Psychometric properties of the revised children's anxiety and depression scale (RCADS) for autistic youth without co-occurring intellectual disability.

Autistic youth often present with comorbid anxiety and depression yet there is a dearth of validated assessment tools. The Revised Children's Anxiety and Depression Scale (RCADS) assesses internalizing symptoms but there is little psychometric data in autistic youth. Treatment-seeking autistic youth with anxiety or obsessive-compulsive symptoms (N = 74; age 6-14 years), and caregivers, were administered the RCADS-Parent, RCADS-Child, and assessments of internalizing, externalizing symptoms and social impairment indicative of autism. RCADS-Parent and RCADS-Child total anxiety scores demonstrated excellent internal consistency, and the six subscales demonstrated acceptable-to-good internal consistency. The RCADS-Child and Parent total anxiety scores were weakly correlated, and neither child age nor gender altered the strength of this association. Convergent validity was supported by moderate-to-strong correlations with clinician and parent-reported anxiety symptoms. Support for divergent validity was mixed. Results provide support for the RCADS-Parent and RCADS-Child as reliable, valid measures of internalizing symptoms in autistic youth.

Validation of the Entrainment Signal Regularity Index and associations with children's changes in BMI.

OBJECTIVE: This study examined the validity of a novel metric of circadian health, the Entrainment Signal Regularity Index (ESRI), and its relationship to changes in BMI during the school year and summer. METHODS: In a longitudinal observational data set, this study examined the relationship between ESRI score and children's (n = 119, 5- to 8-year-olds) sleep and physical activity levels during the school year and summer, differences in ESRI score during the school year and summer, and the association of ESRI score during the school year and summer with changes in BMI across those time periods. RESULTS: The ESRI score was higher during the school year (0.70 ± 0.10) compared with summer (0.63 ± 0.11); t(111) = 5.484, p < 0.001. Whereas the ESRI score at the beginning of the school year did not significantly predict BMI change during the school year (ß = 0.05 ± 0.09 SE, p = 0.57), having a higher ESRI score during summer predicted smaller increases in BMI during summer (ß = -0.22 ± 0.10 SE, p = 0.03). CONCLUSIONS: Overall, children demonstrated higher entrainment regularity during the school year compared with the summer. During summer, having a higher entrainment signal was associated with smaller changes in summertime BMI. This effect was independent of the effects of children's sleep midpoint, sleep regularity, and physical activity on children's BMI.

The roles of sleep and eating patterns in adiposity gain among preschool-aged children.

BACKGROUND: Short sleep durations are related to risks for obesity in preschool children. However, the underlying mechanism or mechanisms are not clear. OBJECTIVES: We evaluated the relationships between sleep characteristics and body composition, energetics, and weight-regulating behaviors in preschool-aged children, as well as the longitudinal associations between children's sleep and eating patterns and body composition at a 1-year follow-up. METHODS: Data were drawn from a longitudinal study of 118 children aged 3-5 years. Sleep (duration, midpoint, regularity) and physical activity (PA) were measured by accelerometry over 6 consecutive days; total energy expenditure (TEE) was measured using the doubly labeled water method; body composition (fat mass, fat-free mass, and percent body fat) was measured by DXA; and dietary intake (energy intake, timing) was measured using two 24-hour recalls. Multivariable regression was used to estimate interindividual associations of sleep parameters with body composition, PA, TEE, and dietary outcomes and to examine the relationships between sleep and dietary behaviors and body composition 1 year later. RESULTS: Cross-sectionally, later sleep midpoint is associated with having a greater fat mass (0.33; 95% CI: 0.05, 0.60) and a higher percent body fat (0.92; 95% CI: 0.15, 1.70). Later sleep midpoint was associated with delayed morning mealtimes (0.51; 95% CI: 0.28, 0.74) and evening mealtimes (0.41; 95% CI: 0.29, 0.53), higher nighttime energy intakes (45.6; 95% CI: 19.7, 71.4), and lower morning energy intakes (-44.8; 95% CI: -72.0, -17.6). Longitudinally, shorter sleep duration (-0.02; 95% CI: -0.03, 0.00) and later meal timing (0.83; 95% CI: 0.24, 1.42) were associated with higher percent body fat measurements 1 year later. CONCLUSIONS: Shorter sleep duration and later meal timing are associated with adiposity gains in preschoolers.

Insight Into the Adolescent Patient Experience With Nonalcoholic Fatty Liver Disease.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is the leading chronic liver disease in youth, yet little is known about the adolescent patient's experience with NAFLD, which is key for treatment engagement. We examined adolescents' experiences with NAFLD diagnosis, thoughts on how NAFLD affects their daily life, understanding and perceptions of diagnosis and treatment, and impressions of how to improve care. METHODS: Utilizing a mixed-method design, adolescents with NAFLD (N = 16; Mean age = 15.8 years; Mean BMI = 37 kg/m 2 ) participated in focus groups. To supplement qualitative data, adolescents and their caregiver completed measures assessing illness perceptions, adolescent quality of life, and eating/activity behaviors. RESULTS: Focus group themes suggested reactions to diagnosis varied from unconcerned to anxious. NAFLD diagnosis occurred within the context of other psychological/medical concerns and was not perceived to affect most adolescents' daily lives. Although adolescents understood general contributors to NAFLD, comprehension of their diagnosis varied. Adolescents were more likely to make lifestyle changes when families were supportive, and they preferred tailored recommendations for health behavior change from the healthcare team. Notably, 62.5% of adolescents were more concerned about their weight than NAFLD. Almost half (43.8%) identified as food insecure. CONCLUSIONS: Adolescents with NAFLD may benefit from personalized treatment. Care could be enhanced by ensuring comprehension of diagnosis, problem-solving personal, and family barriers and increasing family support. Harnessing adolescents' desire for weight loss may be a more salient driver for change in disease status. Interventions should also address systemic barriers such as food insecurity to ensure equitable care.

Primary Outcomes for Adults Receiving the Unified Protocol after Hurricane Harvey in an Integrated Healthcare Setting.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated efficacy for treating anxiety and depression. However, there are limited effectiveness data when conducted in real-world settings with diverse populations, including those with trauma. We evaluated treatment outcomes in a naturalistic, community setting among 279 adults who received UP following Hurricane Harvey. We examined change in overall clinical severity, depression and anxiety symptoms, functional impairment, and baseline outcome predictors (i.e., demographic characteristics, impact from Hurricane Harvey, co-occurrence of depression and anxiety symptoms). Global clinical severity, depression and anxiety symptoms, and functional impairment decreased by end-of-treatment. Participants experienced global symptom improvement to a lesser degree than demonstrated in efficacy trials. Participants who experienced greater storm impact reported larger reductions in anxiety symptoms than those less impacted by Harvey. Further studies evaluating the effectiveness of the UP post-disaster and with diverse samples are needed.

Examining patterns of postnatal feeding in relation to infant's weight during the first year.

BACKGROUND: There is mixed evidence regarding specific infant feeding behaviors and later risk for overweight and obesity. We sought to detect underlying patterns in duration of breastfeeding, introduction of solid foods and sweetened beverages, in order to understand the relation to later weight. METHODS: Patterns of postnatal feeding were examined among infants enrolled in the Infant Feeding Practices Study II (N = 3033). At monthly intervals, mothers reported on the duration of any and exclusive breastfeeding, age of solid food and sweetened beverage introduction, and reported infant weight at ages 9- and 12-months. Latent profile analysis was used to empirically derive patterns of postnatal feeding and examine associations with weight z-scores at 9 and 12 months. RESULTS: Two profiles emerged: (1) Short breastfeeding duration and early introduction to solid foods and sweetened beverages (Short BF/Early Introduction; 53%) and (2) longer breastfeeding duration and later introduction to solid foods and sweetened beverages (Longer BF/Later Introduction; 43%). Infants in the Shorter BF/Early Introduction profile had significantly greater weight z-scores at 9 (M = 0.18) and 12 months (M = 0.26), compared to those in the Longer BF/Later Introduction profile (M = -0.21; M = -0.17, respectively). CONCLUSIONS: Overall, shorter BF duration and earlier food and sweetened beverage introduction is associated with higher weight z-scores at 9 and 12 months. Early intervention should aim to promote breastfeeding and later introduction of solids and discourage consumption of sweetened beverages. These postnatal patterns of feeding behaviors provides important context to inform targeted interventions aimed at reducing risk for later obesity.

Early-life determinants of excess weight in children born heavy.

Infants born heavy are vulnerable to later obesity, but it is unknown whether obesity-related risk factors present between conception and delivery predict their postnatal weight trajectory. We modelled the weight trajectories of infants born high birth weight (HBW, greater than or equal to 4000 g) and/or large for gestational age (LGA, greater than 90th percentile) using data from the Infant Feeding Practices Study II (N = 371). A high percentage of infants were both HBW and LGA, but the trajectories were modelled separately. Weight of infants born heavy begins high, gradually decreases, and then levels off by 12 months. Delivery method was the only predictor of weight. Caesarean-delivered HBW infants were heavier than vaginally-delivered HBW infants although this effect disappeared by 12 months. Findings indicate that early-life influences are not necessarily deterministic of the postnatal weight trajectory of infants born heavy. Future research is needed to examine postnatal behaviours that may be implicated in the relationship between large size at birth and later obesity.

Sleep duration and bedtime in preschool-age children with obesity: Relation to BMI and diet following a weight management intervention.

BACKGROUND: Sleep duration is associated with obesity in preschoolers. Weight-management interventions may be an opportunity to incorporate sleep health recommendations. OBJECTIVES: To examine changes in sleep in preschool-age children with obesity following a family-based weight-management intervention (Learning about Activity and Understanding Nutrition for Child Health [LAUNCH]) compared with motivational interviewing and standard care conditions. Additionally, we examined associations between sleep with body mass index (BMI) z score (BMIz) and diet. METHODS: One hundred fifty-one children (4.6 ± 0.93 y) completed baseline (pretreatment) and posttreatment (week 24) assessments, including anthropometrics, 24-hour dietary recalls, and a 7-day sleep diary. Analysis of variance (ANOVA) and chi-squared tests compared sleep variables between groups; linear regression models examined effects of sleep on BMIz and dietary intake at posttreatment, controlling for baseline values. RESULTS: Bedtime and sleep duration were not significantly different between treatment groups from baseline to posttreatment. After adjusting for baseline sleep, earlier bedtime was associated with lower BMIz (95% CI, 0.00-0.04; .03), intake of added sugars (95% CI, 0.70-4.32; .007), and sweet/dessert food servings (95% CI, 0.00-0.19; .04) at posttreatment. Longer night-time sleep duration was associated with fewer added sugars at posttreatment, adjusting for baseline sleep (95% CI, -3.79 to -0.35; .02). CONCLUSIONS: More comprehensive sleep intervention incorporated into weight-management intervention may be necessary to promote positive changes for preschoolers with obesity. A focus on earlier bedtime and longer sleep duration appears to be important given associations between sleep duration and bedtime with BMIz and dietary intake.

Longer sleep duration during infancy and toddlerhood predicts weight normalization among high birth weight infants.

Study Objectives: High birth weight (HBW; ≥ 4000 g) is strongly associated with later overweight, yet little is known about how to disrupt this trajectory. The current study examined sleep practices during infancy and toddlerhood among children born HBW or normal birth weight (NBW; 2500-3999 g). Methods: Latent growth curve models were used to examine sleep during infancy and toddlerhood among 270 mother-child dyads enrolled in the Health Outcomes and Measures of the Environment Study. Total sleep duration in 24 hr, sleep maintenance, and restlessness/vocalizations were collected at 6 month intervals between ages 6 and 24 months. Height and weight were obtained at ages 24 or 36 months, and normal and overweight BMI were derived. Sleep was examined among children with a normal BMI during the preschool years who were either HBW (HBW-Normal, n = 36) or NBW (NBW-Normal, n = 184) compared with overweight preschoolers (Overweight, n = 50). It was predicted that the Overweight group would have poorer sleep across infancy and toddlerhood compared with HBW-Normal and NBW-Normal. Results: HBW-Normal had the longest and Overweight had the shortest mean 24 hr sleep duration across all time points with NBW-Normal falling in-between the two groups. Compared with Overweight, HBW-Normal exhibited longer 24 hr sleep duration at age 6 months with this group difference maintained over infancy and toddlerhood. No group difference was found for NBW-Normal. Conclusions: A longer sleep duration in the first several years of life is associated with development of normal BMI among HBW children. These findings suggest that longer sleep duration may protect HBW children from becoming overweight.

Greater Breastfeeding in Early Infancy Is Associated with Slower Weight Gain among High Birth Weight Infants.

OBJECTIVE: To examine whether feeding patterns from birth to age 6 months modify the association between birth weight and weight at 7-12 months of age. STUDY DESIGN: Longitudinal mixed models were used to examine feeding trajectories across categories of birth weight and weight at 7-12 months of age in 1799 mother-infant dyads enrolled in the Infant Feeding Practices Study II. The percentage of breast milk received and the average daily formula consumption were calculated from birth to 6 months of age. Birth weights were classified as high (≥4000 g) and normal (≥2500 g and <4000 g). Weights at 7-12 months of age were categorized as high (z score >1) or normal (z score ≤1). A secondary analysis was performed using categories defined by birth weight adjusted for gestational age percentiles (>90% and 10th-90th percentile). RESULTS: High birth weight (HBW) infants with high weights at 7-12 months of age demonstrated a rapid decline in the percentage of breast milk feedings compared with HBW infants with normal weights at 7-12 months of age. Normal birth weight infants with high weights at 7-12 months of age received a lower percentage of breast milk and had greater absolute intakes of formula than those with normal weights at 7-12 months of age; these associations did not vary over time. Results were similar when infants were categorized by birth weight percentiles. CONCLUSIONS: A lower proportion of breast milk feedings was associated with excess weight at 7-12 months of age in HBW infants. These findings suggest an initial target for obesity prevention programs focusing on the first 6 months after birth.

The continuous vs discontinuous use of restorative safety behaviors on symptoms of contamination fear: An experimental investigation.

BACKGROUND AND OBJECTIVES: Cognitive-behavioral theorists posit that safety behaviors (SBs) interfere with important exposure processes and should be removed from therapy. However, there is growing evidence to suggest that restorative SBs (RSB; those that allow for full confrontation with a core threat) do not adversely affect exposure outcomes, and their implementation during exposure should be further examined. METHODS: The current study evaluated exposure with the continuous use of RSB (E + CONT) versus discontinuation of RSB (E + DISC), in comparison to exposure with no RSB (ERP). Sixty-seven nonclinical participants completed 15 trials of exposure in which they touched a potentially contaminated stimulus with or without RSB. Behavioral approach tasks were completed at pretreatment, post-treatment, and two-week follow-up to examine changes in subjective distress and degree of behavioral approach. RESULTS: The three conditions were not different on clinical symptoms and behavioral approach at post-treatment and follow-up, indicating that the hypothesized superiority effect of E + DISC was not supported. However, ratings obtained during repeated exposure trials indicated that E + DISC evidenced greater symptom reduction following the removal of RSB. LIMITATIONS: The use of a healthy undergraduate sample and standardization of the exposure procedure. CONCLUSIONS: Although findings were contrary to hypotheses, these data provide added support for the benign role of RSB as compared to conventional exposure. Furthermore, the removal of RSB may lead to more favorable process outcomes during exposure. The theoretical and clinical implications of these findings are discussed, and future directions are provided.

The functional value of preventive and restorative safety behaviors: A systematic review of the literature.

Safety behaviors are unnecessary actions used to prevent, escape from, or reduce the severity of a perceived threat. Most cognitive-behavioral theorists posit that the use of safety behaviors during exposure is maladaptive because they interfere with fear reduction. However, there is growing evidence suggesting that the use of safety behaviors can facilitate exposure. In general, the findings are mixed as to whether safety behaviors should be made available during exposure-based interventions. The aim of the current review was to evaluate whether safety behaviors should be made accessible during exposure, and whether under certain circumstances, they facilitate or hinder important exposure outcomes. We examined two functional types of safety behaviors: preventive and restorative. A thorough review of the safety behavior literature from the last three decades was conducted. The evidence suggests (restorative) safety behaviors that allow for full confrontation with a core threat do not interfere with meaningful indicators of successful exposure, whereas (preventive) safety behaviors that hinder engagement with the stimulus or experience may weaken exposure outcomes. The theoretical and clinical implications of these findings are discussed and future directions in the investigation of safety behaviors are suggested.

A randomized waitlist-controlled pilot trial of voice over Internet protocol-delivered behavior therapy for youth with chronic tic disorders.

INTRODUCTION: Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be efficacious for chronic tic disorders (CTDs), but utilization is limited by a lack of treatment providers and perceived financial and time burden of commuting to treatment. A promising alternative to in-person delivery is voice over Internet protocol (VoIP), allowing for remote, real-time treatment delivery to patients' homes. However, little is known about the effectiveness of VoIP for CTDs. Therefore, the present study examined the preliminary efficacy, feasibility, and acceptability of VoIP-delivered CBIT (CBIT-VoIP). METHODS: Twenty youth (8-16 years) with CTDs participated in a randomized, waitlist-controlled pilot trial of CBIT-VoIP. The main outcome was pre- to post-treatment change in clinician-rated tic severity (Yale Global Tic Severity Scale). The secondary outcome was clinical responder rate (Clinical Global Impressions - Improvement Scale), assessed using ratings of 'very much improved' or 'much improved' indicating positive treatment response. RESULTS: Intention-to-treat analyses with the last observation carried forward were performed. At post-treatment (10-weeks), significantly greater reductions in clinician-rated, (F(1,18) = 3.05, p < 0.05, partial η(2 )= 0.15), and parent-reported tic severity, (F(1,18) = 6.37, p < 0.05, partial η(2 )= 0.26) were found in CBIT-VoIP relative to waitlist. One-third (n = 4) of those in CBIT-VoIP were considered treatment responders. Treatment satisfaction and therapeutic alliance were high. DISCUSSION: CBIT can be delivered via VoIP with high patient satisfaction, using accessible, low-cost equipment. CBIT-VoIP was generally feasible to implement, with some audio and visual challenges. Modifications to enhance treatment delivery are suggested.

Computerized attention retraining for individuals with elevated health anxiety.

BACKGROUND AND OBJECTIVES: Current cognitive-behavioral theorists conceptualize hypochondriasis as excessive health anxiety (HA). Growing evidence suggests that elevated HA is associated with attentional bias (AB) toward potential health-threat information. DESIGN: This study aimed to examine the effects of attention retraining among individuals with elevated HA, using the established attention modification programs (AMP) designed to train participants to disengage attention from ideographically chosen health-threat words. METHODS: Thirty-six randomly assigned individuals with elevated HA completed eight twice-weekly sessions of the AMP (n = 18) or the attention control condition (ACC; n = 18). RESULTS: Despite using the well-established AMP protocol widely used within the field of anxiety disorders, we did not find evidence for change in AB following training. Further, AMP did not outperform ACC in reducing HA and other relevant emotional symptoms. However, both AMP and ACC evidenced overall significant symptom reduction in most of the outcome measures, including overall HA, anxiety sensitivity, general depression and anxiety, and somatic complaints. CONCLUSIONS: Further research is needed to better understand the effects and mechanisms of AMP as a possible cognitive intervention for HA.

The effects of preventive and restorative safety behaviors on a single-session of exposure therapy for contamination fear.

BACKGROUND AND OBJECTIVES: Recent research suggests that safety behaviors (SB) may not preclude treatment gains in exposure-based therapy for obsessive-compulsive disorder. However, it is relatively unknown what specific types of SBs may be detrimental to the therapeutic process, with some arguing that SBs be classified based on their function. The current study sought to examine the extent to which different SBs enhanced or weakened symptoms of contamination fear during a single session of exposure. METHODS: Sixty-seven non-clinical students were randomly assigned to one of three conditions: (1) exposure with no SBs (NSB), (2) exposure with preventive SBs (PSB), or (3) exposure with restorative SBs (RSB). RESULTS: Among the primary outcome measures, greater reductions in fear and behavioral avoidance were found for RSB in comparison to PSB, and the gains made by RSB were generalizable to other sources of potential contamination. Furthermore, RSB resulted in more rapid reductions in fear and disgust across repeated exposure trials. LIMITATIONS: Limitations include the use of a nonclinical student sample. CONCLUSIONS: Overall, the current study suggests that RSB may be beneficial as an adjunct to therapy whereas PSB are potentially detrimental. Results of the study are discussed in terms of exposure theories and the treatment of anxiety disorders.

Attentional bias toward personally relevant health-threat words.

Conflicting findings have emerged regarding the presence of attentional biases (ABs) in health anxiety, probably due to methodological limitations in the stimuli used in cognitive tasks and the assessment of health anxiety-relevant factors. The current study sought to examine ABs toward health-related threats using idiographically chosen health-threat words in a non-clinical sample. A modified dot-probe task using idiographically selected health-threat words was administered to an undergraduate sample. Self-report measures were administered to assess somatic, cognitive, and behavioral aspects of health anxiety, in addition to assessing negative affect, anxiety sensitivity, and experience of actual medical conditions. Results showed that behavioral and somatic aspects of health anxiety were significantly associated with AB toward personally relevant threat words, even after controlling for negative affect, anxiety sensitivity, and experience of actual medical conditions. Additional analyses revealed that these biases reflected difficulty disengaging attention from threat rather than a facilitated detection of threat. In contrast, illness-related cognitions were found to be unrelated to ABs. These findings suggest an association between threat-related ABs and excessive health-care seeking efforts.

The association between health anxiety and disgust reactions in a contamination-based behavioral approach task.

Existing evidence suggests that disgust is an important affective process related to health anxiety. The present study sought to determine the contribution of health anxiety symptoms in the prediction of disgust and behavioral avoidance in a large, nonclinical sample (N=156). Regression analyses showed that overall health anxiety symptoms predicted disgust on a behavioral approach task independent of gender, negative affect, and fear of contamination. Particularly, health anxiety-related reassurance seeking was found to be uniquely associated with disgust and behavioral avoidance after controlling for the aforementioned covariates. In addition, the interaction between health anxiety and contamination fear was tested, and remained significant when controlling for gender and negative affect. These results suggest that heightened contamination fear is associated with elevated disgust reactions such that high levels of health anxiety leads even those low in contamination fear to be disgusted during a behavioral task. These results are in line with previous research on the role of disgust in health anxiety.

Termination of washing compulsions: a problem of internal reference criteria or 'not just right' experience?

Recent research suggests that obsessive-compulsive washers are more likely than individuals without washing compulsions to use conscious, internal reference criteria when deciding when to terminate compulsions (Wahl, Salkovskis, & Cotter, 2008). An alternative view is that they possess tendencies towards non-cognitive, automatic 'not just right' experiences (NJREs) that influence compulsion duration. The current study sought to investigate the latter explanation using valid behavioral tasks. Non-clinical participants (N=133) completed self-report measures, immersed their hands in a dirt mixture, and afterwards were allowed to wash their hands. Additionally, a subset of participants completed an in vivo assessment of NJRE using a pile of clutter. Total number and intensity of NJREs were predictive of hand-washing duration. Additionally, affective response to the clutter was uniquely predictive of hand-washing duration when controlling for pre-wash anxiety. These results suggest that internal reference criteria as well as NJREs may influence compulsive washing, though the former may be a consequence of the latter.