Pediatric Behavioral Health during the COVID-19 Pandemic: Expert Advice for Preparedness, Response, and Recovery.

The COVID-19 pandemic exacerbated the child mental health crisis and existing disparities. Child anxiety, depression, suicide attempts and completions, and mental-health-related emergency department visits significantly increased. In response to this crisis, the Administration for Strategic Preparedness and Response (ASPR) developed behavioral health task forces associated with funded pediatric centers of disaster excellence. The Health Resources and Services Administration (HRSA) funded the Pediatric Pandemic Network (PPN) to prepare for future endemics and pandemics, with behavioral health identified as a priority in mitigation, preparedness, response, and recovery. This commentary provides insights from pediatric disaster preparedness and response behavioral health subject matter experts. Our roles have been to identify how to build behavioral health professional competencies across disciplines and various medical settings and to strengthen emergency interdisciplinary behavioral health care capability regionally and at the national level. Specific examples of interdisciplinary training and demonstration projects are included as models for enhancing behavioral health situational awareness and developing curricula to support preparedness and response for the current ongoing pandemic and future natural and biological disasters. This commentary also includes a call to action for workforce development to move beyond a boots-on-the-ground mentality for pediatric behavioral health disaster preparedness and response toward a more inclusive role for behavioral health providers of varied specialties. This means that behavioral health providers should become more informed of federal programs in this area, seek further training, and find innovative ways to collaborate with their medical colleagues and community partners.

A Scoping Review of Trauma-Informed Pediatric Interventions in Response to Natural and Biologic Disasters.

A scoping review was performed of trauma-informed psychological interventions to treat anxiety, depression, and posttraumatic stress symptoms in youth in response to natural/biologic disasters. The specific aims were to identify psychosocial interventions used in response to natural/biologic disasters, report the interventions' effectiveness, describe limitations, and provide treatment recommendations and future directions. Of the 45 studies extracted, 28 were on natural disasters and 17 on biologic disasters with the majority related to the COVID-19 pandemic. The most commonly implemented interventions were Cognitive Behavioral Therapy (CBT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and eye movement desensitization and reprocessing (EMDR). The UCLA Posttraumatic Stress Disorder Reaction Index (UCLA PTSD-RI) and the Strengths and Difficulties Questionnaire (SDQ) were the most frequently used measures. Methodological rigor was varied, with 60% randomized, controlled trials. Overall, there was a significant decrease in posttraumatic stress symptoms, distress, anxiety, and depression regardless of whether the participant received CBT, TF-CBT, or EMDR. Generally, there was not a significant decrease in anxiety and depression with yoga, cognitive fear-reduction, emotion-based drawing, and community health education. Recommendations for future directions include larger-scale studies with group and on-line interventions that include younger children with moderation analyses by gender and race/ethnicity.

Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing.

STUDY OBJECTIVES: Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors. METHODS: 298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures. RESULTS: Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function (P = .002). Longer nocturnal sleep (P = .02) and less sleep fragmentation (P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old. CONCLUSIONS: Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040. CITATION: Robinson KA, Wei Z, Radcliffe J, et al. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med. 2023;19(9):1595-1603.

Introduction to the Special Issue on Adverse Childhood Experiences (ACEs): Prevention, Intervention, and Access to Care.

Exposure to adverse childhood experiences (ACEs) is an international public health problem [...].

Dietary patterns and associations with BMI in low-income, ethnic minority youth in the USA according to baseline data from four randomised controlled trials.

Few studies have derived data-driven dietary patterns in youth in the USA. This study examined data-driven dietary patterns and their associations with BMI measures in predominantly low-income, racial/ethnic minority US youth. Data were from baseline assessments of the four Childhood Obesity Prevention and Treatment Research (COPTR) Consortium trials: NET-Works (534 2-4-year-olds), GROW (610 3-5-year-olds), GOALS (241 7-11-year-olds) and IMPACT (360 10-13-year-olds). Weight and height were measured. Children/adult proxies completed three 24-h dietary recalls. Dietary patterns were derived for each site from twenty-four food/beverage groups using k-means cluster analysis. Multivariable linear regression models examined associations of dietary patterns with BMI and percentage of the 95th BMI percentile. Healthy (produce and whole grains) and Unhealthy (fried food, savoury snacks and desserts) patterns were found in NET-Works and GROW. GROW additionally had a dairy- and sugar-sweetened beverage-based pattern. GOALS had a similar Healthy pattern and a pattern resembling a traditional Mexican diet. Associations between dietary patterns and BMI were only observed in IMPACT. In IMPACT, youth in the Sandwich (cold cuts, refined grains, cheese and miscellaneous) compared with Mixed (whole grains and desserts) cluster had significantly higher BMI (ß = 0·99 (95 % CI 0·01, 1·97)) and percentage of the 95th BMI percentile (ß = 4·17 (95 % CI 0·11, 8·24)). Healthy and Unhealthy patterns were the most common dietary patterns in COPTR youth, but diets may differ according to age, race/ethnicity or geographic location. Public health messages focused on healthy dietary substitutions may help youth mimic a dietary pattern associated with lower BMI.

The Society of Behavioral Sleep Medicine (SBSM) COVID-19 Task Force: Objectives and Summary Recommendations for Managing Sleep during a Pandemic.

OBJECTIVE/BACKGROUND: As a response to clinical observations that the pervasive stress and social/environmental disruptions from the 2020 COVID-19 pandemic have also impacted sleep, the Society of Behavioral Sleep Medicine (SBSM) convened the COVID-19 Task Force with goals to identify and disseminate information that could be useful in addressing sleep concerns during this crisis. Participants Members of the SBSM COVID-19 Task Force. Results/Conclusions Herein is a summary of the resources developed by the SBSM COVID-19 Task force, which includes links to online materials developed for use by providers and patients, as well as brief descriptions of key recommendations by the Task Force for specific sleep conditions (e.g., acute insomnia, nightmares) and vulnerable populations (e.g., parents, essential/healthcare workers, older adults).

Weight-Related Teasing of Adolescents Who Are Primarily Obese: Roles of Sociocultural Attitudes Towards Appearance and Physical Activity Self-Efficacy.

Adolescents who are obese are at risk for being teased about their appearance with the concomitant negative psychological sequelae. Identifying modifiable variables associated with teasing could inform pediatric weight-management interventions. Characterizing society's role in the victimization of these at-risk individuals could guide anti-bullying programs for schools and broader public health efforts. This study aims to examine novel societal and cognitive factors associated with weight-related teasing frequency. Participants were adolescents (N = 334) being evaluated for a hospital-affiliated weight-management program. The outcome was perceived weight-related teasing frequency. Predictors were sociocultural awareness and internalization of appearance-related attitudes, physical activity self-efficacy, and psychological functioning. Multivariate regressions controlled for demographics and body mass index (BMI) z-scores with separate regressions testing interactions of BMI z-scores with all predictors. In adjusted analyses, higher physical activity self-efficacy and fewer depressive symptoms related to lower teasing frequency. Interactions indicated that less awareness/internalization of sociocultural attitudes towards appearance, more positive body image, and higher self-esteem related to lower teasing frequency regardless of BMI. Targeted interventions and public health campaigns should be developed and tested for adolescents that improve body image with promotion of diverse views about attractiveness, bolster confidence in overcoming physical activity barriers, and identify and treat mood symptoms.

Impact of lifestyle behavior change on glycemic control in youth with type 2 diabetes.

BACKGROUND: Little is known about the feasibility and impact of lifestyle intervention, determined by change in diet and cardiovascular fitness (CRF), on glycemic control in youth who are overweight with type 2 diabetes. This was examined in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial cohort from across 15 US centers. SUBJECTS: TODAY enrolled 699 youth aged 10 to 17 years with type 2 diabetes <2 years and body mass index ≥85th percentile at baseline. METHODS: Dietary data were collected by an interviewer-administered food frequency questionnaire; CRF was assessed using a submaximal cycle ergometer test. Change from baseline in these variables was analyzed using generalized linear mixed models for both continuous and categorical measures. Models were adjusted for age, baseline HbA1c, treatment group, and medication adherence. Data were collected at baseline, 6, and 24 months. Trial registration ClinicalTrials.gov NCT00081328. RESULTS: At 6 months, ~25% of females and ~33% of males improved CRF. In males, this was related to a decreased HbA1c (P = .001) and a lower percent experiencing glycemic failure (HbA1c ≥8%; P = .007). Females who decreased their saturated fat intake and/or increased their fiber intake had lower HbA1c at month 24 (P = .01 and P = .007, respectively). Males who increased their sweetened beverage intake at 6-month follow-up were at a 1.6-fold higher risk of experiencing glycemic failure (P = .04). CONCLUSIONS: Few youth improved fitness and/or diet over time, although those who did showed a beneficial impact on glycemic outcomes. Although lifestyle behaviors are difficult to change in youth with type 2 diabetes, interventions are needed that are feasible (in scope, complexity, and demands), sustainable, and clinically meaningful.

Predictors of Weight-Related Quality of Life in Adolescents Who Are Overweight or Obese.

OBJECTIVE: Weight-related quality of life (WRQOL) is a type of health-related QOL that may serve as a patient-reported outcome of the potential burden of overweight. The present study uses structural equation modeling path analysis methods to examine body mass index (BMI) and other potential predictors of WRQOL components among adolescents who were overweight/obese from predominantly low-income, urban households. METHODS: Baseline data were obtained from 360 participants (10-13 year olds; 57.8% female; 76.7% black; average BMI of 27.12) and their parents/legal guardians from a randomized, controlled, treatment trial. Youth completed measures of WRQOL, depressive symptoms, and family/friend social support for healthy eating. Parents completed measures of demographics and child social problems. RESULTS: The initial model included BMI, gender, parent education, family/friend social support for healthy eating, child social problems, body esteem and social life WRQOL, and depressive symptoms. The final model fit the data well (χ = 27.738; df = 16; p = .034). Higher BMI was indirectly related to lower social life and body esteem WRQOL through greater social problems. Physical comfort and family relations WRQOL were unrelated to BMI and were not included. Lower social life and body esteem related to more depressive symptoms. Family/friend discouragement for healthy eating was associated with lower body esteem; also, family discouragement was related to lower social life. CONCLUSION: Body mass index may not directly relate to WRQOL but may be associated through other factors, including child social problems. Interventions should screen for and treat mood and social problems and address family/friend support for healthy eating.

Attention-Deficit/Hyperactivity Disorder, Behavior Regulation and Virtual School Support.

CASE: Tony is a 6-year-old multiracial boy diagnosed as having attention-deficit/hyperactivity disorder-combined type who is followed in your primary care practice and has started on a stimulant medication. Tony continues to have difficulty with emotion regulation and impulse control both at home and at school. He was asked to leave his private school soon after beginning first grade because of physical fighting, emotional outbursts, and arguing with teachers.His mother made the decision to enroll Tony in online virtual schooling for the remainder of the academic year, with the plan to transition back to traditional school for the next academic year. They have enrolled in a program that offers lessons online and sends materials to the home for the child to use to complete certain types of assignments (e.g., science experiments). Virtual schools are different from traditional home schooling because children receive their instruction from teachers online with parental assistance as opposed to parents being responsible for teaching all material. Tony's mother comes to your practice requesting assistance with setting up an appropriate school environment for her son at home, where she can monitor and support his academic progress.Tony is a bright child, with an Intelligence Quotient in the superior range. He has advanced academic skills, but he becomes dysregulated if he is told he is wrong or that he has answered a question incorrectly. For example, if he answered a question incorrectly in class, he would become verbally abusive toward his teacher and often have temper tantrums. This challenging behavior occurred daily at school and was one of the factors leading to his expulsion. The behavior had predated the introduction of stimulant medication and had remained consistent after he began medication.Tony's parents are highly educated, and both parents hold professional jobs with steady income. His parents have good command of typical behavior management strategies such as the use of rewards, time out, and behavioral contingencies to target noncompliance and temper tantrums. However, Tony's difficulty identifying and regulating his emotions leads to emotional outbursts and shutdowns that have thus far been unresponsive to standard behavior management techniques. Tony continued to have outbursts even when the behavior was ignored. His mother is concerned not only about his learning during the coming year but also about his social relationships and the family dynamic. Tony's outbursts cause significant disruption in the home and are a source of tension among parents and siblings.His mother is asking for advice on how to support his behavior better at home now that he will be spending his entire day there. How might you assist this child and his mother by helping to integrate therapeutic goals into the academic environment?

Physical Activity Self-Efficacy and Fitness: Family Environment Relationship Correlates and Self-Esteem as a Mediator among Adolescents Who Are Overweight or Obese.

BACKGROUND: Little is known regarding how dimensions of the family social environment relate to fitness levels and physical activity self-efficacy (PASE) among adolescents who are overweight or obese and whether these relationships are mediated by self-esteem. METHODS: Potential associations were evaluated between relationship subdomains (cohesion, conflict, expressivity) of the Family Environment Scale (FES), self-esteem (Rosenberg Self-Esteem Scale, RSES), and PASE and fitness, using recovery heart rate [RHR, beats per minute (bpm)] from a 3-minute submaximal step test at baseline. Participants were 108 adolescents who were overweight or obese and were seeking weight-loss treatment as part of the Healthy Kids, Healthy Weight 12-week multidisciplinary pediatric weight management program. Structural equation modeling (SEM) was used to simultaneously evaluate paths between these variables and test for mediation. RESULTS: In multivariable models, higher FES cohesion (ß = -2.18, s.e. = 0.98; p = 0.02), expressivity (ß = -1.97, s.e. = 0.99; p < 0.05), and PASE (ß = -0.64, s.e. = 0.33; p < 0.05) scores were associated with lower RHR, which represents higher fitness. Furthermore, higher FES conflict scores were associated with lower RSES scores (ß = -0.83, s.e. = 0.29; p < 0.01), and FES conflict (ß = -0.63, s.e. = 0.22; p < 0.01) and RSES (ß = 0.33, s.e. = 0.07; p < 0.01) were associated with PASE scores. In a good-fitting multivariate SEM [Comparative Fit Index (CFI) = 1.00; Standardized Root Mean Square Residual (SRMR) = 0.02; Tucker-Lewis index (TLI) = 1.22; Root Mean Squared Error of Approximation (RMSEA) <0.01], RSES mediated the relationship between FES conflict and PASE (sum of indirect paths: ß = -0.30, s.e. = 0.11; p < 0.01) scores. CONCLUSIONS: Our results highlight the importance of the relationship domain of the family environment on self-esteem, PASE, and physical fitness in adolescents who are overweight or obese.

Attention-Deficit/Hyperactivity Disorder, Behavior Regulation and Virtual School Support.

CASE: Tony is a 6-year-old multiracial boy diagnosed as having attention-deficit/hyperactivity disorder-combined type who is followed in your primary care practice and has started on a stimulant medication. Tony continues to have difficulty with emotion regulation and impulse control both at home and at school. He was asked to leave his private school soon after beginning first grade because of physical fighting, emotional outbursts, and arguing with teachers.His mother made the decision to enroll Tony in online virtual schooling for the remainder of the academic year, with the plan to transition back to traditional school for the next academic year. They have enrolled in a program that offers lessons online and sends materials to the home for the child to use to complete certain types of assignments (e.g., science experiments). Virtual schools are different from traditional home schooling because children receive their instruction from teachers online with parental assistance as opposed to parents being responsible for teaching all material. Tony's mother comes to your practice requesting assistance with setting up an appropriate school environment for her son at home, where she can monitor and support his academic progress.Tony is a bright child, with an Intelligence Quotient in the superior range. He has advanced academic skills, but he becomes dysregulated if he is told he is wrong or that he has answered a question incorrectly. For example, if he answered a question incorrectly in class, he would become verbally abusive toward his teacher and often have temper tantrums. This challenging behavior occurred daily at school and was one of the factors leading to his expulsion. The behavior had predated the introduction of stimulant medication and had remained consistent after he began medication.Tony's parents are highly educated, and both parents hold professional jobs with steady income. His parents have good command of typical behavior management strategies such as the use of rewards, time out, and behavioral contingencies to target noncompliance and temper tantrums. However, Tony's difficulty identifying and regulating his emotions leads to emotional outbursts and shutdowns that have thus far been unresponsive to standard behavior management techniques. Tony continued to have outbursts even when the behavior was ignored. His mother is concerned not only about his learning during the coming year but also about his social relationships and the family dynamic. Tony's outbursts cause significant disruption in the home and are a source of tension among parents and siblings.His mother is asking for advice on how to support his behavior better at home now that he will be spending his entire day there. How might you assist this child and his mother by helping to integrate therapeutic goals into the academic environment?

Dietary Intake and Eating-Related Cognitions Related to Sleep Among Adolescents Who Are Overweight or Obese.

OBJECTIVE : To examine associations of sleep duration and regularity with dietary intake and eating-related cognitions among adolescents who are overweight/obese. METHODS : Participants were 315 adolescents being evaluated through Healthy Kids, Healthy Weight. Outcomes were reported sleep duration and regularity (bedtime shift, wake-time shift, sleep duration shift). Major predictors were dietary intake (e.g., consumption of calories and sugar-sweetened beverages) and eating-related cognitions (food preoccupation, eating self-efficacy). RESULTS : Findings were that staying up (i.e., bedtime shift) and sleeping in later (i.e., wake-time shift) on weekends compared with weekdays significantly relates to drinking more sugar-sweetened beverages, the latter for males. Sleeping in on weekends was related to greater food preoccupation. CONCLUSIONS : Sleep regularity was the most important variable in its relationships with dietary intake. Evaluating sleep patterns and improving them with behavioral interventions should be considered as an additional weight loss strategy to promote dietary adherence.

Social/Electronic Media Use of Children and Adolescents Who Attend the Pediatric Weight Management Programs of the COMPASS Network.

BACKGROUND: Obesity is a major healthcare problem in youth and their social/electronic media (SEM) use has been described as a risk factor. Though much is known about the newer technologies youth use to communicate, little is known about what is used by those in weight management programs. The aim of this study was to determine what types of SEM, including sedentary and active video games, youth in weight management programs use and which they prefer for communicating with healthcare providers. METHODS/DESIGN: This was a multisite study using a 24-question online SurveyMonkey® questionnaire. Youth, 12-17 years old, attending pediatric weight management programs at seven participating centers in the Childhood Obesity Multi Program Analysis and Study System network were eligible. RESULTS: There were 292 responders with a mean age of 14.2 years. Fifty-four percent were female, 36% Caucasian, 35% African American, and 33% were Hispanic. Ninety-four percent had access to a computer, 71% had Internet access, and 63% had smartphones. Whereas 87% had at least one gaming system at home, 50% reported they never played sedentary video games (71% of females vs. 25% males; p < 0.0001) and 63% never played exercise video games during the week. The preferred method of communication with a healthcare provider was face to face (60%), with few indicating a preference for communication by texting (13%), phone (12%), or social media (6%). CONCLUSIONS: Face-to-face communication with healthcare providers is the preferred method for youth in pediatric weight management programs. They self-reported video game use less than previously described.

Longitudinal Correlates of Health Risk Behaviors in Children and Adolescents with Type 2 Diabetes.

OBJECTIVES: To characterize, during a 2-year period, the proportion of youth with type 2 diabetes (T2D) enrolled in the Treatment Options for Type 2 Diabetes in Adolescents and Youth study that reported ever at least trying smoking cigarettes and/or drinking alcohol. STUDY DESIGN: Longitudinal data were examined for participants with T2D ages 10-18 years at baseline. Youth psychosocial, parent/family, environmental, and biological correlates of trying health risk behaviors were tested via cross-sectional multivariate models at each time point. Longitudinal models were explored for selected factors. RESULTS: Data were obtained from the Treatment Options for Type 2 Diabetes in Adolescents and Youth study's ethnically diverse participants at baseline (N=644), 6-month (N=616), and 24-month (N=543) assessments. The percentage of youth ever trying only smoking remained stable at 4%; only drinking alcohol increased from 17% to 26%, and both smoking and drinking increased from 10% to 18% during the 2-year period. Factors related to trying health risk behaviors were older age, male sex, non-Hispanic white race-ethnicity, lower grades, more depressive symptoms, and stressful life events. Depressive symptoms, stressful life events, and body mass index Z-score (the latter with smoking only) were related to engagement in health risk behaviors over time. CONCLUSIONS: Youth with T2D who are already at risk for health complications and who reported engaging in activities that further increase the likelihood of life-threatening morbidities were characterized. Although most correlates of trying these risk behaviors are nonmodifiable, intervention efforts may need to focus on potentially modifiable factors, such as depressive symptoms and lower grades.

Effects of comorbid conditions on health-related quality of life in youth with Type 2 diabetes: the TODAY clinical trial.

AIM: To explore associations between health-related quality of life (HRQOL) and comorbidities in youth with Type 2 diabetes. PATIENTS & METHODS: Of 699 youth in the TODAY study, 685 (98%) had baseline HRQOL data, 649 (93%) at 6 months and 583 (83%) at 24 months. Comorbidities were defined by sustained abnormal values and treatment regimens. RESULTS: At baseline, 22.2% of participants demonstrated impaired HRQOL. Only depressive symptoms distinguished those with versus without impaired HRQOL and were significantly related to later impaired HRQOL (p < 0.0001). A significant correspondence between impaired HRQOL and number of comorbidities (p = 0.0003) was noted, but was driven by the presence of depressive symptoms. CONCLUSION: Results emphasize the need for evaluation of depressive symptoms. Other comorbidities did not have a significant impact on HRQOL in this cohort.

Competencies in Training at the Graduate Student Level: Example of a Pediatric Psychology Seminar Course.

The recently developed competencies in pediatric psychology from the Society of Pediatric Psychology (SPP) Task Force on Competencies and Best Training Practices in Pediatric Psychology provide a benchmark to evaluate training program practices and student progress toward training in level-specific competency goals. Graduate-level training presents a unique challenge for addressing the breadth of competencies required in pediatric psychology while maintaining development of broader clinical psychology training goals. We describe a recurring graduate-level pediatric psychology seminar course that addresses training in a number of the competency cluster areas. The structure of the seminar, examples of classroom topics that correspond with competency cluster areas as well as benchmarks used to evaluate each student's development in the competency area are provided. Specific challenges in developing and maintaining the seminar in this format are identified, and possible solutions are offered. This training format could serve as a model for established pediatric psychology programs to expand their didactic training goals or for programs without formal pediatric psychology training to address competencies outside of clinical placements.

Effective strategies for encouraging behavior change in people with diabetes.

Behavioral management of diabetes leads to better health outcomes. This paper reviews the available literature on facilitators of behavior change in people with diabetes and highlights approaches and strategies diabetes care providers can utilize. The research and clinical evidence points to the critical nature of considering the content and structure of recommendations, and utilizing problem solving and teamwork approaches. Furthermore, close attention to individual and community factors will optimize behavior change. These factors include health literacy, community infrastructure, support within the family, and whether there are co-occurring eating and mood issues. Recommendations are provided to optimize communication and embed behavior change approaches in clinical and community encounters.