Susan N. Sherman

Maternal Feeding Strategies, Child Eating Behaviors, and Child BMI in Low-Income African-American Preschoolers

Objective: To test the hypothesis that low‐income African‐American preschool children would have a higher BMI if their mothers reported greater “restriction” and “control” in feeding and if mothers reported that children showed greater “food responsiveness” and “desire to drink.” In addition, to test whether higher maternal “pressure to eat” would be associated with lower child BMI.

Parental Angst Making and Revisiting Decisions About Treatment of Attention-Deficit/Hyperactivity Disorder

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral conditions of childhood and adolescence. Despite availability of effective treatment options, initiation of treatment is variable and persistence with therapeutic regimens is poor. OBJECTIVE: We sought to better understand how parents make decisions about treatment for their child or adolescent with ADHD. METHODS: We conducted a qualitative study among parents of children and adolescents; 52 parents participated in 1 of 12 focus groups. Parents answered questions about decision-making, information sharing, and sources of conflict and uncertainty. Sessions were audiotaped and transcribed verbatim. Themes were coded independently by 4 of the investigators, who then agreed on common themes. RESULTS: Parents in our study made decisions about treatment for their child with ADHD in the midst of experiencing a variety of emotions as they witnessed child functional impairments at home and at school. In addition, parents felt stress as a result of their daily efforts to manage their childs struggles. Multiple factors influenced the decision to initiate medication. Subsequently, revisiting the decision to give their child medicine for ADHD was common. Many parents contrasted time on and off medicine to help inform management decisions. Trials stopping medication were almost always parent- or child-initiated. CONCLUSIONS: Decisions about medication use for children and adolescents with ADHD are made and frequently revisited by their parents. Choices are often made under stressful conditions and influenced by a variety of factors. Striking a balance between benefits and concerns is an ongoing process that is often informed by contrasting time on and off medication. Development of strategies to support families across the continuum of decisions faced while managing ADHD is warranted.

Societal Values and Policies May Curtail Preschool Children’s Physical Activity in Child Care Centers

BACKGROUND AND OBJECTIVES: Three-fourths of US preschool-age children are in child care centers. Children are primarily sedentary in these settings, and are not meeting recommended levels of physical activity. Our objective was to identify potential barriers to children’s physical activity in child care centers. METHODS: Nine focus groups with 49 child care providers (55% African American) were assembled from 34 centers (inner-city, suburban, Head Start, and Montessori) in Cincinnati, Ohio. Three coders independently analyzed verbatim transcripts for themes. Data analysis and interpretation of findings were verified through triangulation of methods. RESULTS: We identified 3 main barriers to children’s physical activity in child care: (1) injury concerns, (2) financial, and (3) a focus on “academics.” Stricter licensing codes intended to reduce childrens injuries on playgrounds rendered playgrounds less physically challenging and interesting. In addition, some parents concerned about potential injury, requested staff to restrict playground participation for their children. Small operating margins of most child care centers limited their ability to install abundant playground equipment. Child care providers felt pressure from state mandates and parents to focus on academics at the expense of gross motor play. Because children spend long hours in care and many lack a safe place to play near their home, these barriers may limit childrens only opportunity to engage in physical activity. CONCLUSIONS: Societal priorities for young children—safety and school readiness—may be hindering children’s physical development. In designing environments that optimally promote children’s health and development, child advocates should think holistically about potential unintended consequences of policies.

How Low-Income Mothers With Overweight Preschool Children Make Sense of Obesity

Epidemiologic and qualitative studies have found that most mothers with overweight preschool children do not think their children are overweight. This might present a challenge for clinicians who wish to address obesity in young children. To understand mothers’ perceptions of their overweight children’s weight, we conducted semistructured interviews with 21 mothers of overweight preschool children enrolled in Kentucky’s Special Supplemental Nutrition Program for Women, Infants, and Children. Although these mothers did not label their children as overweight, they were worried about children’s weight, particularly as it related to their emotional well-being. These worries about obesity were reflected in three central tensions that shaped the way mothers perceived their children’s weight and informed maternal feeding strategies: (a) nature vs. nurture, (b) medical authority vs. lived experience, and (c) relieving immediate stress vs. preventing long-term consequences. Acknowledging mothers’ concerns and tensions might help clinicians communicate more effectively with them about obesity.

Confirmatory factor analysis of the Child Feeding Questionnaire among low-income African American families of preschool children

This study examined the factor structure for three of the Child Feeding Questionnaire (CFQ) subscales, a widely used measure of parental feeding practices, among 296 low-income parents of African American preschool children. Confirmatory factor analysis showed an overall poor fit among CFQ subscales; Restriction, Pressure to Eat, and Concern about Child Weight, (chi(2), (df=87=300.249, CFI=1.00, NNFI=1.07, RMSEA=.091). Additionally, Cronbachs Alpha coefficients for 2 of the three subscales were below acceptable recommendations (Restriction=0.69; Pressure to Eat=0.58). These results suggest further psychometric clarification is needed to understand commonly reported feeding practice constructs among low-income African American mothers of preschool aged children.

In their own words: Adolescent views on ADHD and their evolving role managing medication

OBJECTIVE Up to 90% of adolescents with attention deficit hyperactivity disorder (ADHD) remain functionally impaired, yet less than half continue to take medication. The objective of this study was to gain a detailed understanding of how adolescents with ADHD contribute to medication treatment decisions. METHODS Forty-four adolescents with ADHD aged 13 to 18 years old participated in 1 of 7 focus groups. An experienced facilitator used a semi-structured focus group guide to prompt discussion which was audio-recorded and transcribed verbatim. We coded transcripts using an inductive approach. Thematic saturation was reached after the seventh focus group. RESULTS Adolescents assumed increased responsibility for managing medication as they matured and developed insight into the functional impact of ADHD and medication on their lives. Insights were often formed by contrasting time spent on and off medication. ADHD impacted functioning in the following domains: academics, social interactions and relationships, creativity, and driving skills. Select domains were relevant for some adolescents but not others. Adolescents described different roles that they played in managing medication as well as strategies they used to exert autonomy over medication use. Side effects were common and contributed to negative feelings toward medication. Some adolescents had begun to use medication selectively. Many expressed uncertainty about future use of medication. CONCLUSIONS Adolescents assume an increasing role in managing medication for ADHD. Well-structured and coordinated trials stopping medication and measuring outcomes relevant to adolescents, parents, teachers, doctors, and/or other stakeholders may help ensure a developmentally appropriate transition from family to self-management of ADHD.

Wide variability in physical activity environments and weather-related outdoor play policies in child-care centers within a single county of Ohio

OBJECTIVES To examine the variability of physical activity environments and outdoor play policies in child care centers and to determine whether this variability is associated with the demographic characteristics of the child care centers surveyed. DESIGN Early Learning Environments Physical Activity and Nutrition Telephone Survey. SETTING Child care centers in Hamilton County (greater Cincinnati area), Ohio, during the period from 2008 to 2009. PARTICIPANTS Directors of all 185 licensed full-time child care centers in Hamilton County. OUTCOME MEASURES Descriptive measures of playground and indoor physical activity environments and weather-related outdoor play policies. RESULTS Of 185 eligible child care centers, 162 (88%) responded to our survey. Of the 162 centers that responded, 151 (93%) reported an on-site playground, but slightly more than half reported that their playgrounds were large, that they were at least one-third covered in shade, or that they had a variety of portable play equipment. Only half reported having a dedicated indoor gross motor room where children could be active during inclement weather. Only 32 centers (20%) allowed children to go outside in temperatures below 32°F (0°C), and 70 centers (43%) reported allowing children outdoors during light rain. A higher percentage of children receiving tuition assistance was associated with lower quality physical activity facilities and stricter weather-related practices. National accreditation was associated with more physical activity-promoting practices. CONCLUSION We found considerable variability in the indoor and outdoor physical activity environments offered by child care centers within a single county of Ohio. Depending on the outdoor play policy and options for indoor physical activity of a child care center, childrens opportunities for physical activity can be curtailed as a result of subfreezing temperatures or light rain. Policy changes and education of parents and teachers may be needed to ensure that children have ample opportunity for daily physical activity.

Flip flops, dress clothes, and no coat: clothing barriers to children's physical activity in child-care centers identified from a qualitative study

BackgroundThree-quarters of 3-6 year-old children in the U.S. spend time in childcare; many spend most of their waking hours in these settings. Daily physical activity offers numerous health benefits, but activity levels vary widely across centers. This study was undertaken to explore reasons why physical activity levels may vary. The purpose of this paper is to summarize an unexpected finding that child-care providers cited was a key barrier to childrens physical activity.MethodsNine focus groups with 49 child-care providers (55% black) from 34 centers (including inner-city, suburban, Head Start and Montessori) were conducted in Cincinnati, OH. Three independent raters analyzed verbatim transcripts for themes. Several techniques were used to increase credibility of findings, including interviews with 13 caregivers.ResultsTwo major themes about clothing were: 1) childrens clothing was a barrier to childrens physical activity in child-care, and 2) clothing choices were a significant source of conflict between parents and child-care providers. Inappropriate clothing items included: no coat/hat/gloves in the wintertime, flip flops or sandals, dress/expensive clothes, jewelry, and clothes that were either too loose or too tight. Child-care providers explained that unless there were enough extra coats at the center, a single child without a coat could prevent the entire class from going outside. Caregivers suggested several reasons why parents may dress their child inappropriately, including forgetfulness, a rushed morning routine, limited income to buy clothes, a childs preference for a favorite item, and parents not understanding the importance of outdoor play. Several child-care providers favored specific policies prohibiting inappropriate clothing, as many reported limited success with verbal or written reminders to bring appropriate clothing.ConclusionInappropriate clothing may be an important barrier to childrens physical activity in child-care settings, particularly if the clothing of a few children preclude physical activity for the remaining children. Center directors and policy makers should consider devising clear and specific policies for the types of clothing that will be permitted in these settings so that childrens active play opportunities are not curtailed. To enhance compliance, parents may need education about the importance and benefits of active play for childrens development.

The Family Perspective on Hospital to Home Transitions: A Qualitative Study

BACKGROUND AND OBJECTIVE: Transitions from the hospital to home can be difficult for patients and families. Family-informed characterization of this vulnerable period may facilitate the identification of interventions to improve transitions home. Our objective was to develop a comprehensive understanding of hospital-to-home transitions from the family perspective. METHODS: Using qualitative methods, focus groups and individual interviews were held with caregivers of children discharged from the hospital in the preceding 30 days. Focus groups were stratified based upon socioeconomic status. The open-ended, semistructured question guide included questions about communication and understanding of care plans, transition home, and postdischarge events. Using inductive thematic analysis, investigators coded the transcripts, resolving differences through consensus. RESULTS: Sixty-one caregivers participated across 11 focus groups and 4 individual interviews. Participants were 87% female and 46% nonwhite; 38% were the only adult in their household, and 56% resided in census tracts with ≥15% of residents living in poverty. Responses from participants yielded a conceptual model depicting key elements of families’ experiences with hospital-to-home transitions. Four main concepts resulted: (1) “In a fog” (barriers to processing and acting on information), (2) “What I wish I had” (desired information and suggestions for improvement), (3) “Am I ready to go home?” (discharge readiness), and (4) “I’m home, now what?” (confidence and postdischarge care). CONCLUSIONS: Transitions from hospital to home affect the lives of families in ways that may affect patient outcomes postdischarge. The caregiver is key to successful transitions, and the family perspective can inform interventions that support families and facilitate an easier re-entry to the home.

Testing a post-discharge nurse-led transitional home visit in acute care pediatrics: the Hospital-To-Home Outcomes (H2O) study protocol.

AIMS The aims of this study were: (1) to explore the family perspective on pediatric hospital-to-home transitions; (2) to modify an existing nurse-delivered transitional home visit to better meet family needs; (3) to study the effectiveness of the modified visit for reducing healthcare re-use and improving patient- and family-centered outcomes in a randomized controlled trial. BACKGROUND The transition from impatient hospitalization to outpatient care is a vulnerable time for children and their families; children are at risk for poor outcomes that may be mitigated by interventions to address transition difficulties. It is unknown if an effective adult transition intervention, a nurse home visit, improves postdischarge outcomes for children hospitalized with common conditions. DESIGN (1) Descriptive qualitative; (2) Quality improvement; (3) Randomized controlled trial. METHODS Aim 1 will use qualitative methods, through focus groups, to understand the family perspective of hospital-to-home transitions. Aim 2 will use quality improvement methods to modify the content and processes associated with nurse home visits. Modifications to visits will be made based on parent and stakeholder input obtained during Aims 1 & 2. The effectiveness of the modified visit will be evaluated in Aim 3 through a randomized controlled trial. DISCUSSION We are undertaking the study to modify and evaluate a nurse home visit as an effective acute care pediatric transition intervention. We expect the results will be of interest to administrators, policy makers and clinicians interested in improving pediatric care transitions and associated postdischarge outcomes, in the light of impending bundled payment initiatives in pediatric care.