Parents as Agents of Change in Managing Pediatric Obesity: A Randomized Controlled Trial Comparing Cognitive Behavioral Therapy versus Psychoeducation Interventions.

Background: Obesity interventions for parents of children with obesity can improve children's weight and health. This randomized controlled trial (RCT) evaluated whether a parent-based intervention based on cognitive behavioral therapy (CBT) principles was superior to a parent-based intervention based on a psychoeducation program (PEP) in improving children's obesity. Methods: This study was a pragmatic, two-armed, parallel, superiority RCT. Conducted at a Canadian outpatient pediatric obesity management clinic (September 2010-January 2014), this trial included families with children 8-12 years with an age- and sex-specific BMI ≥85th percentile. The 16-week manualized interventions were similar in content and delivered to parents exclusively, with different theoretical underpinnings. The primary outcome was children's BMI z-score at postintervention (4 months). Secondary outcomes included anthropometric, lifestyle, psychosocial, and cardiometabolic variables. Data were collected at preintervention (0 months), postintervention (4 months), 10, and 16 months. Intention-to-treat analysis using linear mixed models was used to assess outcomes. Results: Among 52 randomly assigned children, the mean age (standard deviation) was 9.8 (1.7) years and BMI z-score was 2.2 (0.3). Mean differences in BMI z-score were not significantly different between the CBT (n = 27) and PEP (n = 25) groups from 0 to 4-, 10-, and 16-month follow-up. At 4 months, the mean difference in BMI z-score from preintervention between the CBT (-0.05, 95% CI = -0.09 to 0.00) and PEP (-0.04, 95% CI = -0.09 to 0.01) groups was -0.01 (95% CI = -0.08 to 0.06, p = 0.80). Similar results were found across all secondary outcomes. Conclusions: Our CBT-based intervention for parents of children with obesity was not superior in reducing BMI z-score vs. our PEP-based intervention.

Using Intervention Mapping to develop the Parents as Agents of Change (PAC©) intervention for managing pediatric obesity.

BACKGROUND: Pediatric obesity has become increasingly prevalent over recent decades. In view of the psychosocial and physical health risks, and the high likelihood that children with obesity will grow to become adults with obesity, there is a clear need to develop evidence-based interventions that can be delivered in the health care system to optimize the health and well-being of children with obesity and their families. The aim of this paper is to describe the development, implementation, and planned evaluation of a parent-based weight management intervention designed for parents of 8-12 year olds with obesity. METHODS/RESULTS: The principles of Intervention Mapping (IM) were used to develop an intervention called Parents as Agents of Change (PAC©). From 2006 to 2009, an environmental scan plus qualitative (individual interviews with parents and children), quantitative (medical record reviews), and literature review data were collected to gain broad insight into family factors related to pediatric obesity and its management. Theoretical frameworks and empirical evidence guided curriculum development, which was founded primarily on the tenets of family systems theory and cognitive behavioral theory. PAC was developed as a manualized, 16-session, group-based, health care professional-led intervention for parents to address individual, family, and environmental factors related to the management of pediatric obesity. The intervention was refined based on feedback from local and international experts, and has been implemented successfully in a multi-disciplinary weight management centre in a children's hospital. CONCLUSION: IM provided a practical framework to guide the systematic development of a pediatric weight management intervention for parents of children with obesity. This logical, step-by-step process blends theory and practice and is broadly applicable in the context of obesity management intervention development and evaluation. Following intervention development, the PAC intervention was evaluated within a randomized clinical trial. Trial registration NCT01267097; clinicaltrials.gov.

Predictors of Short- and Long-Term Attrition From the Parents as Agents of Change Randomized Controlled Trial for Managing Pediatric Obesity.

INTRODUCTION: Attrition in pediatric weight management is a substantial problem. This study examined factors associated with short- and long-term attrition from a lifestyle and behavioral intervention for parents of children with overweight or obesity. METHOD: Fifty-two families with children ages 6 to 12 years old and body mass index at or above the 85th percentile participated in a randomized controlled trial focused on parents, comparing parent-based cognitive behavioral therapy with parent-based psychoeducation for pediatric weight management. We examined program attrition using two clinical phases of the intervention: short-term and long-term attrition, modeled using the general linear model. Predictors included intervention type, child/parent weight status, sociodemographic factors, and health of the family system. RESULTS: Higher self-assessed health of the family system was associated with lower short-term attrition; higher percentage of intervention sessions attended by parents was associated with lower long-term attrition. DISCUSSION: Different variables were significant in our short- and long-term models. Attrition might best be conceptualized based on short- and long-term phases of clinical, parent-based interventions for pediatric weight management.

Parents as agents of change (PAC) in pediatric weight management: the protocol for the PAC randomized clinical trial.

BACKGROUND: There is an urgent need to develop and evaluate weight management interventions to address childhood obesity. Recent research suggests that interventions designed for parents exclusively, which have been named parents as agents of change (PAC) approaches, have yielded positive outcomes for managing pediatric obesity. To date, no research has combined a PAC intervention approach with cognitive behavioural therapy (CBT) to examine whether these combined elements enhance intervention effectiveness. This paper describes the protocol our team is using to examine two PAC-based interventions for pediatric weight management. We hypothesize that children with obesity whose parents complete a CBT-based PAC intervention will achieve greater reductions in adiposity and improvements in cardiometabolic risk factors, lifestyle behaviours, and psychosocial outcomes than children whose parents complete a psycho-education-based PAC intervention (PEP). METHODS/DESIGN: This study is a pragmatic, two-armed, parallel, single-blinded, superiority, randomized clinical trial. The primary objective is to examine the differential effects of a CBT-based PAC vs PEP-based PAC intervention on children's BMI z-score (primary outcome). Secondary objectives are to assess intervention-mediated changes in cardiometabolic, lifestyle, and psychosocial variables in children and parents. Both interventions are similar in frequency of contact, session duration, group facilitation, lifestyle behaviour goals, and educational content. However, the interventions differ insofar as the CBT-based intervention incorporates theory-based concepts to help parents link their thoughts, feelings, and behaviours; these cognitive activities are enabled by group leaders who possess formal training in CBT. Mothers and fathers of children (8-12 years of age; BMI ≥85th percentile) are eligible to participate if they are proficient in English (written and spoken) and agree for at least one parent to attend group-based sessions on a weekly basis. Anthropometry, cardiometabolic risk factors, lifestyle behaviours, and psychosocial health of children and parents are assessed at pre-intervention, post-intervention, 6-, and 12-months follow-up. DISCUSSION: This study is designed to extend findings from earlier efficacy studies and provide data on the effect of a CBT-based PAC intervention for managing pediatric obesity in a real-world, outpatient clinical setting. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01267097.

Food portion estimation by children with obesity: the effects of estimation method and food type.

Several factors influence children's ability to report accurate information about their dietary intake. To date, one understudied area of dietary assessment research relates to children's ability to estimate portion sizes of food. The purpose of this cross-sectional research was to examine food portion size estimation accuracy in 7- to 18-year-old children with obesity. Two within-subject experiments (Experiment 1: n=28, Experiment 2: n=27) were conducted in Edmonton, Alberta, Canada, during 2007-2008. Three types of portion size measurement aids (PSMAs) (eg, measuring cups and spoons, household objects [full and half-sized], and modeling clay) were counterbalanced in a Latin Square design for participants to estimate four types of foods (ie, solid, liquid, amorphous pieces, and amorphous masses). Analyses of variance conducted on percent of signed and absolute errors yielded significant PSMA type×food type interactions (P<0.01) in both experiments. Across all food types, for Experiments 1 and 2, measuring cups and spoons produced the least accurate estimates with respect to absolute error (54.2% and 53.1%, respectively), whereas modeling clay produced the most accurate estimates (40.6% and 33.2%, respectively). Half sizes of household objects also yielded enhanced accuracy (47.9% to 37.2%). Finally, there were significant differences in accuracy between amorphous pieces (eg, grapes) vs amorphous masses (eg, mashed potatoes; P<0.01), indicating that there are qualitative differences in how different amorphous foods are estimated. These data are relevant when collecting food intake data from children with obesity and indicate that different PSMAs may be needed to optimize food portion size estimation accuracy for different food types.

Who comes back? Characteristics and predictors of return to emergency department services for pediatric mental health care.

OBJECTIVES: The objective of this study was to investigate predictors of emergency department (ED) return visits for pediatric mental health care. The authors hypothesized that through the identification of clinical and health system variables that predict return ED visits, which children and adolescents would benefit from targeted interventions for persistent mental health needs could be determined. METHODS: Data on 16,154 presentations by 12,589 pediatric patients (

A 4-year review of pediatric mental health emergencies in Alberta.

OBJECTIVE: We sought to determine and compare rates of pediatric mental health presentations and associated costs in emergency departments (EDs) in Alberta. METHODS: We examined 16 154 presentations by 12 589 patients (patient age < or = 17 yr) between April 2002 and March 2006 using the Ambulatory Care Classification System, a province-wide database for Alberta. The following variables of interest were extracted: patient demographics, discharge diagnoses, triage level, disposition, recorded costs for ED care, and institutional classification and location (i.e., rural v. urban, pediatric v. general EDs). RESULTS: A 15% increase in pediatric mental health presentations was observed during the study period. Youth aged 13-17 years consistently represented the most common age group for first presentation to the ED (83.3%). Of the 16 154 recorded presentations, 21.4% were related to mood disorders and 32.5% to anxiety disorders. Presentations for substance misuse or abuse were the most prevalent reasons for a mental health-related visit (41.3%). Multiple visits accounted for more than one-third of all presentations. Presentations for mood disorders were more common in patients with multiple compared with single visits (29.3% v. 16.9%), and substance abuse or misuse presentations were more common in patients with single compared with multiple visits (47.4% v. 30.5%). The total direct ED costs for mental health presentations during the study period was Can$3.5 million. CONCLUSION: This study provides comprehensive data on trends of pediatric mental health presentation, and highlights the costs and return presentations in this population. Psychiatric and medical care provided in the ED for pediatric mental health emergencies should be evaluated to determine quality of care and its relationship with return visits and costs.

An interdisciplinary, family-centered approach to treating pediatric obesity in an 11-year-old female: a case report.

Pediatric obesity has become increasingly prevalent over the past 2-3 decades. Recently-published clinical practice guidelines and expert recommendations provide guidance for obesity treatment, but therapy is often complicated by a host of medical, behavioural, psychosocial, and interpersonal issues. We report the case of an 11-year-old obese girl and her family referred for weight management. Our case underscores the need for an interdisciplinary, family-centered approach to the assessment and treatment of pediatric obesity, and highlights the value of understanding familial complexities that often accompany this health issue. The importance of utilizing multiple health indicators to assess weight management 'success' is discussed.

The object relations of bulimic women in context: an integration of two studies.

The purpose of this paper is to investigate and contextualize the object relations of bulimic women. Two independent studies, one quantitative and one qualitative, were conducted. In the quantitative study, 77 undergraduate women completed self-report measures of eating behavior, interpersonal dependency, and object relations. In the qualitative study, four bulimic women participated in semi-structured interviews that were coded for relational themes and contextualized through a feminist socio-cultural analysis. Results supported the strong association between dependency and eating disorders and demonstrated that the object relationships of the participants were characterized by both insecure attachment and egocentricity. Socio-cultural analysis suggests that the development of these object relations can be partially accounted for by conflicting cultural expectations for women.