One Year Follow-up of Outcomes from the Randomized Clinical Trial of the Building on Family Strengths Program.

Objectives Test the 12-month efficacy of an inclusive non-diagnosis-specific, parent education program with seven in-person sessions. Methods Parents of 110 children, 2-11 years old, with a variety of special health care conditions, were recruited to participate in a randomized clinical trial. At twelve months data from 104 parents were available for longitudinal analysis. Linear mixed models, with the interaction term of group by time, were used to assess the efficacy of the intervention over 12 months using data from 3 time points: baseline, 6 and 12 months. The outcome measures were self-efficacy, parent and child shared management of chronic condition, coping skills, parental depressive symptoms and quality of life. Results All of the outcomes improved within the intervention group over 12 months. Self-efficacy was the strongest outcome which remained significantly different from the control group 12 months post intervention, without any statistical adjustment (p = 0.045). The coefficient of the interaction term for study group (intervention or control) by time, quantifying the intervention effect, was statistically significant for four of five pre-specified study outcomes, favorably so toward the intervention group (p < 0.05, with the 5th outcome, parental depression, p = 0.052). Conclusions for Practice The Building on Family Strengths intervention was efficacious in improving self-efficacy, shared management, coping skills, and quality of life and decreasing depressive symptoms in parents, in particular for parents who were most impacted by the lack of these strengths and skills at baseline. These results are encouraging and future studies to investigate the efficacy of this intervention in an Internet-based setting or other modalities are encouraged.

Re-Envisioning a DNP Program for Quality and Sustainability.

When the University of Washington, School of Nursing determined that its post-BSN-DNP degree program, with multiple specialty tracks and programs of study, was not sustainable, the curriculum was re-envisioned. The revised program is consistent with the American Association of Colleges of Nursing (AACN) Essentials of Doctoral Education for Advanced Nursing Practice and the national Licensure Accreditation, Certification, and Education (LACE) model. The re-envisioned program was conceptualized as a single degree in which students preparing for any specialty would have the same number of required credits with the majority of courses (DNP core) required for all students. Two major pathways, 1) advanced practice registered nursing and 2) advanced systems and population health were identified. The model allows for specialties to be added or discontinued without major disruption to the core curriculum. The consolidated curriculum reduced instructional costs to the school by approximately 26% and reduced and made more equitable the tuition costs for the majority of students. The revised consolidated program is innovative, maintains quality, attracts students, and aligns with resources. This article discusses how we achieved revision and consolidation of a post-BSN DNP program with multiple specialty tracks that is innovative, high quality, sustainable, and replicable by other schools of nursing.

Relationship between sleep disturbance and functional outcomes in daily life habits of children with Down syndrome.

OBJECTIVES: The goal of this study was to describe sleep patterns and accomplishment of daily life habits in children with Down syndrome (DS) and to investigate the relationship between subjective indicators of sleep disturbance with functional outcomes in daily life. DESIGN: Cross-sectional study with an Internet sample. SETTING: Online survey filled out at home. PARTICIPANTS: 110 parents of children with DS and 29 parents of children with typical development (TD), age 5 to 18 years. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Children's Sleep Habits Questionnaire was employed to collect information about sleep disturbances in 8 domains (subscales) and a total score. The Life Habits (Life-H) questionnaire sampled information about daily life habits in 11 domains. Multivariable regression modeling was used to assess the associations between sleep disturbances and the accomplishment of daily life habits. Sleep disordered breathing (SDB) was a significant explanatory factor in 10 of 11 daily life habits and the total Life-H score. Sleep anxiety and parasomnias significantly influenced the accomplishment of life habits in children with DS as compared to children with typical development. When evaluated in multivariable models in conjunction with the other 7 domains of sleep disturbances, SDB was the most dominant explanatory factor for accomplishment of life habits. CONCLUSIONS: Sleep disturbances are negatively related to accomplishment of daily life functions. Prevention and treatment of sleep problems, particularly sleep disordered breathing, in children with DS may lead to enhanced accomplishment of daily life habits and activities.

Feasibility of using actigraphy and motivational-based interviewing to improve sleep among school-age children and their parents.

Inadequate sleep occurs in 25% of our nation's children; poor sleep is associated with physical, cognitive, and social consequences. Developing good sleep hygiene in middle childhood is important, because habits typically extend to adolescence and adulthood; yet, there has been little research on sleep interventions for school-age children. The purpose of this study was to determine the feasibility of a developmentally tailored, motivation-based intervention (MBI) focused on improving sleep behaviors in school-age children aged 8-11. Nine parent-child dyads participated in an 8-week protocol utilizing MBI and comparisons of objective (actigraphy) and subjective (sleep diaries) data. Results suggest that parent and children are able to identify a target behavior to change and complete the protocol. Further, preliminary evidence indicates that sleep patterns change using MBI. Future research will be directed toward comparative effectiveness testing and exploring ways in which it can be adapted and incorporated into school nursing practice.

A randomized clinical trial of the building on family strengths program: an education program for parents of children with chronic health conditions.

To test the 6-month efficacy of an inclusive non-diagnosis-specific, 7-session parent education curriculum on five pre-specified outcomes. A randomized clinical trial with 100 parents having children 2-11 years with a variety of chronic conditions was conducted. The 7-session curriculum, Building on Family Strengths (BFS), was created by an interdisciplinary pediatric team as a derivative of a successful adult chronic disease self-Management program distributed by Stanford University Patient and Education Research Center. Despite no differences at baseline, intervention participants had higher scores on self-efficacy to manage the child's condition (p = 0.049), coping with childhood chronic illness (p < 0.001), parent-child shared management of the condition (p = 0.097), family quality of life (p = 0.010), and, lower scores on a measure of depressive symptoms (p = 0.046) at the 6-month end-point. Average effect-sizes were modest across outcomes (7-11% improvement) with intervention participants having baseline scores in the least favorable quartile improving the most (12-41%). This research provides evidence that the BFS curriculum can yield significant improvements across five important outcomes for parents of children with various chronic conditions. Parent education programs should be offered especially to parents of children with chronic health conditions, regardless of the type of condition, who lack adequate support. These programs can help parents cope with and manage their children's chronic conditions more effectively.

A systematic review of the association between obesity and asthma in children.

AIM: To provide a comprehensive integration of contemporary studies focusing on the relationship between obesity and asthma in paediatric populations. BACKGROUND: The simultaneous increase in asthma and obesity prevalence has been widely discussed over the past 20 years. Although studies have discovered a positive correlation between the two, evidence-based findings are needed to develop nursing interventions. DESIGN: A quantitative systematic review on the literature was conducted from June-December 2011. DATA SOURCES: An electronic database search was conducted for studies published between January 1966-May 2011. Additional articles were identified through the reference lists of reviewed papers. REVIEW METHODS: Inclusion/exclusion criteria and quality appraisal were applied to ensure research primarily designed to study the relationship between obesity and asthma in children was included. RESULTS: The majority of studies support a positive association between obesity and asthma in children. Among correlates recognized as important effect modifiers, gender was the most prominent, with obese girls more likely to have asthma diagnoses than obese boys. Scrutinization of covariates in selected studies revealed that most related to children's demographic characteristics and were inconsistent across the studies. CONCLUSIONS: This review was designed to integrate contemporary scientific findings on the association between obesity and asthma by including a large number of studies with variant research designs. To identify high-risk groups and develop nursing interventions to help children affected by both epidemics, more interdisciplinary and well-designed investigations focusing on an expanded spectrum of correlates including demographic and behavioural factors are warranted.

School nurses can address existing gaps in school-age sleep research.

Sleep has been linked to a host of physical, behavioral, and emotional outcomes, and research has documented that youth across the globe are experiencing inadequate sleep. Despite this knowledge, however, very little research has been conducted on school-age children; much of the extant research has focused on infants, toddlers, preschoolers, adolescents, and adults. School-age children exhibit increasing independence around health-related behaviors, which provide health professionals the opportunity to educate and promote healthy sleep behaviors. This commentary extends previous research reviews by identifying the current gaps in sleep research, highlighting future directions needed in sleep research, and explaining why school nurses are best suited to address this growing public health issue.

Daytime physical activity levels in school-age children with and without asthma.

BACKGROUND: Physical activity (PA) is a significant predictor of health outcomes in children with and without chronic conditions. Few researchers have used actigraphy as an objective measure of PA during the child's normal daily routines, and the findings have been inconsistent. It is unclear if asthma can contribute to low PA levels. OBJECTIVES: The aim of this study was to compare daytime PA levels in children with and without asthma and examine the relationships among asthma, PA, body mass index (BMI), and child reports of symptoms. METHODS: Physical activity as measured by actigraphy and self-report symptoms of coughing, wheezing, chest tightness, perceived tiredness, sleepiness, and alertness were obtained in 54 children aged 9-11 years with and without asthma for 7 consecutive days. Activity variables derived from actigraphy included (a) mean daytime activity level; (b) peak daytime activity level; and (c) time duration spent in sedentary, light, moderate, vigorous, and total moderate plus vigorous PA (MVPA). RESULTS: Children with and without asthma did not differ on BMI or activity levels. Children with asthma reported more activity limitations due to breathing problems than children without asthma (p < .01). In multivariate analyses, asthma predicted reduced mean, peak, and total time spent in MVPA level after controlling for gender, BMI, and self-report of symptoms. A significant interaction was found between asthma and BMI on mean, peak, and total time spent in MVPA. DISCUSSION: The association between asthma and PA is complex when the child's BMI is considered. Results suggest that reduced PAs with respect to respiratory symptom severity, childhood obesity, and functional impairment are important areas for future studies.

Sleep measurement and monitoring in children with Down syndrome: a review of the literature, 1960-2010.

Children with Down syndrome (DS) are at risk for sleep disturbances due to the anatomical features of the syndrome. Over the past 50 years research studies have measured sleep in children with DS to characterize sleep architecture and its relation to developmental delay. In the 1980s sleep disordered breathing (SDB) was recognized as a major cause of sleep disturbance in DS. The aim of this comprehensive review is to synthesize studies and present the historical context of evolving technologies, methodologies, and knowledge about SDB and DS. Future research opportunities and practice implications are discussed.

Polysomnography and actigraphy concordance in juvenile idiopathic arthritis, asthma and healthy children.

The aims of this study were to evaluate sensitivity, specificity and accuracy with an epoch-by-epoch comparison of polysomnography (PSG) and actigraphy with activity counts scored at low, medium and high thresholds, and to compare PSG-derived total sleep time (TST), sleep efficiency (SE) and wake after sleep onset (WASO) to the same variables derived from actigraphy at low, medium and high thresholds in 9- to 11-year-old children with juvenile idiopathic arthritis (JIA), asthma and healthy control children. One night of PSG and actigraphy were recorded. Pairwise group comparisons for sensitivity showed significant differences at the low [Tukey's honest significant difference (HSD) P < 0.002], medium (P < 0.001) and high thresholds (P < 0.001) between JIA and asthma groups, and at the high threshold between JIA and controls (P < 0.009). Significant differences were found for specificity at the low (P < 0.001), medium (P < 0.001) and high thresholds (P < 0.001) between JIA and asthma groups, and between JIA and controls (low, P < 0.002: medium, P < 0.002: high, P < 0.008 threshold). PSG TST, WASO and SE were not significantly different among the groups, but significant group differences were found for actigraphy TST, WASO and SE at all three thresholds. Actigraphy showed the least overestimation or underestimation of sleep or wakefulness at the medium threshold for TST and WASO for all three groups. Compared to PSG, actigraphy was most accurate in the identification of sleep from wakefulness in 9- to 11-year-old healthy children, and less accurate in children with JIA and asthma.

The feasibility and acceptability of a home-visitation, asthma education program in a rural, Latino/a population.

OBJECTIVES: The effectiveness of community health worker-delivered interventions to decrease environmental triggers for asthma in the home has been well documented in urban populations, but has had little evaluation in rural, Latino/a families. The purpose of this study was to evaluate the feasibility and acceptability of a home-visitation intervention designed to decrease environmental triggers for pediatric asthma in rural, Latino/a families. METHODS: Data from a large community health clinic's pediatric asthma program (2002, 2003, 2004, 2005, 2006) were used to retrospectively explore associations between program participation and asthma-related health outcomes. Demographic data were collected on 866 patients. Behavioral outcomes were evaluated in 374 participants. A medical record abstraction was conducted in a subsample of 400 patients to evaluate asthma-related urgent care use. Nonparametric tests were used to compare outcomes before and after the intervention. Demographic attributes associated with program participation were examined using logistic regression. RESULTS: Most (91%) participants were Hispanic, and 61% of participants' caregivers were either seasonal or migrant farmworkers. Over half (61%) of the participants did not complete the full intervention. A statistically significant improvement was found in caregivers' abilities to manage asthma medications and adopt behaviors to decrease triggers inside the home. Behaviors related to decreasing outside triggers did not significantly change. Asthma-related urgent care use significantly decreased; however, there was no association between intervention dose and a decrease in urgent care use. Demographic attributes were generally not associated with program completion, having baseline and exit data on intermediate outcomes, and/or inclusion in the chart review. CONCLUSIONS: Results suggest that the asthma intervention helped caregivers improve the air quality in their homes and reduce urgent care admissions among pediatric participants. The intervention dose may be less important than taking part in an intervention to the extent feasible or desired by the family. Findings suggest that policy-level interventions need to address reimbursement for home visitation and environmental exposures that are beyond caregiver control, such as support for healthy and affordable housing in farmworker communities.

Randomized trial of teaching brief motivational interviewing to pediatric trainees to promote healthy behaviors in families.

HYPOTHESIS: That pediatric resident trainees would demonstrate increased counseling skill following training in brief motivational interviewing (MI). DESIGN: Randomized controlled trial. SETTING: University of Washington Pediatric Residency. PARTICIPANTS: Pediatric residents (N = 18), including residents in postgraduate years 1, 2, 3, and 4. INTERVENTIONS: Collaborative Management in Pediatrics, a 9-hour behavior change curriculum based on brief MI plus written feedback on communication skills (based on a 3-month Objective Standardized Clinical Evaluation [OSCE]). MAIN OUTCOME MEASURE: The percentage of MI-consistent behavior (%MICO), a summary score for MI skill, was assessed via OSCEs in which standardized patients portray parents of children with asthma in 3 clinical scenarios (stations). The OSCEs were conducted at baseline and 3 and 7 months. Blinded coders rated videotaped OSCEs using a validated tool to tally communication behaviors. Training effects were assessed using linear regression controlling for baseline %MICO. Global ratings of counseling style served as secondary outcome measures. RESULTS: Trained residents demonstrated a trend toward increased skill (%MICO score) at 3 months compared with control residents. At 7 months, %MICO scores increased 16% to 20% (P < .02) across all OSCE stations after the combined intervention of Collaborative Management in Pediatrics training plus written feedback. The effect of training on global ratings supported the main findings. CONCLUSIONS: Pediatric trainees' skills in behavior change counseling improved following the combination of training in brief MI plus personalized feedback.

Changes in the health burden of a national sample of children with asthma.

This paper focused on the extent to which factors that are modifiable by health policies or provider recommendations influenced the level and changes in the burden of childhood asthma. Demographic factors, access to health care services, and asthma control activities were posited to potentially influence the level and changes in health burden of children with asthma. The Medical Expenditure Panel Survey data from 1996-1999 on 3-11 year old U.S. children with asthma (N=784) were used. The findings of multilevel models of perceived burden indicated unfavorable trajectories among those families who had public health insurance. Asthma control activities were associated with favorable trajectories of both perceived and objectively measured burden. These findings emphasized the significance of asthma control and access to high quality and stable health care services as health policy targets.

Parents of children with special health care needs who have better coping skills have fewer depressive symptoms.

OBJECTIVES: Describe and quantify coping skills and prevalence of depressive symptoms in parents of children with special health care needs (CSHCN). Describe the association of coping skills with parental depressive symptoms, severity of child's condition and family demographic characteristics. METHODS: A baseline questionnaire was administered to parents of CSHCN 2-11 years old. Data were analyzed cross-sectionally. Coping skills were assessed using F-COPES, and depressive symptoms were measured using CESD 10, both previously tested tools. Multivariable regression models measured the association of coping skills with depressive symptoms, parents' rating of severity and demographic characteristics. RESULTS: Among 129 parents 54% had depressive symptoms above standard normal threshold. Parents with better coping skills had significantly fewer depressive symptoms. The severity of child's condition, parental marital status and employment status were significantly related to depressive symptoms; after accounting for these factors, better coping skills were still associated with fewer depressive symptoms (P-value < 0.05). CONCLUSIONS: Parents of CSHCN are at increased risk for depressive symptoms, especially if single and unemployed. In this study better parental coping skills were associated with fewer depressive symptoms, regardless of the severity of child's condition; and remained significant after accounting for demographic factors. Educational interventions to improve coping skills for parents of children who have a variety of diagnoses and severity levels may potentially mitigate the manifestation of depressive symptoms and in turn improve parenting.

Parent-child agreement in report of nighttime respiratory symptoms and sleep disruptions and quality.

INTRODUCTION: Asthma control requires assessment of nighttime symptoms and sleep disruption. Cognitive and emotional development enables most school-aged children to report nocturnal problems, but providers often rely only on parental report, potentially limiting the comprehensiveness of their assessments and their ability to support the child's emerging efforts at shared management of their illness. This study investigated parent-child concordance in report of nighttime respiratory symptoms, sleep disruption, and quality of sleep in a sample of 9- to 11-year-old children with asthma. Secondarily, similar concordance patterns in an equal number of dyads where the child was asthma free were examined to illustrate the potential influence of asthma. METHOD: Parents and children completed 1-week diaries in their homes without confiding in one another. The probability of knowing the child's report on a specific item if the parent's report was known was assessed using contingency tables. RESULTS: Within the asthma group, parent-child reports differed significantly across all symptoms and sleep parameters. Parents most often reported fewer symptoms and awakenings and better quality of sleep than did their child. Concordance rates were lowest for morning perceptions of tiredness, sleepiness, and alertness in both asthma and non-asthma groups. DISCUSSION: Both parents and school-aged children with asthma need to be asked about nighttime asthma symptoms, sleep, and morning perceptions when attempting to evaluate asthma control. Assessment of sleep in all children should include parent and child reports and would benefit by the addition of objective measures.

Community health workers and environmental interventions for children with asthma: a systematic review.

Community health worker (CHW)-delivered, home-based environmental interventions for pediatric asthma were systematically reviewed. Seven PubMed/MEDLINE listed randomized controlled trials that encompassed the following intervention criteria were identified: (1) home-based; (2) delivered by a CHW; (3) delivered to families with children with asthma; and (4) addressed multiple environmental triggers for asthma. Details of research design, intervention type, and setting, interventionist, population served, and the evaluated outcomes were abstracted. Outcome assessment was broad and non-uniform. Categories included direct mediators of improved health outcomes, such as trigger-related knowledge, trigger reduction behaviors and allergen or exposure levels, and asthma-related health outcomes: change in lung function, medication use, asthma symptoms, activity limitations, and health care utilization. Indirect mediators of health outcomes, or psychosocial influences on health, were measured in few studies. Overall, the studies consistently identified positive outcomes associated with CHW-delivered interventions, including decreased asthma symptoms, daytime activity limitations, and emergency and urgent care use. However, improvements in trigger reduction behaviors and allergen levels, hypothesized mediators of these outcomes, were inconsistent. Trigger reduction behaviors appeared to be tied to study-based resource provision. To better understand the mechanism through which CHW-led environmental interventions cause a change in asthma-related health outcomes, information on the theoretical concepts that mediate behavior change in trigger control (self-efficacy, social support) is needed. In addition, evaluating the influence of CHWs as clinic liaisons that enhance access to health professionals, complement clinic-based teaching, and improve appropriate use of asthma medications should be considered, alongside their effect on environmental management. A conceptual model identifying pathways for future investigation is presented.

Measuring parent-child shared management of chronic illness.

UNLABELLED: Over time, most children with special health needs must become partners in their disorder management. Because most care of chronic conditions takes place in the home, parents assume significant responsibility in starting and supporting the child's role in parent-child shared management over time. This article describes findings from analysis of one attempt to measure this important construct. METHODS: Cross-sectional descriptive study with 129 parents of children with chronic conditions. RESULTS: Internal consistency of the shared management scale was adequate (Cronbach's Alpha: overall scale, 0.91; and subscales: desire, 0.79; knowledge, 0.76; and current actions, 0.86). Observed relationships were in theoretically expected directions. In unadjusted univariate analyses, there were statistically significant associations between parent-child shared management and each of the following variables: (a) condition grouping and severity, (b) parent self-efficacy and coping, (c) amount and frequency of child's limitation to do things, and (d) emergency visits in the past 6 months (all at p < 0.01 levels). Adjusted multivariable analysis retained condition severity, parent self-efficacy, and coping as significant factors. CONCLUSIONS: The parent-child shared management tool can be used in research to broaden understanding of this important construct and identify precursors and outcomes of high or low shared management in a family. Nurses might use the tool in clinical practice to more accurately gauge parent desire for, knowledge of, and current actions in support of parent-child shared management so interventions can be individualized to the family's unique wishes.

Parent and community participation in program design.

Parents of children with chronic illnesses face many challenges not faced by other parents. A family-centered parent support and education program, Building on Family Strengths (BFS), was designed to help parents meet these challenges by gaining new skills and learning new ways to support their children. BFS researchers involved potential participant families in the refinement of the BFS curriculum to make it truly family centered. The article reports major feedback received from parent focus groups, leaders in several cultural communities, and participants in a pilot class as BFS underwent final refinement. This feedback greatly influences the development of the BFS curriculum, as without it the final product going into a randomized clinical trial would be less attuned to the needs of parents of children with chronic illnesses. Other researchers and family educators may find this feedback useful as they improve their own research and program offerings.

Managing childhood chronic illness: parent perspectives and implications for parent-provider relationships.

When children have special health care needs, parents assume the roles of care coordinator, medical expert, and systems advocate as well as their typical parenting roles. They face many challenges in managing their child's chronic condition in the context of everyday life. Health care providers are uniquely positioned to assist parents in meeting those challenges and to promote parent competency and confidence in their child's care. The data for this analysis were collected during classes for parents of children with chronic conditions who took part in a randomized controlled study of a curriculum's effectiveness. During facilitated discussions, parents discussed challenges they faced and generated strategies they found helpful. Qualitative data analysis revealed dominant themes across subject areas. Challenges included social isolation, strained relationships and ongoing frustrations with health care and educational systems. Helpful strategies focused on being prepared, connecting with peers, becoming an advocate, developing partnerships and caring for one's self. Implications for health care providers include: understanding common challenges parents face; promoting parent-to-parent connections; and building partnerships with parents and their children with special needs.