Kate Lycett

Shared care obesity management in 3-10 year old children: 12 month outcomes of HopSCOTCH randomised trial

Objective To determine whether general practice surveillance for childhood obesity, followed by obesity management across primary and tertiary care settings using a shared care model, improves body mass index and related outcomes in obese children aged 3-10 years. Design Randomised controlled trial. Setting 22 family practices (35 participating general practitioners) and a tertiary weight management service (three paediatricians, two dietitians) in Melbourne, Australia. Participants Children aged 3-10 years with body mass index above the 95th centile recruited through their general practice between July 2009 and April 2010. Intervention Children were randomly allocated to one tertiary appointment followed by up to 11 general practice consultations over one year, supported by shared care, web based software (intervention) or “usual care” (control). Researchers collecting outcome measurements, but not participants, were blinded to group assignment. Main outcome measures Children’s body mass index z score (primary outcome), body fat percentage, waist circumference, physical activity, quality of diet, health related quality of life, self esteem, and body dissatisfaction and parents’ body mass index (all 15 months post-enrolment). Results 118 (60 intervention, 56 control) children were recruited and 107 (91%) were retained and analysed (56 intervention, 51 control). All retained intervention children attended the tertiary appointment and their general practitioner for at least one (mean 3.5 (SD 2.5, range 1-11)) weight management consultation. At outcome, children in the two trial arms had similar body mass index (adjusted mean difference −0.1 (95% confidence interval −0.7 to 0.5; P=0.7)) and body mass index z score (−0.05 (−0.14 to 0.03); P=0.2). Similarly, no evidence was found of benefit or harm on any secondary outcome. Outcomes varied widely in the combined cohort (mean change in body mass index z score −0.20 (SD 0.25, range −0.97-0.47); 26% of children resolved from obese to overweight and 2% to normal weight. Conclusions Although feasible, not harmful, and highly rated by both families and general practitioners, the shared care model of primary and tertiary care management did not lead to better body mass index or other outcomes for the intervention group compared with the control group. Improvements in body mass index in both groups highlight the value of untreated controls when determining efficacy. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12608000055303.

A prospective study of sleep problems in children with ADHD

BACKGROUND Behavioral sleep problems are common in children with attention-deficit/hyperactivity disorder (ADHD), yet their persistence or otherwise is unknown. We examined behavioral sleep problem trajectories, types of sleep problems experienced, and associated risk/protective factors. METHODS DESIGN Prospective cohort study. SETTING Twenty-one pediatric practices across Victoria, Australia. PARTICIPANTS A total of 195 children with ADHD (5-13 years). OUTCOMES Sleep problem trajectories classified as never, transient, or persistent on the basis of sleep problem severity measured at baseline, 6, and 12 months. Explanatory variables: Types of sleep problems, internalizing and externalizing comorbidities, ADHD symptom severity and medication use, autism spectrum disorder, caregiver mental health, and sociodemographic factors. ANALYSES Multinomial logistic regression models. RESULTS Sleep problems fluctuated over 12 months, but for 10% of children they persisted. In adjusted analyses, co-occurring internalizing and externalizing comorbidities were a risk factor for persistent (odds ratio (OR) 9.2, 95% confidence interval (CI) 1.6, 53.9, p = 0.01) and transient (OR 3.7, 95% CI 1.5, 8.8, p = 0.003) sleep problems, while greater ADHD symptom severity and poorer caregiver mental health were risk factors for persistent and transient sleep problems, respectively. CONCLUSIONS Sleep problems in children with ADHD are commonly transient, but in a subgroup they are characterized as persistent. Early preventive/intervention strategies should target children at risk of persistent sleep problems.

Anxiety in Children With Attention-Deficit/Hyperactivity Disorder

OBJECTIVES: Although anxiety is common in children with attention-deficit/hyperactivity disorder (ADHD), it is unclear how anxiety influences the lives of these children. This study examined the association between anxiety comorbidities and functioning by comparing children with ADHD and no, 1, or ≥2 anxiety comorbidities. Differential associations were examined by current ADHD presentation (subtype). METHODS: Children with diagnostically confirmed ADHD (N = 392; 5–13 years) were recruited via 21 pediatrician practices across Victoria, Australia. Anxiety was assessed by using the Anxiety Disorders Interview Schedule for Children—IV. Functional measures included parent-reported: quality of life (QoL; Pediatric Quality of Life Inventory 4.0), behavior and peer problems (Strengths and Difficulties Questionnaire), daily functioning (Daily Parent Rating of Evening and Morning Behavior), and school attendance. Teacher-reported behavior and peer problems (Strengths and Difficulties Questionnaire) were also examined. Linear and logistic regression controlled for ADHD severity, medication use, comorbidities, and demographic factors. RESULTS: Children with ≥2 anxiety comorbidities (n = 143; 39%) had poorer QoL (effect size: –0.8) and more difficulties with behavior (effect size: 0.4) and daily functioning (effect size: 0.3) than children without anxiety (n = 132; 36%). Poorer functioning was not observed for children with 1 anxiety comorbidity (n = 95; 26%). Two or more anxiety comorbidities were associated with poorer functioning for children with both ADHD-Inattentive and ADHD-Combined presentation. CONCLUSIONS: Children with ADHD demonstrate poorer QoL, daily functioning and behavior when ≥2 anxiety comorbidities are present. Future research should examine whether treating anxiety in children with ADHD improves functional outcomes.

Use of sleep medication in children with ADHD

OBJECTIVE Sleep problems are common in children with attention-deficit/hyperactivity disorder (ADHD), yet little is known about sleep medication use in this population. The aim of this study was to describe sleep medication use, as well as associated child and family characteristics in school-aged children with ADHD. METHOD Sleep medication use was ascertained using a prospective parent-completed seven-night sleep and medication log. Exposure variables included socio-demographic characteristics, total sleep problem severity (Childrens Sleep Habits Questionnaire), ADHD severity and subtype (ADHD Rating Scale IV), ADHD medication use, internalising and externalising co-morbidities (Anxiety Disorders Interview Schedule for Children/Parent version IV) and parent mental health (Depression Anxiety Stress Scale). RESULTS Two hundred and fifty-seven children with ADHD participated and of these 57 (22%) were taking sleep medication (melatonin 14% and clonidine 9%). Sleep medication use was associated with combined-type ADHD and ADHD medication use. The presence of co-occurring internalising and externalising co-morbidities was also associated with sleep medication use in ad hoc analyses. CONCLUSION Sleep medication use is common in children with ADHD and is associated with combined-type ADHD and use of ADHD medication. Further research is needed on the broad functional benefits and long-term safety of sleep medication in this population.

Behavioural sleep problems in children with attention-deficit/hyperactivity disorder (ADHD): protocol for a prospective cohort study

Introduction Children with attention-deficit/hyperactivity disorder (ADHD) commonly experience behavioural sleep problems, yet these difficulties are not routinely assessed and managed in this group. Presenting with similar symptoms to ADHD itself, sleep problems are complex in children with ADHD and their aetiology is likely to be multifactorial. Common internalising and externalising comorbidities have been associated with sleep problems in children with ADHD; however, this relationship is yet to be fully elucidated. Furthermore, limited longitudinal data exist on sleep problems in children with ADHD, thus their persistence and impact remain unknown. In a diverse sample of children with ADHD, this study aims to: (1) quantify the relationship between sleep problems and internalising and externalising comorbidities; (2) examine sleep problem trajectories and risk factors; and (3) examine the longitudinal associations between sleep problems and child and family functioning over a 12-month period. Methods and analysis A prospective cohort study of 400 children with ADHD (150 with no/mild sleep problems, 250 with moderate/severe sleep problems) recruited from paediatric practices across Victoria, Australia. The childrens parents and teacher provide data at baseline and 6-month and 12-month post enrolment. Key measures Parent report of childs sleep problem severity (no, mild, moderate, severe); specific sleep domain scores assessed using the Child Sleep Habits Questionnaire; internalising and externalising comorbidities assessed by the Anxiety Disorders Interview Schedule for Children IV/Parent version. Analyses Multiple variable logistic and linear regression models examining the associations between key measures, adjusted for confounders identified a priori. Ethics and dissemination Ethics approval has been granted. Findings will contribute to our understanding of behavioural sleep problems in children with ADHD. Clinically, they could improve the assessment and management of sleep problems in this group. We will seek to publish in leading paediatric journals, present at conferences and inform Australian paediatricians through the Australian Paediatric Research Network.

A shared-care model of obesity treatment for 3–10 year old children: Protocol for the HopSCOTCH randomised controlled trial

BackgroundDespite record rates of childhood obesity, effective evidence-based treatments remain elusive. While prolonged tertiary specialist clinical input has some individual impact, these services are only available to very few children. Effective treatments that are easily accessible for all overweight and obese children in the community are urgently required. General practitioners are logical care providers for obese children but high-quality trials indicate that, even with substantial training and support, general practitioner care alone will not suffice to improve body mass index (BMI) trajectories. HopSCOTCH (the Shared Care Obesity Trial in Children) will determine whether a shared-care model, in which paediatric obesity specialists co-manage obesity with general practitioners, can improve adiposity in obese children.DesignRandomised controlled trial nested within a cross-sectional BMI survey conducted across 22 general practices in Melbourne, Australia.ParticipantsChildren aged 3–10 years identified as obese by Centers for Disease Control criteria at their family practice, and randomised to either a shared-care intervention or usual care.InterventionA single multidisciplinary obesity clinic appointment at Melbourne’s Royal Children’s Hospital, followed by regular appointments with the child’s general practitioner over a 12 month period. To support both specialist and general practice consultations, web-based shared-care software was developed to record assessment, set goals and actions, provide information to caregivers, facilitate communication between the two professional groups, and jointly track progress.OutcomesPrimary - change in BMI z-score. Secondary - change in percentage fat and waist circumference; health status, body satisfaction and global self-worth.DiscussionThis will be the first efficacy trial of a general-practitioner based, shared-care model of childhood obesity management. If effective, it could greatly improve access to care for obese children.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12608000055303

Preventing mental health problems in children: the Families in Mind population-based cluster randomised controlled trial

BackgroundExternalising and internalising problems affect one in seven school-aged children and are the single strongest predictor of mental health problems into early adolescence. As the burden of mental health problems persists globally, childhood prevention of mental health problems is paramount. Prevention can be offered to all children (universal) or to children at risk of developing mental health problems (targeted). The relative effectiveness and costs of a targeted only versus combined universal and targeted approach are unknown. This study aims to determine the effectiveness, costs and uptake of two approaches to early childhood prevention of mental health problems ie: a Combined universal-targeted approach, versus a Targeted only approach, in comparison to current primary care services (Usual care).Methods/designThree armed, population-level cluster randomised trial (2010–2014) within the universal, well child Maternal Child Health system, attended by more than 80% of families in Victoria, Australia at infant age eight months.Participants were families of eight month old children from nine participating local government areas. Randomised to one of three groups: Combined, Targeted or Usual care.The interventions comprises (a) the Combined universal and targeted program where all families are offered the universal Toddlers Without Tears group parenting program followed by the targeted Family Check-Up one-on-one program or (b) the Targeted Family Check-Up program. The Family Check-Up program is only offered to children at risk of behavioural problems.Participants will be analysed according to the trial arm to which they were randomised, using logistic and linear regression models to compare primary and secondary outcomes. An economic evaluation (cost consequences analysis) will compare incremental costs to all incremental outcomes from a societal perspective.DiscussionThis trial will inform public health policy by making recommendations about the effectiveness and cost-effectiveness of these early prevention programs. If effective prevention programs can be implemented at the population level, the growing burden of mental health problems could be curbed.Trial registrationISRCTN61137690

Time-Use Patterns and Health-Related Quality of Life in Adolescents

In this cross-sectional study of 1455 11- to 12-year-olds, we examined the association between 24-hour time-use patterns and HRQoL. OBJECTIVES: To describe 24-hour time-use patterns and their association with health-related quality of life (HRQoL) in early adolescence. METHODS: The Child Health CheckPoint was a cross-sectional study nested between Waves 6 and 7 of the Longitudinal Study of Australian Children. The participants were 1455 11- to 12-year-olds (39% of Wave 6; 51% boys). The exposure was 24-hour time use measured across 259 activities using the Multimedia Activity Recall for Children and Adolescents. “Average” days were generated from 1 school and 1 nonschool day. Time-use clusters were derived from cluster analysis with compositional inputs. The outcomes were self-reported HRQoL (Physical and Psychosocial Health [PedsQL] summary scores; Child Health Utility 9D [CHU9D] health utility). RESULTS: Four time-use clusters emerged: “studious actives” (22%; highest school-related time, low screen time), “techno-actives” (33%; highest physical activity, lowest school-related time), “stay home screenies” (23%; highest screen time, lowest passive transport), and “potterers” (21%; low physical activity). Linear regression models, adjusted for a priori confounders, showed that compared with the healthiest “studious actives” (mean [SD]: CHU9D 0.84 [0.14], PedsQL physical 86.8 [10.8], PedsQL psychosocial 79.9 [12.6]), HRQoL in “potterers” was 0.2 to 0.5 SDs lower (mean differences [95% confidence interval]: CHU9D −0.03 [−0.05 to −0.00], PedsQL physical −5.5 [−7.4 to −3.5], PedsQL psychosocial −5.8 [−8.0 to −3.5]). CONCLUSIONS: Discrete time-use patterns exist in Australian young adolescents. The cluster characterized by low physical activity and moderate screen time was associated with the lowest HRQoL. Whether this pattern translates into precursors of noncommunicable diseases remains to be determined.

The bidirectional relationship between sleep problems and internalizing and externalizing problems in children with ADHD: a prospective cohort study.

BACKGROUND Behavioral sleep problems are common in children with attention deficit hyperactivity disorder (ADHD), and longitudinal studies have found sleep problems to be both a predictor and outcome of internalizing and externalizing problems. We investigated the potential bidirectional relationship between sleep problems and internalizing/externalizing problems. METHODS Children with ADHD, aged 5-13 years, were recruited from 21 pediatric practices across Victoria, Australia (N = 270). Across a 12-month period, at three time points, parents reported on their childs sleep problems (Childrens Sleep Habits Questionnaire) and emotional and behavioral functioning (Strengths and Difficulties Questionnaire). Data were analyzed using autoregressive cross-lagged panel models. RESULTS Sleep problem severity and emotional/behavioral problem severity were very stable across the 12-month period. Sleep problems at baseline predicted emotional problems at six months (r = 0.17, p < 0.01), and emotional problems at baseline predicted sleep problems at six months (r = 0.07, p < 0.05). However, there was no predictive relationship between sleep problems and emotional problems from 6-12 months. No bidirectional relationship was observed between sleep problems and conduct problems. CONCLUSIONS In children with ADHD, there is weak evidence of a bidirectional relationship between sleep problems and emotional problems. These symptoms are also very stable over time; therefore, the best treatment approach to improve overall functioning may be to target both sleep and emotional functioning in these children.

Children referred for evaluation for ADHD: comorbidity profiles and characteristics associated with a positive diagnosis

BACKGROUND The symptoms of attention-deficit/hyperactivity disorder (ADHD) are non-specific, and a range of possible causes and comorbidities need to be considered in children referred for assessment. OBJECTIVE To examine the factors associated with ADHD diagnosis following multidisciplinary assessment. METHODS Children underwent multidisciplinary evaluation including parent and teacher questionnaires; semi-structured interview to screen for internalizing and externalizing diagnoses; paediatric, psychology and special education assessments; and case conference. Predictors of ADHD diagnosis were examined in univariable and multivariable logistic regression models. RESULTS Data from 190 assessments (82% male, mean age 6.8 years) were included. ADHD was diagnosed in 132 (70%) cases, of which 77% had one or more comorbidities. In children not diagnosed with ADHD, 60% had one or more alternate diagnosis made. Teacher-reported ADHD symptom severity and learning difficulties were the strongest predictors of ADHD diagnosis. The pattern of comorbid/alternative diagnoses was similar between those diagnosed with ADHD and those not diagnosed with ADHD. CONCLUSIONS Direct report from teachers is the most critical element of the clinical dataset for the evaluation for ADHD. These findings emphasize the importance of cross-situational impairment to ADHD diagnosis. The frequency and similarity of diagnoses in both groups highlight the overlapping nature of childhood developmental disorders, and the importance of evaluating for comorbid disorders regardless of the primary diagnosis.