Longitudinal Impact of a Randomized Clinical Trial to Improve Family Function, Reduce Maternal Stress and Improve Child Outcomes in Families of Children with ADHD.

Objective Evaluate the efficacy of a 12 month nursing case-management intervention over a period of 18 months, 6 months after the end of intervention, for families of children attention deficit hyperactivity disorder (ADHD). Methods Mother and child dyads were enrolled to participate in a randomized controlled clinical trial. Children were 4-18 years old. Data were collected at baseline, 6, 12, and 18 months or 6 months after the termination of direct intervention. Longitudinal analyses, using generalized estimating equations, were conducted to assess change in study outcomes relating to family function, maternal stress, and child behavior over the 18 month period. Results Compared to control families, some family function outcomes were moderately improved in the intervention group. In particular, intervention families demonstrated substantial improvement in implementing family behavior controls (p value = 0.038) and improvement in family satisfaction (not statistically significant p = 0.062). Although there was improvement in the overall family function measure there was not a statistically significant difference between groups. Maternal stress and child behavior outcomes were not significantly different between control and intervention groups by the end of the intervention. Conclusions for Practice Addressing ADHD is complex and requires the assessment of comorbidities that might exacerbate negative behavior. Our findings support the latest American Academy of Pediatrics guidelines to use behavioral therapy as the first line of treatment in young children. Nursing case-management interventions that provide direct family education and improve family function, especially with respect to providing structure and behavior control, may complement and facilitate behavioral therapy for treatment of ADHD and improving child behavior.

Commitment to Breastfeeding in the Context of Phenylketonuria.

OBJECTIVE: To describe the meaning and importance of breastfeeding to mothers of infants with phenylketonuria (PKU). DESIGN: Qualitative description. SETTING: Mothers from the United States and Canada were recruited from the PKU Listserv and interviewed by telephone. PARTICIPANTS: Ten breastfeeding mothers with infants who had PKU and were younger than age 36 months. METHODS: Mothers' thoughts, decisions, and experiences of breastfeeding their infants with PKU were collected through telephone interviews. Interviews were transcribed verbatim, and data were analyzed using thematic descriptive analysis in the context of PKU. RESULTS: Participants felt that that breastfeeding an infant with PKU was the healthiest choice and was therefore worth the labor. These women believed that this was what a loving mother would choose. As they continued to breastfeed their infants after diagnosis, the views of the participants changed. Initially they saw PKU as a disorder and felt that their infants were ill; later they felt that their infants were healthy in spite of PKU. Normal could mean a breastfeeding infant with PKU. CONCLUSION: Findings demonstrate the importance mothers attribute to breastfeeding and their willingness to invest considerable effort to breastfeed. Health care providers working with these mothers should help them strategize for success.

Challenges to breastfeeding infants with phenylketonuria.

Breastfeeding duration for infants with phenylketonuria (PKU) is less than other full-term infants. However, no study has examined the challenges encountered by mothers' breastfeeding infants with PKU. In 75 mothers of a child with PKU, three categories of breastfeeding challenges were identified: common breastfeeding issues, breastfeeding and PKU, and no challenges. The common breastfeeding issues can be identified in the literature but for these mothers, the issues are heightened due to frequent phenylalanine (Phe) monitoring. Even so, many mothers adapt breastfeeding to maintain desired Phe levels. A few mothers had no issues and were the exception, not the norm.

Breastfeeding infants with phenylketonuria in the United States and Canada.

OBJECTIVE: This study described the prevalence and duration of mothers' breastfeeding infants with phenylketonuria (PKU) and explored factors related to duration of breastfeeding as a surrogate for breastfeeding success. SUBJECTS AND METHODS: Descriptive analysis as performed from an international Internet survey of mothers (n=103) who met the inclusion criteria: (1) at least 21 years of age, (2) able to read and write in English, (3) child with PKU, and (4) living in the United States or Canada. RESULTS: Of the 103 mothers, 89 (86%) initiated breastfeeding immediately following delivery, whereas 14 (14%) chose bottle feeding. In comparison to breastfeeding after delivery, significantly fewer mothers breastfed after diagnosis (McNemar's χ(2)=30.33, p<0.001; n=72 vs. n=89). Breastfeeding duration ranged from less than 1 month to 24 months with one modal duration category (n=20, 22%) at less than 1 month. The timing of the addition of commercial infant formula to supplement breastfeeding or expressed mothers' milk was associated with a shorter duration of breastfeeding among infants with PKU: χ(2) (42, n=73)=88.13, p<0.001. CONCLUSIONS: PKU is treated with phenylalanine (Phe) restriction. Breastfeeding infants with PKU is challenging in part because Phe intake is difficult to determine precisely. We studied breastfeeding duration in infants with PKU and factors associated with success. Further research should identify the unique needs of mothers' breastfeeding infants with PKU to guide the development of interventions specific to these mothers to support their efforts to continue breastfeeding after the diagnosis of PKU.

Growing old with fibromyalgia: factors that predict physical function.

BACKGROUND: Fibromyalgia, a persistent, widespread pain condition, significantly limits physical function, threatening an older adult's health and ability to live independently. OBJECTIVES: The aim of the study was to identify predictors of physical function in older adults living with fibromyalgia and to examine the influence of resilience on the relationship between fibromyalgia pain and physical function. METHODS: This was a descriptive correlational, cross-sectional design using mailed questionnaires to analyze relationships between health-related variables and physical function in a convenience sample of community-dwelling older adults diagnosed with fibromyalgia (n = 224; age M = 62.1 years, SD = 6.75 years). Multiple regression was used to identify a priori predictors of physical function; hierarchical multiple regression was used to examine resilience as a moderator of pain and physical function. RESULTS: The sample was predominantly women, Caucasian, married, well educated, had moderate levels of income and tangible social support, and had low levels of physical function. Three-fourths were overweight or obese. Despite impaired physical function (Late Life Function and Disability Index, M = 51.5/100, SD = 9) and moderate levels of pain (Numeric Rating Scale, M = 5.47/10, SD = 2.6), resilience was moderately high (Resilience Scale, M = 137/175, SD = 20). An eight-variable disablement-based model accounted for 48% of variance in physical function: age, income, education, depressive symptoms, body mass index, and physical activity accounted for 31%; pain added 14%; and resilience contributed an additional 3%. Resilience was not a moderator of fibromyalgia pain and physical function; resilience did contribute uniquely to physical function variance. DISCUSSION: Resilience, a novel variable in fibromyalgia research, was a unique predictor of physical function. Further research is needed to learn more about the relationships between resilience, fibromyalgia impact, and the aging process.

Breast-feeding success among infants with phenylketonuria.

Breast milk is the nutrition of choice for human infants (American Academy of Pediatrics, 2005; American Association of Family Physicians, 2008; Association of Women's Health Obstetric and Neonatal Nurses, 2005; Canadian Paediatric Society, 2005; U.S. Preventive Services Task Force, 2008; World Health Organization, 2009). In comparison to standard commercial formula, human breast milk has a lower concentration of protein and a lower content of the amino acid phenylalanine (Phe). For infants with phenylketonuria (PKU), these attributes of human breast milk make it ideal as a base source of nutrition. The purpose of this study was to compare the incidence and duration of breast-feeding and corresponding Phe levels of breast-fed and formula-fed infants with PKU in the caseload of a pediatric metabolic clinic at an urban tertiary-care medical center. Charts were reviewed for infants diagnosed with PKU beginning with 2005 and ending with 1980, the year no further breast-feeding cases were identified in the PKU population. During the first year of life, most of the infants, whether breast-fed or formula-fed, had similar mean Phe levels. However, the frequency distributions revealed that more breast-fed infants with PKU had Phe levels within the normal range (120-360 µmol/L) and were less likely to have low Phe levels (<120 µmol/L) than formula-fed infants with PKU. Further research is needed to understand how mothers manage breast-feeding in the context of PKU.

Validity of the nursing child assessment feeding scale during toddlerhood.

This study examined the validity of the Nursing Child Assessment of Feeding Scale (NCAFS) during toddlerhood, using a longitudinal design to assess the scale's convergence with the Toddler Snack Scale (TSS) between 12 and 36 months, and comparing videotaped interactions of 116 mother-toddler dyads. Differences between TSS mutuality classifications were found for the NCAFS subscales at each age. The pattern of mean scores followed expected directions at 12 and 36 months, but only two of the six NCAFS subscales maintained this pattern at 24 months. Significant differences were found between TSS mutuality classifications and NCAFS dyadic scores at each age. With one exception, "connected" and "marginal" dyads had consistently higher dyadic scores than dyads classified as "poor" in mutuality. There were no differences between connected and marginal dyads. The NCAFS does not appear to capture control-autonomy balance as well as the TSS, and a revision for toddlerhood may be needed.

Reliability of the Nursing Child Assessment Feeding Scale during toddlerhood.

The quality of the maternal-child feeding interaction has been proposed to be an important contributor to a child's being overweight, yet assessment of this proposition has been hindered by a lack of age-appropriate instrumentation. The primary aim of this study was to examine the reliability of the Nursing Child Assessment of Feeding Scale (NCAFS) if extended to use during toddlerhood. A longitudinal design was used to assess NCAFS reliability at 12, 24, and 36 months. The NCAFS was used to code videotaped feeding observations of 116 mother-toddler dyads collected as part of a larger study examining mother-child interactions and adaptations of toddlers. Reliability was explored through the assessment of interrater reliability, internal consistency of the various subscales and the scale as a whole, and stability of the scale measurements over time. At each age, interrater reliability was generally quite good whereas the NCAFS' internal consistency was low. Maternal contributions to feeding interaction quality were stable over time but dyadic and child contributions were not. The lower internal consistency estimates were likely due to relatively low levels of variance among the dyads within each age. Another probable contributor to diminished internal consistency was the attrition of several behavior items due to zero variance. Possible explanations for this restriction of variance and several approaches for improving the NCAFS internal consistency during toddlerhood are considered. With revision, the NCAFS could be useful in assessment of feeding interaction quality during the transition to toddlerhood when issues of control and autonomy become increasingly prominent.

Maternal limit-setting in toddlerhood: Socialization strategies for the development of self-regulation.

Early findings from the Prohibition Coding Scheme (PCS; Houck & LeCuyer, 1995; LeCuyer-Maus & Houck, 2002; Medvin & Spieker, 1985) revealed that maternal limit-setting styles with toddlers were differentially related to later child social competence, self-concept, and delay of gratification. For this study, the PCS was revised to provide more information about the specific strategies mothers used during limit-setting in relation to those outcomes. Results from the PCS-Revised (PCS-R; LeCuyer & Houck, 2004) included that the more time mothers spent actively distracting their toddlers away from a prohibited object during limit-setting, as early as 12 months, the longer their children could delay gratification at age 5 years. Mothers who spent more time sensitively following and being engaged in their toddler's own interests (other than the prohibited object), again as early as 12 months, had more socially competent children with more developed self-concepts at age 3 years. Maternal use of reasoning statements later in toddlerhood also related to higher levels of social competence. Maternal limits and prohibitions were not related to these outcomes, and appeared to contribute to the development of self-regulation mainly by creating the opportunity for the use of other, less directive strategies. The findings indicate that these strategies may be important to include in intervention programs for the promotion of toddler and child development of self-regulation.

Assessing the feeding/eating interaction as a context for the development of social competence in toddlers.

Social competence likely develops through the reciprocal nature of mother-child interactions. Interactions around food provide the young child with consistent and predictable social experiences with the mother, which may establish templates for interactive patterns with others. The Toddler Snack Scale (TSS) assesses the pattern of toddler social behaviors in relation to maternal behaviors during an eating episode. Scale reliability was examined with a sample of 126 dyads at the child's ages of 12, 24, and 36 months. Significant associations were found between TSS classifications and concurrent measures assessed with the Nursing Child Assessment Teaching Scale (NCATS), the Control-Autonomy Balance Scale (CABS), and the Adaptive Social Behavioral Inventory (ASBI). Child temperament contributed to child expressions of social competence, but not to the assignment of maternal or child interaction styles. The scale identifies salient areas for parent-child assessment and intervention throughout infancy and toddlerhood.

Increased mental health needs and new roles in school communities.

TOPIC: Mental health issues and partnership roles in school communities. PURPOSE: To heighten the awareness of healthcare providers about the multiple mental health conditions students bring into school communities and the impact of these conditions on students' ability to learn; to encourage partnering between healthcare providers and educators to support students in achieving academic and developmental success. SOURCES: Literature review and authors' experiences with assessment of and intervention with school-age children presenting with impaired mental health. CONCLUSIONS: Health and education systems must increase their partnerships on behalf of children for a healthy future.

A program to educate school nurses about mental health interventions.

Concerned with the increasing incidence of mental health problems in children and adolescents and the impact of these problems on students' school success and predisposition to self- and other-directed violence, the Multnomah Education Service District Department of School Health Services determined to become proactive by providing preventive interventions for students experiencing actual or potential mental health problems. An educational program was designed to assist school nurses in the identification of potential mental health problems. In addition, information about appropriate interventions for students at risk for aggression, violence, and other mental health pathology was presented. The program involved education on mental health assessment and intervention, as well as expert psychiatric clinical support for the development of student support groups. School nurses were then challenged to develop practice improvement projects incorporating this knowledge for a group of students in their work setting. This introductory article describes the project's general rationale and implementation process. The four articles following in this issue of The Journal of School Nursing describe the goals, implementation, and outcomes of the practice improvement projects developed for early intervention with students exhibiting attention disorders, school absenteeism, social withdrawal, and depression.

Small group intervention for children with attention disorders.

Children with attention disorders can experience adverse long-term effects on academic performance, vocational success, and socioemotional development. They experience some level of functional impairment that extends across settings, including the home and school. In combination with medication, group interventions with school-age children were found to be effective for enhancing social behavior. This article describes two practice improvement projects that provided group experiences for children with attention-deficit/hyperactivity disorder (ADHD) symptoms, including disruptive behavior. Four skill domains were addressed: communication, friendship, self-control, and social problem solving. One project provided activities for early school-age children with ADHD who were treated with medication only. Another provided a support group on self-management for freshman boys with ADHD who were also treated with medication only. In both projects, the disruptive behavior of the participants decreased by the end of the group sessions.

A support group for absentee middle school students.

For this practice improvement project, an interview guide was developed to identify chronically absent middle school students' reasons for school absence. Of the 17 students interviewed, 82% (n = 14) identified illness as the reason for absence, although they rarely saw a health care provider. The students all shared dreams for the future; 50% involved further education, and 50% involved job training. A support group intervention was offered to the 17 students during spring term. Only three students were able to participate in a weekly group meeting for 5 weeks. Two of the three students were depressed and referred to their health care providers for evaluation. The topics presented to the group included being sick and options available, setting weekly attendance goals, identifying depressive symptoms and what they mean, and likes and dislikes about school. The support group occurred late in the school year, so its effect on attendance was not determined.

Small group experience for socially withdrawn girls.

Social competence is the effectiveness of social interaction behavior. Given its link to mental health outcomes, it is an important consideration in child and adolescent development. Social withdrawal is associated with depression. Socially withdrawn children make few social initiations and tend to be isolated in their play, further limiting their social involvement. To develop effective social behavior, experiences must be provided to learn relationship skills. This practice improvement project provided a small group experience for five socially withdrawn school-age girls. Weekly group meetings provided a social situation in which conversations could occur around a shared snack and craft project. The school nurse facilitated self-assertion and the expression of prosocial behavior in a socially safe (nonrejecting) environment and promoted social problem solving. On completion of the program, the participants not only showed more effective social reasoning and social skills, but developed friendships with each other that lasted beyond the life of the group.

A support group intervention for at-risk female high school students.

School nurses have an opportunity to engage in early intervention with high-risk adolescents. School-based support groups for depressed adolescents have been effective when aimed at providing skills training as well as emotional support. In this practice improvement project, 14 high-risk female adolescents from two high schools were identified on the basis of signs associated with depression. The students completed a questionnaire about risk and protective factors during the assessment and at the end of the intervention. Twelve students participated in a weekly support group designed to enhance coping skills and to provide emotional support. Assessment revealed that the students were at suicide risk. At the conclusion of the group intervention, there was a 55% decrease in suicidal ideation, a 27% decrease in perceived stress, and a 26% decrease in family distress. In addition, most of the students became engaged in formal treatment for the first time.

Maternal characteristics and maternal limit-setting styles.

In a longitudinal study of 126 mothers and toddlers during toddlerhood, maternal limit-setting styles were assessed at 12, 24, and 36 months in relation to selected maternal characteristics. Mothers using teaching-based limit-setting styles at 12 months reported more optimal relationship histories of care and overprotection/control in their own families of origin. The main contributor to a maternal teaching-based limit-setting style in this sample was years of formal education, followed by a more multicausal conceptualization of how children develop. Thus, while years of formal education appear to facilitate the use of a teaching-based limit-setting style, formal education is not the only way to develop these skills. Maternal conceptualization of development may be amenable to intervention through a number of alternative learning activities. Further research is needed to explore the effects of different types of educational and learning opportunities on current maternal behavior, with the goal of optimizing socialization skills related to the development of toddler self-regulation.

Mother-toddler interaction and the development of self-regulation in a limit-setting context.

The Prohibition Coding Scheme was used to longitudinally assess observations of maternal and toddler limit-setting interactions at 12, 24, and 36 months. The final sample consisted of 126 mother-toddler dyads. Toddler behavior in a limit-setting context exemplified progressing skill in self-regulation from 12 to 36 months. Specifically, toddlers exhibited less persistence, increasing autonomy, and increasing ability to inhibit their behavior, with half of the toddlers classified as "autonomous-compliant" by 36 months of age. As a group, mothers also adapted their socializing behavior during toddlerhood, decreasing their use of directive structure and distractions, and using more cognitive strategies. A maternal "teaching-based", limit-setting pattern was associated with more competent toddler response-to-limits patterns at each age, and more mothers used a teaching-based limit-setting style by 36 months of age. These findings provide validity for the Prohibition Coding Scheme and extend our knowledge base for guiding parents in their socializing strategies relative to developing self-regulation. Clinical implications and areas for further research are addressed.

Maternal limit-setting patterns and toddler development of self-concept and social competence.

In 126 mother-toddler dyads, the relationships between maternal limit-setting patterns at 12, 24, and 36 months were examined in relation to toddler self-concept and social competence at 3 years. Maternal limit-setting patterns differentiated toddler self-concept and social competence scores, demonstrating effects of socialization as well as cognitive maturation. Less optimal toddler outcomes at 36 months were associated with an inconsistent maternal limit-setting style and an indirect style. Children of mothers with a teaching-based pattern yielded the most positive outcomes. Although a power-based maternal limit-setting style was related to diminished self-regulatory behavior in a concurrent limit-setting context, outcomes for children of power-based mothers in terms of self-concept and social competence were not as negative as expected.