Lori J. Stark

Evidence-Based Practice Recommendations for Nutrition-Related Management of Children and Adults with Cystic Fibrosis and Pancreatic Insufficiency: Results of a Systematic Review

The Cystic Fibrosis Foundation established a process of systematic review of evidence to inform the development of clinical care guidelines and encourage evidence-based practice. The Subcommittee on Growth and Nutrition reviewed the evidence in two areas: energy intake and dosing for pancreatic enzyme replacement therapy. Evidence-based recommendations are presented here. Also, an ad hoc working group conducted a review of the literature and performed new analyses using the Cystic Fibrosis Foundation Patient Registry to update the recommendations for growth and weight-status monitoring. These Registry data-based recommendations are presented.

Common problems and coping strategies reported in childhood and early adolescence

This research investigated problems commonly experienced by children and young adolescents, and the strategies they use to cope with these events. Six hundred seventy-six children, ages 9–13 years, were asked to identify a problem they recently experienced and to describe the strategies they used to cope with it. In addition, they were also asked to complete a scale describing how they coped with a common problem (being grounded by parents). In general, we found that children reported four common Stressors: parents, siblings, school, and friends. These Stressors were the same across age and sex; however, the coping strategies employed differed by age and type of problem. Both age and sex effects were found in reported use of coping strategies to deal with being grounded by parents. The results of this study suggest that more research must be performed to offset the lack of data in the area of childrens normative coping. The implications of the findings for clinical assessment and treatment of children are discussed.

The Hopelessness Scale for Children: Psychometric Properties with Normal and Emotionally Disturbed Adolescents.

The psychometric properties of the Hopelessness Scale for Children (HSC) were evaluated with a sample of 834 normal adolescents and 93 adolescent suicide attempters. Factor analyses studies revealed two factors with both groups. Internal consistency with item-total score correlations were acceptable, while moderate test-retest reliability was found over a 10-week period with the normal sample. Support for the validity of the HSC was provided via studies with the suicide attempter group in which positive correlations with depression and depressive attributional style were found. Predicted differences between the suicide attempters, an outpatient psychiatric sample, and normal controls were also found. However, some items did not appear to discriminate suicide attempters from controls. Results are discussed in terms of the utility of the HSC with adolescents and adolescent suicide attempters and with regard to differences between child and adult samples in hopelessness.

a Pilot Randomized Controlled Trial of a Clinic and Home-Based Behavioral Intervention to Decrease Obesity in Preschoolers

We evaluated the efficacy of a 6‐month clinic and home‐based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health; LAUNCH) to reduce obesity in preschool children ≥95th BMI percentile compared to enhanced standard of care (Pediatrician Counseling; PC). LAUNCH was a family‐based behavioral intervention that taught parents to use child behavior management strategies to increase healthy eating and activity for their children and themselves. PC presented the same diet and activity recommendations, but was delivered in a one‐time PC session. Eighteen children aged 2–5 years (mean 4.71 ± 1.01) with an average BMI percentile of 98 (±1.60) and an overweight parent were randomized to LAUNCH or PC. Assessments were conducted at baseline, 6 months (end of LAUNCH treatment) and 12 months (6 months following LAUNCH treatment). LAUNCH showed a significantly greater decrease on the primary outcomes of child at month 6 (post‐treatment) BMI z (−0.59 ± 0.17), BMI percentile (−2.4 ± 1.0), and weight gain (−2.7 kg ± 1.2) than PC and this difference was maintained at follow‐up (month 12). LAUNCH parents also had a significantly greater weight loss (−5.5 kg ± 0.9) at month 6 and 12 (−8.0 kg ± 3.5) than PC parents. Based on the data from this small sample, an intensive intervention that includes child behavior management strategies to improve healthy eating and activity appears more promising in reducing preschool obesity than a low intensity intervention that is typical of treatment that could be delivered in primary care.

Coping with Everyday and Disease-Related Stressors by Chronically III Children and Adolescents

OBJECTIVE This study examines those aspects of disease that chronically ill children find stressful and the coping strategies they report using to manage these stressors. In particular, we examined whether a state or trait conceptualization of coping was most applicable to this population. METHOD A total of 177 children with varying chronic illnesses were asked to complete a coping checklist in response to a self-generated illness-related problem and an everyday problem. RESULTS Analyses of coping strategy stability revealed gender but not age effects. Some coping strategies were used equally across varying illness-related stressors, but others, e.g. distraction, blaming others, and emotional regulation, varied by type of stressor. Moderately consistent patterns were found across illness-related and non-illness-related situations for the same individual. CONCLUSIONS The results suggest that coping strategies used by chronically ill children have some stability but do vary across situations. Clinicians might benefit from routine screening of coping in chronically ill children.

Common problems and coping strategies II: Findings with adolescent suicide attempters

This study investigated the most common precipitants of adolescent suicide attempts and the strategies used to cope with such problems. Adolescent suicide attempters were compared with both distressed and nondistressed nonsuicidal adolescents on problems reported and coping strategies utilized. All three groups reported four problems as occurring most frequently: school, parents, friends, or boyfriend/girlfriend. The suicide attempters and distressed controls reported problems with parents more frequently than did nondistressed controls, while this latter group reported problems at school more frequently than did suicide attempters or distressed controls. Suicide attempters used social withdrawal, problem solving, and emotional regulation more than did nondistressed controls, but not more frequently than distressed controls. Distressed controls used wishful thinking and resignation more than did suicide atempters. Results are discussed in terms of the similarities between suicide attempters and nonsuicidal distressed adolescents and the need to more closely investigate specific subgroups of suicide attempters.

Nutrition intervention for weight gain in cystic fibrosis: a meta analysis.

OBJECTIVES A meta analysis of the literature on treatment approaches to malnutrition in cystic fibrosis (CF) was conducted to evaluate the effectiveness of oral supplementation, enteral nutrition, parenteral nutrition, and behavioral intervention on weight gain before and after treatment. STUDY DESIGN Eighteen studies were reviewed: four behavioral, six supplement, five enteral nutrition, and three parenteral nutrition. RESULTS The weighted effect size for weight gain was large for each intervention: 1.51 behavioral, 1.62 oral, 1.78 enteral, and 2.20 parenteral intervention. All interventions produced a large effect for weight gain in patients with CF. A univariate analysis of variance indicated no significant difference among the four interventions, F(3, 17) = 0.87, p > 0.05. Effect size for calorie intake was also evaluated when data were available (N = 7 studies), yielding a sample size of three behavioral, two enteral, and two oral supplement studies. Analysis of variance indicated a significant effect for treatment, F(2,4) = 13.34, p < 0.05, with post hoc analysis indicating that the behavioral intervention had a greater effect size for calorie intake than oral supplement. CONCLUSIONS All interventions were effective in producing weight gain in patients with CF. Behavioral intervention appeared to be as effective in improving weight gain in patients with CF as more invasive medical procedures. These findings support continued research on nutrition intervention with patients with CF including controlled clinical trials of the interventions and long-term follow-up on the impact of nutrition on disease progression.

Behavioral intervention to improve calorie intake of children with cystic fibrosis : Treatment versus wait list control

Changes in calorie intake and weight gain were evaluated in five children with cystic fibrosis (CF) who received behavioral intervention and four children with CF who served as wait list controls. The behavioral intervention was a 6-week group treatment that provided nutritional education plus management strategies aimed at mealtime behaviors that parents find most problematic. The control group was identified prospectively and was evaluated on all dependent measures at the same points in time pre- and posttreatment as the intervention group. Difference scores on calorie intake and weight gain from pre- to posttreatment were compared between groups using t tests for independent samples. The behavioral intervention group increased their calorie intake by 1,032 calories per day, while the control groups intake increased only 244 calories per day from pre- to posttreatment [t(6) = 2.826, p = 0.03]. The intervention group also gained significantly more weight (1.7 kg) than the control group (0 kg) over the 6 weeks of treatment [t(7) = 2.588, p = 0.03] and demonstrated catchup growth for weight, as indicated by improved weight Z scores (-1.18 to -0.738). The control group showed a decline in weight Z scores over this same time period (-1.715 to -1.76). One month posttreatment, the intervention was replicated with two of the four children from the control group. Improved calorie intake and weight gain pre- to posttreatment were again found in these children. At 3- and 6-month follow-up study of children receiving intervention, maintenance of calorie intake and weight gain was confirmed. No changes were found on pulmonary functioning, resting energy expenditure, or activity level pre- to posttreatment. This form of early intervention appears to be promising in improving nutritional status and needs to be investigated over a longer period of time to evaluate the effects of treatment gains on the disease process.

Peer relations and social adjustment of chronically ill children and adolescents

Abstract This article reviews available literature on the peer relations and social adjustment of children and adolescents with chronic illnesses. Although a topic of considerable theoretical and clinical speculation, empirical work specifically addressing peer relations in chronic illness has been limited. Available research frequently suffers from inadequate methodology, particularly with respect to the assessment of peer relations. Whether differences exist between chronically ill and healthy children in the quality of peer relations is unclear at this time due to contradictory findings; however, there is currently little support for the contention that most chronically ill children experience poorer peer relations than healthy children. The limited number of studies available also precludes drawing conclusions about individual diseases. However, there do appear to be certain problems, i.e., change in physical appearance and restrictions placed on activities, that arise secondary to chronic illness and specifically affect peer relations of these children. Suggestions for future research, including examination of variables that mediate the impact of illness, are discussed.

Community-wide Intervention to Improve the Attention-Deficit/Hyperactivity Disorder Assessment and Treatment Practices of Community Physicians

OBJECTIVES. The goals were to implement and to test a quality-improvement intervention aimed at improving community-based primary care providers’ adherence to the American Academy of Pediatrics, evidence-based diagnostic and treatment guidelines for attention-deficit/hyperactivity disorder. METHODS. Nineteen practices (with 84 primary care providers) from a large urban community were trained by using quality-improvement methods with some academic detailing. Pretraining and posttraining adherence to evidence-based practices was assessed through review of patient charts. RESULTS. Preintervention rates of guideline usage were uniformly low. After the intervention, primary care providers showed substantial improvement in their use of the guidelines for the assessment and treatment of elementary school-aged patients with newly diagnosed attention-deficit/hyperactivity disorder. Use of parent and teacher assessment rating scales increased from levels of 52% to 55% to levels of nearly 100%. Systematic monitoring of responses to medication improved from a baseline level of 9% to 40%. CONCLUSIONS. Quality-improvement interventions such as the one used in this study seem quite effective in improving primary care providers’ practices at offices that express interest in improving the quality of care for attention-deficit/hyperactivity disorder. The design of the intervention, problems associated with improving and sustaining treatment monitoring, and issues related to generalizability of the intervention model are discussed.