injunctive Norms About Spanking.

OBJECTIVE: To assess United States pediatricians' attitudes, beliefs, and perceived professional injunctive norms regarding spanking. METHOD: A self-administered questionnaire was mailed to a nationwide random sample of 1500 pediatricians in the US, drawn from a database maintained by IMS Health. Four survey mailings were conducted and cash incentives of up to $20 were provided. The response rate was 53% (N = 787). RESULTS: Most respondents were members of the American Academy of Pediatrics (85%), had been practicing physicians for 15 years or more (66%), and were white (69%) and female (59%). All US regions were represented. About 3-quarters of pediatricians did not support the use of spanking, and most perceived that their colleagues did not support its use either. Pediatricians who were male, black, and/or sometimes spanked as children had more positive attitudes toward spanking and expected more positive outcomes from spanking than their counterparts. Nearly 80% of pediatricians never or seldom expected positive outcomes from spanking, and a majority (64%) expected negative outcomes some of the time. CONCLUSION: The majority of pediatricians in the US do not support the use of spanking with children and are aware of the empirical evidence linking spanking with increased risk of poor health outcomes for children. Pediatricians are a key, trusted professional source in advising parents about child discipline. These findings suggest that most pediatricians will discourage the use of spanking with children, which over time could reduce its use and associated harms in the population. This is of clinical relevance because, despite strong and consistent evidence of the harms that spanking raises for children, spanking is still broadly accepted and practiced in the US.

How to Convince Parents to Stop Spanking Their Children.

English- and Spanish-speaking parents of 1- to 5-year-old children were invited to view 5-10 minutes of parent training program, "Play Nicely," as part of the well-child checkup. Key measures were parents' plans to change how they discipline and, if they planned to use less spanking, how the program worked in their situation. Of 197 parents who participated, 128 (65.0%) planned to change how they discipline. Nineteen parents (9.6%) reported that they planned to spank less. The most common reasons for parents to plan to spank less were that the program taught other discipline options (12/19, 63.2%) and that the program taught that spanking was not recommended as a form of discipline (6/19, 31.6%). The majority of parents report that the program works because it offers alternatives to spanking. This study has implications for the development of parent training programs and the primary prevention of child abuse, violence, and other health problems.

Can Discipline Education be Culturally Sensitive?

Objectives Inappropriate discipline such as harsh physical punishment is a social determinant of health. The objective was to determine if a brief parent training intervention that teaches discipline strategies is culturally sensitive. Methods English or Spanish-speaking parents of 1-5 year old children viewed a multimedia program that teaches appropriate discipline strategies. The intervention, Play Nicely, was viewed in the exam room before the physician's visit. Parents viewed 4 of 20 discipline strategies of their choosing; the average viewing time was 7 min. Results Of 204 parents eligible to participate, 197 (96 %) completed the study; 41 % were Black, 31 % were White, and 21 % were Hispanic. At least 80 % of parents from each racial/ethnic group reported that the program built their confidence to care for their child, addressed their family needs, explained things in a way they could understand, respected their family values, and was sensitive to their personal beliefs. Overall, 80 % of parents reported that the program answered individual questions. One parent (0.5 %) reported that the program did not respect her family values. Conclusions for Practice Discipline education can be integrated into the pediatric primary care clinic in a way that is family-centered and culturally sensitive for the majority of parents. The results have implications for the development and implementation of population-based parenting programs and the primary prevention of child abuse and violence.

A Brief Intervention Facilitates Discussions About Discipline in Pediatric Primary Care.

BACKGROUND: Participants were consecutive English or Spanish speaking parents of 1- to 5-year-old children presenting for a well-child visit. Parents viewed a 5- to 10-minute intervention that teaches appropriate discipline strategies. The participation rate was 99% (129/130). Thirty-six percent (46/129) reported they had a discussion about discipline with their pediatrician. Of the parents who had a discussion, 93% (43/46) agreed or strongly agreed that the intervention program helped with a discussion about discipline. One hundred percent (19/19) of Hispanic parents reported that the program was helpful compared with 86% (12/14) of Black parents and 91% (10/11) of White parents. Parents' qualitative responses revealed that the intervention helped by facilitating communication with their physician and/or by providing information. Brief interventions, integrated into the primary care visit can help parents have discussions about discipline with their physician. The results have implications for improving pediatric primary care services, violence prevention, and child abuse prevention.

The effect of primary care interventions on children's media viewing habits and exposure to violence.

OBJECTIVE: To determine if brief primary care interventions can affect children's media viewing habits and exposure to violence. METHODS: English- and Spanish-speaking parents of 2- to 12-year-old children presenting to a pediatric primary care clinic participated in a randomized controlled trial. There were 2 intervention groups; one group viewed 5 minutes from the Play Nicely program and another received a handout, "Pulling the Plug on TV Violence." There were 2 control groups; the primary control group received standard primary care, and the alternative control group viewed a program about obesity prevention. The outcome measure was parental report of changes in media viewing habits and changes in exposure to violence. RESULTS: A total of 312 of 443 parents who were randomized completed a 2-week follow-up survey. Compared with the primary control group, parents in the video intervention group were more likely to report a change in their children's media viewing habits (odds ratio [OR] 3.29; 95% confidence interval [CI] 1.66-6.51) and a change in their children's exposure to violence (OR 4.26; 95% CI 1.95-9.27). Compared with the primary control group, parents in the handout group were more likely to report a change in their children's media viewing habits (OR 4.35; 95% CI 2.20-8.60) and a change in their children's exposure to violence (OR 3.35; 95% CI 1.52-7.35). CONCLUSIONS: Brief primary care interventions can affect children's media viewing habits and children's exposure to violence. These results have implications for how to improve primary care services related to decreasing children's media exposure and violence prevention.

A brief intervention affects parents' attitudes toward using less physical punishment.

Consecutive English and Spanish speaking caregivers of 6-24 month old children were randomly assigned to either a control or intervention group. Parents in the intervention group were instructed to view at least 4 options to discipline a child in an interactive multimedia program. The control group participants received routine primary care with their resident physician. After the clinic visit, all parents were invited to participate in a research study; the participation rate was 98% (258/263). The key measure was the Attitudes Toward Spanking (ATS) scale. The ATS is correlated with parents' actual use of physical punishment. Parents with higher scores are more likely to use physical punishment to discipline their children. Parents in the intervention group had an ATS score that was significantly lower than the ATS score of parents in the control group (median=24.0, vs. median=30; p=0.043). Parents in the control group were 2 times more likely to report that they would spank a child who was misbehaving compared with parents in the intervention group (16.9% vs. 7.0%, p=0.015). In the short-term, a brief intervention, integrated into the primary care visit, can affect parents' attitudes toward using less physical punishment. It may be feasible to teach parents to not use physical punishment using a population-based approach. The findings have implications for how to improve primary care services and the prevention of violence.

Why parents value a brief required primary care intervention that teaches discipline strategies.

English- or Spanish-speaking caregivers of 1- to 5-year-old children were instructed to view a 5- to 10-minute educational intervention in a pediatric clinic as part of the well child visit. Almost all (128/129) parents reported that the program was a valuable component of the well child visit, and of these, all 128 (100%) gave at least one reason. Most parents valued the program at a personal level, reporting that the program was educational (76.6%), reinforced their parenting (8.6%), or facilitated a discussion with their physician (2.3%). A total of 16% valued the program because it might benefit other parents. A brief routine primary care intervention that teaches discipline strategies is valued by English- and Spanish-speaking parents of young children. These findings have implications for how to routinely teach parents about discipline in primary care and the primary prevention of violence.

A brief program improves counseling of mothers with children who have persistent aggression.

OBJECTIVE: To assess whether a multimedia program can affect counseling behavior related to one of the strongest risk factors for violence later in life, persistent early childhood aggression. METHOD: The design was a controlled trial with unobtrusive measurement in a clinic setting. A researcher, pretending to be the mother of a 2 ½ year old boy, called 19 pediatric residents during clinic hours and requested advice on how to manage her child's persistently hurtful behavior. The intervention was a 40-min lecture focusing on a multimedia program, Play Nicely, which teaches accepted strategies for managing aggression in young children ages 1-7 years. Residents' responses were blindly assessed to determine the treatment effect of the intervention. RESULTS: Compared with the control group (C), residents in the intervention (I) group were more likely to recommend setting the rule (I: 100% vs. C: 31%, p = .01), redirecting (I: 83% vs. C: 8%, p = .003), promoting empathy (I: 50% vs. C: 0%, p = .02), and more likely to discourage the use of physical punishment (I: 83% vs. C: 31%). These are the primary strategies encouraged by the intervention. The magnitude of the effect size was very large for each of these three strategies, ranging from d = 1.1 to 2.3. CONCLUSIONS: A brief intervention can improve the counseling behavior of primary care physicians regarding persistent childhood aggression. The findings have implications for child abuse prevention, violence prevention, medical education, and how to improve anticipatory guidance within primary care.

The effect of physician--parent discussions and a brief intervention on caregivers' plan to discipline: is it time for a new approach?

Consecutive English- or Spanish-speaking caregivers of 1- to 5-year-old children were randomized to view a multimedia program (approximately 5-10 minutes) in a pediatric primary care clinic. After the clinic visit, 258/259 caregivers participated in a brief personal interview. In the multivariate logistic model, caregivers were more likely to have been assisted in their plans to discipline if they had had a discussion about discipline with their physician (odds ratio [OR] = 4.93; 95% confidence interval [CI] = 1.08-22.46), viewed the multimedia program (OR = 259.29; 95% CI = 56.56-1188.61), or viewed the multimedia program and had had a discussion with their physician (OR = 507.05; 95% CI = 86.81-2961.45) than if they had had no discussion and had not viewed the multimedia program. In addition to face-to-face discussions, routinely viewed educational material may help teach caregivers about discipline. The results have implications for improving primary care services, child abuse prevention, and violence prevention.

A brief intervention may affect parents' attitudes toward using less physical punishment.

Ninety-six parents in a preschool and pediatric clinic participated in a randomized study of a brief parenting intervention. The Attitudes Toward Spanking (ATS) scale was measured at baseline, and, on average, 4 months postintervention. Higher ATS scores are correlated with increased use of physical punishment. In the intervention group, there was a 2.7-point decrease in the ATS score at follow-up compared with baseline (P = 0.01). There was no decrease in the ATS in the control group. Brief interventions may shift parental attitudes toward using less physical punishment and have implications for improving anticipatory guidance within primary care and early education.

A brief primary care intervention helps parents develop plans to discipline.

OBJECTIVE: The objective was to determine if a primary care intervention can help caregivers develop appropriate methods of discipline. PATIENTS AND METHODS: A randomized, controlled trial was conducted in a pediatric primary care clinic. Consecutive English- or Spanish-speaking caregivers of 1- to 5-year-old children were randomly assigned (1:1 ratio) at triage. Members of the intervention group (n = 130) were instructed (ie, required) to view at least 4 strategies of their choosing for responding to childhood aggression in the Play Nicely educational program; Spanish-speaking caregivers viewed the Spanish edition. The intervention duration was 5 to 10 minutes. Those in the control group (n = 129) received standard care. At the end of the clinic visit, 258 of 259 caregivers (99.6%) consented to participate in a brief personal interview. The key measure was whether caregivers were helped in their plans to discipline, defined as a caregiver who could verbalize an appropriate change in how they would discipline their child in the future. RESULTS: Overall, caregivers in the intervention group were 12 times more likely to have been helped in developing methods of discipline compared with caregivers in the control group (83% vs 7%; P < .001). Within this group, Spanish-speaking caregivers (n = 59) in the intervention group were 8 times more likely to have been helped compared with those in the control group (91% vs 12%; P < .001). Caregivers in the intervention group were more likely than caregivers in the control group to report that they planned to do less spanking (9% vs 0%; P < .001). CONCLUSIONS: A brief, required, primary care intervention helps English- and Spanish-speaking caregivers develop appropriate methods of discipline. The findings have implications for violence prevention, child abuse prevention, and how to incorporate counseling about childhood aggression and discipline into the well-child care visit.