David M. Janicke

Extended-Care Programs for Weight Management in Rural Communities: The Treatment of Obesity in Underserved Rural Settings (TOURS) Randomized Trial

BACKGROUND Rural counties in the United States have higher rates of obesity, sedentary lifestyle, and associated chronic diseases than nonrural areas, yet the management of obesity in rural communities has received little attention from researchers. METHODS Obese women from rural communities who completed an initial 6-month weight-loss program at Cooperative Extension Service offices in 6 medically underserved rural counties (n = 234) were randomized to extended care or to an education control group. The extended-care programs entailed problem-solving counseling delivered in 26 biweekly sessions via telephone or face to face. Control group participants received 26 biweekly newsletters containing weight-control advice. RESULTS Mean weight at study entry was 96.4 kg. Mean weight loss during the initial 6-month intervention was 10.0 kg. One year after randomization, participants in the telephone and face-to-face extended-care programs regained less weight (mean [SE], 1.2 [0.7] and 1.2 [0.6] kg, respectively) than those in the education control group (3.7 [0.7] kg; P = .03 and .02, respectively). The beneficial effects of extended-care counseling were mediated by greater adherence to behavioral weight-management strategies, and cost analyses indicated that telephone counseling was less expensive than face-to-face intervention. CONCLUSIONS Extended care delivered either by telephone or in face-to-face sessions improved the 1-year maintenance of lost weight compared with education alone. Telephone counseling constitutes an effective and cost-efficient option for long-term weight management. Delivering lifestyle interventions via the existing infrastructure of the Cooperative Extension Service represents a viable means of adapting research for rural communities with limited access to preventive health services. Trial Registration clinicaltrials.gov Identifier: NCT00201006.

Comparison of Parent-Only vs Family-Based Interventions for Overweight Children in Underserved Rural Settings: Outcomes From Project STORY

OBJECTIVE To assess the effectiveness of parent-only vs family-based interventions for pediatric weight management in underserved rural settings. DESIGN A 3-arm randomized controlled clinical trial. SETTING All sessions were conducted at Cooperative Extension Service offices in underserved rural counties. PARTICIPANTS Ninety-three overweight or obese children (8-14 years old) and their parent(s). INTERVENTION Families were randomized to (1) a behavioral family-based intervention, (2) a behavioral parent-only intervention, or (3) a wait-list control group. OUTCOME MEASURE The primary outcome measure was change in childrens standardized body mass index (BMI). RESULTS Seventy-one children completed posttreatment (month 4) and follow-up (month 10) assessments. At the month 4 assessment, children in the parent-only intervention demonstrated a greater decrease in BMI z score (mean difference [MD], 0.127; 95% confidence interval [CI], 0.027 to 0.226) than children in the control condition. No significant difference was found between the family-based intervention and the control condition (MD, 0.065; 95% CI, -0.027 to 0.158). At month 10 follow-up, children in the parent-only and family-based intervention groups demonstrated greater decreases in BMI z score from before treatment compared with those in the control group (MD, 0.115; 95% CI, 0.003 to 0.220; and MD, 0.136; 95% CI, 0.018 to 0.254, respectively). No difference was found in weight status change between the parent-only and family-based interventions at either assessment. CONCLUSIONS A parent-only intervention may be a viable and effective alternative to family-based treatment of childhood overweight. Cooperative Extension Service offices have the potential to serve as effective venues for the dissemination of obesity-related health promotion programs.

Impact of Psychosocial Factors on Quality of Life in Overweight Youth

Objective: The psychosocial functioning of overweight youth is a growing concern. Research has shown that overweight children report lower quality of life (QOL) than their non‐overweight peers. This study sought to extend the literature by examining the association between peer victimization, child depressive symptoms, parent distress, and health‐related QOL in overweight youth. Mediator models are used to assess the effect of child depressive symptoms on the relationship between psychosocial variables and QOL.

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 (Hedges 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.

Comparison of program costs for parent-only and family-based interventions for pediatric obesity in medically underserved rural settings.

PURPOSE To compare the costs of parent-only and family-based group interventions for childhood obesity delivered through Cooperative Extension Services in rural communities. METHODS Ninety-three overweight or obese children (aged 8 to 14 years) and their parent(s) participated in this randomized controlled trial, which included a 4-month intervention and 6-month follow-up. Families were randomized to either a behavioral family-based intervention (n = 33), a behavioral parent-only intervention (n = 34), or a waitlist control condition (n = 26). Only program costs data for the parent-only and family-based programs are reported here (n = 67). Assessments were completed at baseline, post-treatment (month 4) and follow-up (month 10). The primary outcome measures were total program costs and cost per child for the parent-only and family interventions. FINDINGS Twenty-six families in the parent-only intervention and 24 families in the family intervention completed all 3 assessments. As reported previously, both intervention programs led to significantly greater decreases in weight status relative to the control condition at month 10 follow-up. There was no significant difference in weight status change between the parent-only and family interventions. Total program costs for the parent-only and family interventions were 13,546 US dollars and 20,928, US dollars respectively. Total cost per child for the parent-only and family interventions were 521 US dollars and 872 US dollars, respectively. CONCLUSIONS Parent-only interventions may be a cost-effective alternative treatment for pediatric obesity, especially for families in medically underserved settings.

The Impact of Peer Victimization, Parent Distress and Child Depression on Barrier Formation and Physical Activity in Overweight Youth

Objective: With the prevalence of childhood overweight reaching epidemic proportions, there is an increased need to identify factors which may aid in the development of successful weight intervention programs. Given that lower levels of physical activity are inversely correlated with weight status in children, research has focused on identifying and addressing reported barriers to physically activity. A relationship exists between the number of reported barriers and weight status such that children who are overweight report more barriers to being physically active. However, important demographic and psychosocial correlates of barriers have not been examined. Methods: This study investigates the relationship among parent distress, peer victimization, childhood depression, barriers to physical activity, and physical activity among a sample of 95 clinically overweight children and adolescents. Higher levels of parent distress, peer victimization, and childhood depression are predictive of a variety of barriers to physical activity, with peer victimization emerging as the strongest predictor of barriers. Barriers to physical activity mediate the relationships between peer victimization, parent distress, child depression and physical activity. Results: These findings have significant implications for the development/design of weight intervention programs. Interventions targeting increases in physical activity should not only focus on the barriers children report, but should also include a psycho-emotional component to address factors such as parent distress, peer victimization and child mood that may contribute to barrier formation/maintenance. Conclusion: Future interventions may benefit from the identification of additional factors that impact barrier formation and physical activity levels among children.

Commentary: Healthcare Reform and Psychology's Workforce: Preparing for the Future of Pediatric Psychology

Upcoming changes to the healthcare delivery system, detailed in the Patient Protection and Affordable Care Act (ACA; Public Law No: 111–148, March 23, 2010), focus on the growing expectation that interprofessional organizations (institutional practices such as accountable care organizations (ACOs) and patient center healthcare homes) will become the nexus of the delivery of efficient, cost effective, and quality healthcare services (Orszag & Emanuel, 2010; Rozensky, 2011). If the legislation survives the legal battles currently being waged, the healthcare delivery system will look very different by the end of this decade (Clay, 2011). The healthcare workforce of the future must be prepared to enhance quality of patient care utilizing defined, interprofessional competencies as they practice within an increasingly evidence-based, team-based, integrated care system—from prevention to primary to tertiary care—and for patients and families across the lifespan (Institute of Medicine, 2001; Wilson, Rozensky, & Weiss, 2010). This article describes several challenges and opportunities facing professional psychology given the upcoming demands of the ACA and evolving healthcare system. We argue that preparation for increased institutional practice is required and that several philosophical and practical changes will be necessary as our profession adapts to this new healthcare system. The interprofessional strengths of pediatric psychology are discussed in particular and specific opportunities and recommendations are offered to enhance the future of pediatric psychology in (the new) healthcare. Some Questions Professional Psychology Might Answer to Prepare to Successfully Participate in Upcoming Changes to the Healthcare System

Psychiatric diagnosis in children and adolescents with obesity-related health conditions.

Objective: Childhood obesity is linked with a number of problematic health conditions. While data suggest that children who are obese are at increased risk of psychosocial distress relative to nonobese peers, there are limited data outlining the rates of psychiatric diagnoses in children with obesity-related health conditions such as type 2 diabetes and the metabolic syndrome. Methods: This study used Medicaid claims data from the State of Florida to compare the rates of psychiatric diagnoses for children with obesity-related health conditions, aged 5 to 18 years, to those of children with comparison chronic health conditions. Results: Overall, 35% of children with an obesity-related diagnosis had a psychiatric diagnosis. While controlling for age, gender, and race, youths with type 2 diabetes, the metabolic syndrome, and dyslipidemia had higher rates of International Classification of Disease, Ninth Revision (ICD-9) psychiatric diagnoses than children with cystic fibrosis, sickle cell disease, and juvenile rheumatoid arthritis (p < .001), but similar to those of children with asthma. Non-Hispanic white children with an obesity-related health condition had greater odds of receiving a psychiatric diagnosis than African American (odds ratio [OR] = 0.54, p < .001) or Hispanic (OR = 0.41, p < .001) children. Males and females differed in rates of externalizing and internalizing diagnoses. Conclusions: The data suggest that children with an obesity-related health condition have higher rates of internalizing and externalizing mental health conditions relative to children with other chronic health conditions. Prospective, longitudinal research is needed to further confirm these findings and examine factors that affect this association and potential impacts on the health care system.

Factors associated with parental use of restrictive feeding practices to control their children's food intake §

There is a critical need to identify risk factors that make parents more likely to restrict their childs food intake. Child weight and ethnicity, parent weight, parent body dissatisfaction, and parent concern of child weight were examined as correlates of parent use of restrictive feeding practices in a diverse sample of 191 youth (ages 7-17). Participants attending a pediatric outpatient visit completed the Child Feeding Questionnaire (parent feeding practices and beliefs), the Figure Rating Scale (body dissatisfaction) and a demographic form. Parent BMI and child degree of overweight were calculated. Parent use of restrictive feeding practices was positively associated with parent BMI and was moderated by parent body dissatisfaction. Parent concern of child weight mediated the relationship between increasing child degree of overweight and parent use of restrictive feeding practices. There were no differences by child gender or ethnicity in parent use of restrictive feeding practices. These preliminary findings highlight the importance of assessing for underlying parent motivations for utilizing restrictive feeding practices and may help to identify and intervene with families at-risk for engaging in counterproductive weight control strategies. Continued identification of correlates of parent use of restrictive feeding practices is needed across child development and among individuals from diverse backgrounds.

Recommendations for Training in Pediatric Psychology: Defining Core Competencies Across Training Levels

OBJECTIVE As a field, pediatric psychology has focused considerable efforts on the education and training of students and practitioners. Alongside a broader movement toward competency attainment in professional psychology and within the health professions, the Society of Pediatric Psychology commissioned a Task Force to establish core competencies in pediatric psychology and address the need for contemporary training recommendations.  METHODS  The Task Force adapted the framework proposed by the Competency Benchmarks Work Group on preparing psychologists for health service practice and defined competencies applicable across training levels ranging from initial practicum training to entry into the professional workforce in pediatric psychology.  RESULTS  Competencies within 6 cluster areas, including science, professionalism, interpersonal, application, education, and systems, and 1 crosscutting cluster, crosscutting knowledge competencies in pediatric psychology, are presented in this report.  CONCLUSIONS  Recommendations for the use of, and the further refinement of, these suggested competencies are discussed.