Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019).

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Psychosocial Moderators and Outcomes of a Randomized Effectiveness Trial for Child Asthma.

OBJECTIVE: Psychosocial factors play a role in child asthma morbidity and disparities, but their impact on asthma intervention effectiveness is less understood. This study examined how child, parent, and family psychosocial factors moderated asthma response to, and changed in response to, 2 community asthma interventions among urban minority youth. METHODS: Asthma Action at Erie was a randomized comparative effectiveness trial examining a community health worker (CHW) home intervention versus certified asthma educator (AE-C) services for children aged 5-16 with uncontrolled asthma (N = 223; mean age = 9.37, SD = 3.02; 85.2% Hispanic). Asthma control was assessed via the Asthma Control Test (ACT)/childhood ACT and activity limitation. Baseline child/parent depression and posttraumatic stress disorder (PTSD) symptoms, family chaos, and social support were examined as treatment moderators. We also tested intervention effects on psychosocial outcomes. RESULTS: For parents with higher baseline depression symptoms, youth in the CHW group had greater ACT improvement by 24 months (7.49 points) versus AE-C (4.76 points) and 51% reduction in days of limitation by 6 months versus AE-C (ß = -0.118; p = .0145). For higher parent PTSD symptoms, youth in CHW had 68% fewer days of limitation at 24 months versus AE-C (ß = -0.091; p = .0102). Psychosocial outcomes did not vary by group, but parent depression, parent and child PTSD symptoms, and social support improved for all. CONCLUSIONS: CHW intervention was associated with improved asthma control among families with higher parent strain. Findings have implications for utilizing tailored CHW home interventions to optimize asthma outcomes in at-risk families.

Dynamic associations of negative mood and smoking across the development of smoking in adolescence.

Self-medication models of smoking posit that the emotional benefits of smoking reinforce and maintain cigarette use, yet research demonstrates both positive and adverse affective consequences of smoking. The current study examined longitudinal changes in adolescent mood variability and overall negative mood at various stages of smoking behavior to inform understanding of the etiology of adolescent smoking. Participants included 461 adolescents (M age = 15.67 years, SD = 0.61; 55% girls, 56.8% White) drawn from a longitudinal study of adolescent smoking. Youth provided data on smoking behavior at baseline and a 15-month follow-up wave. Ecological momentary assessments were used to measure overall levels of negative mood as well as within-person mood fluctuations (i.e., negative mood variability) at each wave. Findings revealed that smoking-mood relations vary across different stages of smoking behavior. Youth who rapidly escalated in their smoking during the study experienced improved mood regulation (for girls) and improved overall mood (for boys) as smoking increased. However, mood improvements were not observed among youth with sustained heavy use and symptoms of dependence. The current data argue for a model of smoking that accounts for changes in risk and maintenance factors at different points along the developmental trajectory of smoking, involving elements of both self-medication and dependence.

Improving Adherence in Urban Youth With Asthma: Role of Community Health Workers.

BACKGROUND: The Asthma Action at Erie Trial is a comparative effectiveness trial comparing a community health worker (CHW) versus certified asthma educator (AE-C) intervention in low-income minority children. OBJECTIVES: Determine whether asthma medication possession, adherence, technique, and triggers differ in children receiving an asthma CHW compared with an AE-C intervention. METHODS: Children with uncontrolled asthma were randomized to receive 10 CHW home visits or 2 AE-C sessions in a clinic over 1 year. Asthma medication possession and inhaler technique were observed; adherence was measured using self-report, dose counters, and electronic monitors. Environmental triggers were captured by self-report, observation, and objective measurement. Mixed effects linear and logistic regression models were estimated for continuous and binary outcomes. RESULTS: Children (n = 223) were mainly Hispanic (85%) and ages 5 to 16 years. Quick-relievers (82%), spacers (72%), and inhaled corticosteroid (ICS)-containing medications (44%) were tracked. Of those with uncontrolled asthma, 35% lacked an ICS prescription (n = 201). Children in the CHW arm were more likely to have an ICS prescription at 12 months (odds ratio 2.39; 95% CI 0.99-5.79). Inhaler technique improved 9.8% in the CHW arm at 6 months (95% CI 4.20-15.32). The ICS adherence improved in the CHW arm at 12 months, with a 16.0% (95% CI 2.3-29.7; P = .02) difference between arms. Differences in trigger exposure over time were not observed between arms. CONCLUSIONS: The CHW services were associated with improved ICS adherence and inhaler technique, compared with AE-C services. More information is needed to determine the necessary dosage of intervention to sustain adherence.

Assessing change in suicidal ideation intensity for youth in treatment for pediatric bipolar disorder.

OBJECTIVE: Suicidal ideation (SI) is significantly higher for youth with pediatric bipolar disorder (PBD), yet clinical correlates of suicidality remain poorly understood in this population. The current study investigates how change in risk factors for SI relate to change in SI intensity over a 6-month period of treatment. METHOD: Children ages 9 to 13 (N = 71; 41% female; 54% Caucasian; Mean age = 9.17) engaged in one of two psychotherapy treatment conditions and completed assessments of SI risk factors and psychopathology symptoms at baseline (pre-treatment), 4 and 8 weeks (during treatment), 12 weeks (post-treatment), and 39 weeks (follow-up assessment at 6 months post-treatment). Children also completed assessments of SI intensity at baseline, post-treatment (12 weeks), and 6 months post-treatment. RESULTS: Mixed-effects regression models indicate that increases in health-related quality of life in the family, mobilization of the family to acquire/accept help for PBD, and child self-concept were associated with decreased SI intensity over time. CONCLUSIONS: Findings highlight the importance of family and child level factors in influencing longitudinal change in SI intensity in youth with PBD. Clinical implications and future directions are discussed.

Parent Nativity and Child Asthma Control in Families of Mexican Heritage: The Effects of Parent Depression and Social Support.

OBJECTIVE: Research has repeatedly demonstrated that parent foreign nativity has a protective effect on child asthma outcomes among Mexican Americans, but the mechanisms underlying this relationship are not well understood. The current study explored parent depression as a mediator and social support as a moderator of the parent nativity-child asthma control pathway. METHODS: Data come from the baseline sample of a trial (NCT02481986) testing community interventions for 223 children aged 5 to 16 with uncontrolled asthma. We focused on parent/child dyads of Mexican heritage (N = 165; mean age = 9.08, standard deviation = 2.94; 57.3% with Mexico-born parent). Asthma control was defined using the child and adult versions of the Asthma Control Test (ACT). Psychosocial factors included parent depression symptoms and social (instrumental, informational, and emotional) support. RESULTS: Mexican-born parents had fewer depressive symptoms (ß^ = -2.03, SE^ = 0.24) and children with better asthma control (ß^ = 1.78, SE^ = 0.24) than US-born parents, P < .0001. Analyses suggested partial mediation of the nativity-ACT path via parent depression (P < .001). An interaction between Instrumental Support and Nativity was marginally significant (ß^ = -0.10, SE^ = 0.05, P = .07), with protective effects only observed at higher support levels. Last, among Mexico-born parents, the protective nativity effects on ACT declined with increasing residential years in the United States through 12 years. CONCLUSIONS: This study is novel in identifying parent depression as one mechanism underlying the effects of parent nativity on child asthma control, but results suggest that the health advantages may depend on availability of support. Providing resources for parent depression and instrumental support (transportation, childcare) can optimize asthma interventions in this population.

Implementation Lessons From a Randomized Trial Integrating Community Asthma Education for Children.

This study characterized and compared the implementation of clinically integrated community health workers (CHWs) to a certified asthma educator (AE-C) for low-income children with asthma. In the AE-C arm (N = 115), 51.3% completed at least one in-clinic education session. In the CHW arm (N = 108), 722 home visits were completed. The median number of visits was 7 (range, 0-17). Scheduled in-clinic asthma education may not be the optimal intervention for this patient population. CHW visit completion rates suggest that the schedule, location, and content of CHW asthma services better met patients' needs. Seven to 10 visits seemed to be the preferred CHW dose.

Family Chaos and Asthma Control.

OBJECTIVES: Asthma is a highly prevalent childhood chronic disease, with particularly high rates among poor and minority youth. Psychosocial factors have been linked to asthma severity but remain poorly understood. This study examined (1) relationships between parent and child depression and posttraumatic stress disorder (PTSD) symptoms, family functioning, and child asthma control in a sample of urban minority youth with uncontrolled asthma and (2) family functioning as a pathway linking parent depression and asthma outcomes. METHODS: Data were drawn from the baseline cohort of a randomized trial testing community interventions for children aged 5 to 16 with uncontrolled asthma (N = 223; mean age = 9.37, SD = 3.02; 85.2% Hispanic). Asthma control was defined by using the Asthma Control Test and Childhood Asthma Control Test, activity limitation, and previous-12-month asthma severity. Psychosocial measures included parent and child depression and PTSD symptoms, family chaos, and parent social support. RESULTS: Parent and child depression symptoms, but not PTSD, were associated with worse asthma control (ß = -.20 [SE = 0.06] and ß = -.12 [SE = -.03]; P < .001). Family chaos corresponded to worse asthma control, even when controlling for parent and child depression (ß = -.33; [SE = 0.15]; P < .05), and was a mediator of the parent depression-asthma path. Emotional triggers of asthma also mediated the parent depression-asthma relationship. CONCLUSIONS: Findings highlight family chaos as a mechanism underlying the relationship between parent depression and child asthma control. Addressing parent and child depression, family routines, and predictability may optimize asthma outcomes.

"THINK" Before You Order: Multidisciplinary Initiative to Reduce Unnecessary Lab Testing.

Inappropriate daily lab testing can have adverse effects on patients, including anemia, pain, and interruption of sleep. We implemented a student-led, multifaceted intervention featuring clinician education, publicity campaign, gamification, and system changes, including a novel nurse-driven protocol to reduce unnecessary daily lab testing in a teaching hospital. We applied a quasi-experimental interrupted time series design with a segmented regression analysis to estimate changes before and after our 14-month intervention with a comparison to a control surgical unit. There was an increasing trend in the baseline period, which was mitigated by the intervention (postintervention effect estimate -0.04 labs per patient day/month, p < .05), which was not seen in the control unit. Estimated cost savings was $94,269 ($6,734/month). A student-led, multidisciplinary campaign involving nurse-driven pathway, education, publicity, gamification, and system changes was effective in reducing daily lab testing.

Design and baseline characteristics of a low-income urban cohort of children with asthma: The Asthma Action at Erie Trial.

OBJECTIVE: To describe the methodology of a randomized controlled trial comparing the efficacy of integrated asthma community health workers (CHW) and a certified asthma educator (AE-C) to improve asthma outcomes in low-income minority children in Chicago. METHODS: Child/caregiver dyads were randomized to CHW home visits or education in the clinic from an AE-C. Intervention was delivered in the first year after enrollment. Data collection occured at baseline, 6-, 12-, 18, and 24-months. The co-primary outcomes included asthma control using the Asthma Control Test/childhood Asthma Control Test (ACT/cACT) and activity limitation over the past 14 days. RESULTS: A total of 223 participants ages 5-16 years were randomized. The majority of children were in the 5-11 year old range (78.9%). Most caregivers (96.9%) and 44% of children were female. Approximately 85% of caregivers and children reported Hispanic ethnicity and 62.3% reported a household income of ≤ $59,000. Over half (55.7%) had uncontrolled asthma as measured by ACT/cACT; 13.9% had a normal ACT/cACT score but were uncontrolled using the Asthma Control Questionnaire and 20.2% were controlled on both measures but had received oral steroids in the past year for asthma. CONCLUSION: The Asthma Action at Erie Trial successfully recruited a largely Hispanic cohort of children with uncontrolled or high-risk asthma to study the differential effects of clinic-based AE-C and home-based CHW interventions. Strengths of the trial include its comparative effectivness design that integrates interventionists and intervention delivery into a clinical setting. Categorizing asthma control in community settings for research purposes presents unique challenges. CLINICAL TRIAL REGISTRATION: University of Illinois at Chicago Protocol Record R01HL123797, Asthma Action at Erie TrialClinicalTrials.gov Identifier: NCT02481986 "ClinicalTrials.gov Registration" register@clinicaltrials.gov.

Mood variability and cigarette smoking escalation among adolescents.

The current study examined how affect dysregulation, as indexed via within-person negative mood variability, related to longitudinal patterns of smoking among adolescents. Students in the 8th and 10th grades (N = 517, 56% girls) provided data on cigarette use at baseline, 6-, and 12-month waves and provided ecological momentary assessments of negative moods via palmtop computers for 1 week at each wave. Mood variability was examined via the intraindividual standard deviations of negative mood reports at each wave. As predicted, high levels of negative mood variability at baseline significantly differentiated participants who escalated in their smoking behavior over time from participants who never progressed beyond low levels of experimentation during the course of the study. Mixed-effects regression models revealed that participants who escalated in their smoking experienced a reduction in mood variability as smoking increased, whereas participants with consistently high or low levels of cigarette use had more stable mood variability levels. Results suggest that high negative mood variability is a risk factor for future smoking escalation and that mood-stabilizing effects may reinforce and maintain daily cigarette use among youths.

Non-Suicidal Self-Injury in Pediatric Bipolar Disorder: Clinical Correlates and Impact on Psychosocial Treatment Outcomes.

Non-suicidal self-injury (NSSI) in childhood is not well documented, especially among youth with pediatric bipolar disorder (PBD). The current study evaluated prevalence and correlates of NSSI, and its impact on intervention response, in a randomized trial of Child- and Family-Focused Cognitive-Behavioral Therapy (CFF-CBT) versus Treatment As Usual (TAU), adjunctive to pharmacotherapy. This study included 72 children ages 7-13 (58% male) with PBD. NSSI and correlates were assessed at baseline; mood and psychiatric severity were measured longitudinally. NSSI was common: 31% endorsed NSSI behaviors; 10% reported thoughts of NSSI, in the absence of behaviors. Children engaging in NSSI reported higher depression, psychosis, suicidality, and hopelessness; lower self-esteem; and reduced family help-seeking in univariate analyses. In a multivariate logistic regression, high child depression and psychosis, and low family help-seeking, remained significantly associated with baseline NSSI. In mixed-effects regression models, presence of NSSI at baseline did not influence the response of depressive symptoms to treatment. Children who endorsed NSSI experienced steeper response trajectories for psychiatric severity, regardless of treatment group. Youth who denied NSSI showed poorer response to TAU for manic symptoms; mania trajectories in CFF-CBT were similar across youth. Thus, NSSI in PBD is common and associated with impairment. As children might engage in NSSI for different reasons, the function of NSSI should be considered in treatment. Since children without NSSI fared worse in TAU, it may be important to ensure that youth with PBD receive structured, intensive interventions. CFF-CBT was efficacious regardless of NSSI, and thus shows promise for high-risk children with PBD.

Child- and Family-Focused Cognitive Behavioral Therapy for Pediatric Bipolar Disorder: Applications for Suicide Prevention.

Despite high rates of suicide ideation (SI) and behavior in youth with pediatric bipolar disorder (PBD), little work has examined how psychosocial interventions impact suicidality among this high-risk group. The current study examined SI outcomes in a randomized clinical trial comparing Child- and Family-Focused Cognitive Behavioral Therapy (CFF-CBT) for PBD versus psychotherapy treatment-as-usual (TAU). Although not designed for suicide prevention, CFF-CBT addresses child and family factors related to suicide risk and thus was hypothesized to generalize to the treatment of suicidality. Participants included 71 youth aged 7-13 years (M = 9.17, SD = 1.60) with DSM-IV-TR bipolar I, II, or not otherwise specified randomly assigned, with parent(s), to receive CFF-CBT or TAU. Both treatments consisted of 12 weekly and 6 monthly booster sessions. Suicide ideation was assessed via clinician interview at baseline, posttreatment, and 6-month follow-up. Results indicated that SI was prevalent pretreatment: 39% of youth reported current suicidal thoughts. All youth significantly improved in the likelihood and intensity of ideation across treatment, but group differences were not significant. Thus, findings suggest that early intervention for these high-risk youth may reduce SI, and at this stage of suicidality, youth may be responsive to even nonspecialized treatment.

Symptom Dimensions and Trajectories of Functioning Among Bipolar Youth: A Cluster Analysis.

BACKGROUND: Accurate assessment of pediatric bipolar disorder (BD) is important for allocating appropriate treatment, but it is complicated by significant heterogeneity in symptom presentation and high rates of comorbidity. Investigating clinical subtypes of the disorder may help to clarify diagnostic boundaries and inform targeted treatment. This study used a full diagnostic instrument to examine symptom patterns among youth with BD. METHOD: Trained interviewers completed the Washington University Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) with 71 children (7 to 13 y of age) and families as part of the baseline assessment for a randomized clinical trial of Child- and Family-focused Cognitive-Behavioral Therapy (CFF-CBT) compared with treatment as usual (TAU) for pediatric BD. All participants met DSM-IV-TR criteria for a bipolar spectrum disorder. Hierarchical and K-means cluster analyses were performed. Resultant clusters were compared on symptom severity and psychosocial functioning at baseline and across treatment. RESULTS: Two distinct symptom profiles emerged: "dysregulated/defiant" and "classic presentation." The dysregulated/defiant cluster was characterized by more externalizing and disruptive behaviors, whereas the classic cluster presented with more severe depression, hallmark manic symptoms, anxiety, and inattention. CFF-CBT consistently promoted psychosocial coping skills, such as problem solving and self-control, for the dysregulated/defiant cluster. TAU also promoted these skills among the individuals in the classic presentation group but not those with symptoms in the dysregulated/defiant cluster. DISCUSSION: Pediatric BD may be characterized by distinct phenotypes with unique etiologies and pathways to impairment. The use of a parametric approach to classify the diverse symptom presentations helped yield valuable insights into how to promote the best prognosis for improved functional outcomes in CFF-CBT versus TAU for youth with pediatric BD.

The time-varying influences of peer and family support on adolescent daily positive and negative affect.

The time-varying influences of peer and family support on adolescent daily mood were explored among youth transitioning from middle school to high school (8th to 9th grade, N = 268) as compared to youth transitioning from 10th to 11th grade (N = 240). Real-time measures of daily positive and negative affect (ecological momentary assessments) were collected via palmtop computers at baseline, 6 months, and 12 months. Participants rated 12 mood adjectives in response to 5 to 7 random prompts per day for 7 consecutive days. Perceived peer and family support were assessed via self-report. Mixed-effects regression analyses revealed significant grade by time by peer support interactions for positive and negative mood, with the younger cohort showing greater increases in the relation between peer support and affect over time than the older cohort. Family support did not interact with cohort or time.

Mediators in the randomized trial of Child- and Family-Focused Cognitive-Behavioral Therapy for pediatric bipolar disorder.

Mediation analyses can identify mechanisms of change in Cognitive-Behavioral Therapy (CBT). However, few studies have analyzed mediators of CBT for youth internalizing disorders; only one trial evaluated treatment mechanisms for youth with mixed mood diagnoses. This study evaluated mediators in the randomized trial of Child- and Family-Focused CBT (CFF-CBT) versus Treatment As Usual (TAU) for pediatric bipolar disorder (PBD), adjunctive to pharmacotherapy. Sixty-nine children ages 7-13 with PBD were randomly assigned to CFF-CBT or TAU. Primary outcomes (child mood, functioning) and candidate mediators (family functioning, parent/child coping) were assessed at baseline and 4-, 8-, 12- (post-treatment), and 39-weeks (follow-up). Compared with TAU, children receiving CFF-CBT exhibited greater improvement in mania, depression, and global functioning. Several parent and family factors significantly improved in response to CFF-CBT versus TAU, and were associated with the CFF-CBT treatment effect. Specifically, parenting skills and coping, family flexibility, and family positive reframing showed promise as mediators of child mood symptoms and global functioning. Main or mediating effects for youth coping were not significant. CFF-CBT may impact children's mood and functioning by improving parenting skills and coping, family flexibility, and family positive reframing. Findings highlight the importance of parent coping and family functioning in the treatment of PBD.