Publications by authors named "Christopher C Cushing"

50 Publications

Daily adherence variability and psychosocial differences in adolescents with asthma: a pilot study.

J Behav Med 2021 Aug 6. Epub 2021 Aug 6.

Department of Clinical and Health Psychology, University of Florida, P.O. Box 100165, Gainesville, FL, 32610-0165, USA.

Adolescents with asthma endorse psychosocial difficulties as barriers to inhaled corticosteroid adherence. This study examined patterns of variability in adherence and within-person associations of psychosocial variables with adherence across days. Participants included twenty-five adolescents (M = 14.7, SD = 1.68; 48% male) with persistent asthma. We measured adherence via electronic monitoring. Adolescents completed daily surveys measuring asthma symptoms, stress, mood, and affect. We examined within-person differences in the effect of symptoms and psychosocial variables on adherence. Adherence decreased over time. The addition of a random slope improved model fit (- 2ΔLL(1) = 9.36, p < .01). Greater asthma symptoms were significantly associated with higher adherence at the within-person level and with lower adherence between persons. We observed evidence of individual differences in the associations of stress and affect with adherence. Within-person, day-level fluctuations in adherence occur. Symptoms and psychosocial variables may influence adherence. Individually tailored interventions may effectively address nonadherence.
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http://dx.doi.org/10.1007/s10865-021-00247-5DOI Listing
August 2021

Meta-Analysis of Adherence Promotion Interventions in Pediatric Asthma.

J Pediatr Psychol 2021 10;46(10):1195-1212

Department of Clinical & Health Psychology, University of Florida.

Background: Youth with asthma commonly have suboptimal adherence to inhaled corticosteroids (ICS). It is critical to systematically evaluate the effectiveness of ICS adherence promotion interventions and discern which techniques are most effective.

Objective: This study aims to (1) quantify the extent to which interventions improve ICS adherence in pediatric asthma, (2) explore differences in effect size estimates based on intervention and study characteristics, and (3) characterize the risk of bias across interventions.

Methods: We conducted literature searches across five databases. Included studies quantitatively measured ICS adherence as an intervention outcome among youth (<18 years old) diagnosed with asthma and were published after 1997. We analyzed aggregate effect sizes and moderator variables using random-effects models and characterized risk of bias using the Cochrane Collaboration tool.

Results: Thirty-three unique studies met inclusion criteria. At post-intervention, the aggregate effect size for pediatric ICS adherence promotion interventions was small but significant (n = 33, g = 0.39, 95% confidence interval [CI] = 0.24-0.54); however, the aggregate effect size at follow-up was not statistically significant (n = 6, g = 0.38, 95% CI = -0.08 to 0.83). Method of adherence measurement and intervention format were significant moderators. Most interventions had a high risk of performance bias and an unclear risk of bias in one or more domains.

Conclusions: ICS adherence promotion interventions are effective among youth with asthma. Additional longitudinal research is needed to quantify a more precise measure of intervention effectiveness over time, and moderators of intervention effectiveness should be reassessed as the literature base expands.
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http://dx.doi.org/10.1093/jpepsy/jsab057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8521221PMC
October 2021

Prospective quality of life outcomes in pediatric fecal incontinence following bowel management.

J Pediatr Surg 2021 Aug 5;56(8):1459-1464. Epub 2021 Jun 5.

Cincinnati Children's Hospital Colorectal Center for Children, Cincinnati, OH, United States.

Background: Severe fecal incontinence (FI) is common in patients both with and without anorectal malformations. Whether a formal bowel management program (BMP) has significant effects on FI, psychosocial development of the child, and caregiver stress is poorly understood. We hypothesize that BMP participation results in long-term clinical and quality of life (QOL) improvements for patients and caregivers.

Methods: Using a prospective cohort study over three years, 342 children (age 3-12 years) and caregivers were followed for one year after attending a week-long BMP, during which a regimen was tailored to promote daily stool evacuation.FI QOL was measured with the validated Cincinnati Fecal Incontinence Scale (CINCY-FIS), evaluating multiple subscales, including parental stress. Scores were obtained at multiple timepoints following BMP (baseline, 2 weeks, 3 months, 1 year).

Results: Within 2 weeks, BMP participation significantly improved FI with increased frequency of daily daytime voluntary bowel movements (20%-70%, p < 0.001) and decreased daily daytime and nighttimeinvoluntary bowel movements (60%-20%, p < 0.001; 30%-10%, p < 0.05). Marked improvements in CINCY-FIS were observed across multiple QOL subscales, with the greatest in parental stress, and sustained through one year.

Conclusions: BMP results in significant and sustained improvement in FI and QOL for patients and caregivers.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.04.025DOI Listing
August 2021

Evaluating associations between fitspiration and thinspiration content on Instagram and disordered-eating behaviors using ecological momentary assessment: A registered report.

Int J Eat Disord 2021 07 9;54(7):1307-1315. Epub 2021 Apr 9.

Research Design and Analysis Unit, Lifespan Institute, University of Kansas, Lawrence, Kansas, USA.

Introduction: Greater use of appearance-focused social media, such as Instagram, is associated with increased body dissatisfaction and eating disorder (ED) symptoms; however, questions remain about the mechanism connecting social media use to disordered-eating behaviors (DEBs). The proposed study evaluates how and for whom exposure to fitspiration or thinspiration on Instagram is associated with DEBs.

Methods: We will evaluate a hypothesized pathway from Instagram use to disordered-eating mediated by negative affect. We will test how individual differences in internalized weight stigma, trait self-esteem, and trait self-comparison moderate the pathway from social media use to negative affect. We will recruit 175 undergraduate women who report engaging in DEBs on average at least once per week over the past 3 months. Participants will complete a 7-day ecological momentary assessment protocol, during which they will report their Instagram use, affect, and engagement in DEBs.

Results: Multi-level modeling will be used to assess moderated mediation. Results from this study will provide increased specificity about how Instagram usage is linked to eating pathology and who may be most vulnerable to experiencing distress.

Discussion: Information about negative affect from Instagram and engagement in DEBs could contribute to the development of Just-In-Time Interventions for problematic social media use.
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http://dx.doi.org/10.1002/eat.23518DOI Listing
July 2021

Adaptive mHealth Intervention for Adolescent Physical Activity Promotion.

J Pediatr Psychol 2021 06;46(5):536-546

Department of Biobehavioral Health, The Pennsylvania State University.

Objective: The present nonrandomized controlled trial aimed to evaluate feasibility, acceptability, and preliminary efficacy of a tailored text message intervention for increasing adolescent physical activity, as compared with passive monitoring.

Methods: Forty adolescents (13-18 years old) received either a tailored text messaging intervention (Network Underwritten Dynamic Goals Engine [NUDGE]; N = 20), or participated in an attention-control condition (N = 20), for 20 days. Physical activity was measured for all participants via continuous accelerometry. Frequency analyses were conducted on program usage and satisfaction ratings to evaluate feasibility and acceptability, and multilevel models were used to evaluate the efficacy hypotheses.

Results: The vast majority of participants (90%) reported being very or mostly satisfied with the NUDGE program and rated their enjoyment as above average. The intervention group was estimated to spend an average of 20.84 more minutes per day in moderate-to-vigorous physical activity relative to the attention-control group (β = 20.84, SE = 8.19). Exploratory analyses revealed that the intervention group also engaged in 82 fewer minutes of sedentary time per day on average, although this effect was not significant due to the large variability in sedentary time (β = -81.98, SE = 46.86).

Conclusions: The NUDGE tailored text messaging intervention was feasible, acceptable, and efficacious in increasing physical activity in this sample. Findings warrant additional evaluation of NUDGE as both a standalone physical activity intervention or as part of a multicomponent package.
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http://dx.doi.org/10.1093/jpepsy/jsaa125DOI Listing
June 2021

Individual Differences in the Relationship Between Pain Fear, Avoidance, and Pain Severity in a Chronic Abdominal Pain Sample and the Moderating Effect of Child Age.

Ann Behav Med 2021 06;55(6):571-579

Division of Gastroenterology, Hepatology, & Nutrition, Children's Mercy, MO, USA.

Background/purpose: Most studies examining the components of the fear-avoidance model have examined processes at the group level. The current study used ecological momentary assessments to: (a) investigate the group and intraindividual relationships between pain fear, avoidance, and pain severity, (b) identify any heterogeneity between these relationships, and (c) explore the role of moderators to explain such heterogeneity.

Methods: Seventy-one pediatric patients with chronic abdominal pain (M = 13.34 years, standard deviation = 2.67 years) reported pain fear, avoidance, and pain severity four times per day over 14 days.

Results: Results indicated significant individual differences in the relationship between pain fear and pain avoidance predicting pain severity. Child age helped explain the heterogeneity in the relationships between pain avoidance and pain severity such that older children had a stronger and more positive relationship between these variables. The random effect between pain fear and pain severity also indicated a moderator trend of child age such that older children were likely to have a stronger and more positive relationship.

Conclusions: The present study extends the fear-avoidance model by highlighting the importance of identifying potential individual differences when examining pain fear, avoidance, and pain severity. Furthermore, the current study suggests that child development should be considered in the model. However, future randomized control designs are necessary to explore the causal relationships between pain fear and avoidance on pain severity and potential developmental differences.
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http://dx.doi.org/10.1093/abm/kaaa096DOI Listing
June 2021

Differences in adolescent activity and dietary behaviors across home, school, and other locations warrant location-specific intervention approaches.

Int J Behav Nutr Phys Act 2020 09 29;17(1):123. Epub 2020 Sep 29.

Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Kansas City, 610 E. 22nd Street, Kansas City, MO, USA.

Background: Investigation of physical activity and dietary behaviors across locations can inform "setting-specific" health behavior interventions and improve understanding of contextual vulnerabilities to poor health. This study examined how physical activity, sedentary time, and dietary behaviors differed across home, school, and other locations in young adolescents.

Methods: Participants were adolescents aged 12-16 years from the Baltimore-Washington, DC and the Seattle areas from a larger cross-sectional study. Participants (n = 472) wore an accelerometer and Global Positioning Systems (GPS) tracker (Mean days = 5.12, SD = 1.62) to collect location-based physical activity and sedentary data. Participants (n = 789) completed 24-h dietary recalls to assess dietary behaviors and eating locations. Spatial analyses were performed to classify daily physical activity, sedentary time patterns, and dietary behaviors by location, categorized as home, school, and "other" locations.

Results: Adolescents were least physically active at home (2.5 min/hour of wear time) and school (2.9 min/hour of wear time) compared to "other" locations (5.9 min/hour of wear time). Participants spent a slightly greater proportion of wear time in sedentary time when at school (41 min/hour of wear time) than at home (39 min/hour of wear time), and time in bouts lasting ≥30 min (10 min/hour of wear time) and mean sedentary bout duration (5 min) were highest at school. About 61% of daily energy intake occurred at home, 25% at school, and 14% at "other" locations. Proportionately to energy intake, daily added sugar intake (5 g/100 kcal), fruits and vegetables (0.16 servings/100 kcal), high calorie beverages (0.09 beverages/100 kcal), whole grains (0.04 servings/100 kcal), grams of fiber (0.65 g/100 kcal), and calories of fat (33 kcal/100 kcal) and saturated fat (12 kcal/100 kcal) consumed were nutritionally least favorable at "other" locations. Daily sweet and savory snacks consumed was highest at school (0.14 snacks/100 kcal).

Conclusions: Adolescents' health behaviors differed based on the location/environment they were in. Although dietary behaviors were generally more favorable in the home and school locations, physical activity was generally low and sedentary time was higher in these locations. Health behavior interventions that address the multiple locations in which adolescents spend time and use location-specific behavior change strategies should be explored to optimize health behaviors in each location.
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http://dx.doi.org/10.1186/s12966-020-01027-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526379PMC
September 2020

Developing Empirical Decision Points to Improve the Timing of Adaptive Digital Health Physical Activity Interventions in Youth: Survival Analysis.

JMIR Mhealth Uhealth 2020 06 10;8(6):e17450. Epub 2020 Jun 10.

Clinical Child Psychology Program, University of Kansas, Lawrence, KS, United States.

Background: Current digital health interventions primarily use interventionist-defined rules to guide the timing of intervention delivery. As new temporally dense data sets become available, it is possible to make decisions about the intervention timing empirically.

Objective: This study aimed to explore the timing of physical activity among youth to inform decision points (eg, timing of support) for future digital physical activity interventions.

Methods: This study comprised 113 adolescents aged between 13 and 18 years (mean age 14.64, SD 1.48 years) who wore an accelerometer for 20 days. Multilevel survival analyses were used to estimate the most likely time of day (via odds ratios and hazard probabilities) when adolescents accumulated their average physical activity. The interacting effects of physical activity timing and moderating variables were calculated by entering predictors, such as gender, sports participation, and school day, into the model as main effects and tested for interactions with the time of day to determine conditional main effects of these predictors.

Results: On average, the likelihood that a participant would accumulate a typical amount of moderate-to-vigorous physical activity increased and peaked between 6 PM and 8 PM before decreasing sharply after 9 PM. Hazard and survival probabilities suggest that optimal decision points for digital physical activity programs could occur between 5 PM and 8 PM.

Conclusions: Overall, the findings of this study support the idea that the timing of physical activity can be empirically identified and that these markers may be useful as intervention triggers.
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http://dx.doi.org/10.2196/17450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315372PMC
June 2020

Adaptive Mobile Health Intervention for Adolescents with Asthma: Iterative User-Centered Development.

JMIR Mhealth Uhealth 2020 05 6;8(5):e18400. Epub 2020 May 6.

Department of Psychology, Drexel University, Philadelphia, PA, United States.

Background: Adolescents diagnosed with persistent asthma commonly take less than 50% of their prescribed inhaled corticosteroids (ICS), placing them at risk for asthma-related morbidity. Adolescents' difficulties with adherence occur in the context of normative developmental changes (eg, increased responsibility for disease management) and rely upon still developing self-regulation and problem-solving skills that are integral for asthma self-management. We developed an adaptive mobile health system, Responsive Asthma Care for Teens (ReACT), that facilitates self-regulation and problem-solving skills during times when adolescents' objectively measured ICS adherence data indicate suboptimal rates of medication use.

Objective: The current paper describes our user-centered and evidence-based design process in developing ReACT. We explain how we leveraged a combination of individual interviews, national crowdsourced feedback, and an advisory board comprised of target users to develop the intervention content.

Methods: We developed ReACT over a 15-month period using one-on-one interviews with target ReACT users (n=20), national crowdsourcing (n=257), and an advisory board (n=4) to refine content. Participants included 13-17-year-olds with asthma and their caregivers. A total of 280 adolescents and their caregivers participated in at least one stage of ReACT development.

Results: Consistent with self-regulation theory, adolescents identified a variety of salient intrapersonal (eg, forgetfulness, mood) and external (eg, changes in routine) barriers to ICS use during individual interviews. Adolescents viewed the majority of ReACT intervention content (514/555 messages, 93%) favorably during the crowdsourcing phase, and the advisory board helped to refine the content that did not receive favorable feedback during crowdsourcing. Additionally, the advisory board provided suggestions for improving additional components of ReACT (eg, videos, message flow).

Conclusions: ReACT involved stakeholders via qualitative approaches and crowdsourcing throughout the creation and refinement of intervention content. The feedback we received from participants largely supported ReACT's emphasis on providing adaptive and personalized intervention content to facilitate self-regulation and problem-solving skills, and the research team successfully completed the recommended refinements to the intervention content during the iterative development process.
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http://dx.doi.org/10.2196/18400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240449PMC
May 2020

Do differences between individuals who are healthy weight or overweight on self-report measures of disinhibited eating and restrained eating reflect reality or item "bias"?

Psychol Assess 2020 Jun 19;32(6):553-567. Epub 2020 Mar 19.

Department of Internal Medicine.

In light of increasing rates of overweight and obesity worldwide, there is a critical need for accurate self-report measures of disinhibited and restrained eating behaviors across the weight spectrum. Item response theory was used to determine whether differences in disinhibited and restrained eating between healthy weight and overweight or obese individuals were due to item bias (i.e., differential item functioning). Study 1 participants were healthy weight ( = 510) or overweight or obese ( = 304) adults recruited from the community. Study 2 participants were healthy weight ( = 778) or overweight or obese ( = 320) college students. Study 1 participants completed the Eating Disorder Examination-Questionnaire (EDE-Q), Eating Disorder Inventory-3, Dutch Eating Behaviors Questionnaire, Restraint Scale, and Three-Factor Eating Questionnaire. Study 2 participants completed the Eating Pathology Symptoms Inventory (EPSI). Items on the Restraint Scale demonstrated the most evidence for bias (60% of items), whereas the majority of other scales demonstrated low to moderate levels of item bias (17-38% of items). However, EDE-Q Restraint and EPSI Binge Eating, Cognitive Restraint, Excessive Exercise, Muscle Building, and Negative Attitudes Toward Obesity scales did not show any evidence of differential item functioning among weight groups. Participants with the same level of disordered eating responded differently to certain eating disorder self-report items due to weight-bias, rather than true between-groups differences. Nevertheless, EDE-Q Restraint, EPSI Cognitive Restraint, and EPSI Binge Eating did not exhibit any evidence of bias and are ideal for assessing restrained and disinhibited eating across the weight spectrum in both research and clinical settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/pas0000810DOI Listing
June 2020

The Association Between Affect and Sleep in Adolescents With and Without FGIDs.

J Pediatr Psychol 2020 01;45(1):110-119

Developmental and Behavioral Sciences, Children's Mercy Hospital.

Objective: Adolescents with chronic pain associated with functional gastrointestinal disorders (FGIDs) experience negative impacts on their health behaviors (i.e., sleep) and are at risk for a range of problems related to negative affect, which may serve to exacerbate one another in a reciprocal fashion. This study aimed to determine if the strength of the relationship between affect and sleep differs across community adolescents and adolescents with FGIDs. It was hypothesized that shorter sleep durations would be associated with more negative affect and longer sleep durations would be associated with more positive affect, and that group membership would moderate these relationships.

Methods: Twenty-five adolescents with FGIDs were compared with 25 matched peers to examine the differential association between affect and total sleep time (TST). Models were estimated using SAS PROC MIXED for inter- and intraindividual differences.

Results: Models predicting TST revealed a significant three-way interaction among weekday, group status, and negative affect. Simple slopes indicated that when negative affect is one standard deviation below the child's own average on weekends, participants with FGIDs obtained significantly more sleep than those in the comparison group (β = 47.67, p < .05).

Conclusions: The findings of the present study show that when adolescents with FGIDs have lower negative affect on the weekend, when demands are likely reduced, they are able to obtain more TST. These findings confirm that unique relationships exist between negative affect and sleep duration for youth with FGIDs, and their interaction may hold value in understanding and addressing these targets.
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http://dx.doi.org/10.1093/jpepsy/jsz092DOI Listing
January 2020

Tailoring Individualized Evaluation of Pediatric Abdominal Pain Using Ecological Momentary Assessment (EMA): A Pilot Study Testing Feasibility and Acceptability.

Clin J Pain 2019 11;35(11):859-868

Children's Mercy Kansas City, Kansas City, MO.

Objective: The current study aimed to determine if it was feasible and acceptable to use ecological momentary assessment to assess individual associations between biopsychosocial contributors to chronic abdominal pain with 2 objective sensors and a mobile application. Specifically, we aimed to determine if it was possible to identify individualized associations between idiopathic pain associations. The goal was to determine if idiographic profiles have clinical value while the field works torward consensus about nomothetic trends.

Materials And Methods: Participants included 30 pediatric chronic abdominal pain patients, aged 8 to 17, who wore a physiological monitor and accelerometer that measured sleep and physical activity and answered 4 surveys per day on an app over the course of a 14-day study period.

Results: Results indicated that participants were 96.2% and 95.5% compliant to the wrist-worn accelerometer measuring sleep and physical activity, respectively. Participants completed 76.3% of expected surveys and were least adherent to the physiological monitor (37.9%). In addition, it was possible to generate 24 (80%) personalized reports describing unique associations with pain for participants in the study.

Discussion: Findings provide initial support for the use of ecological momentary assessment over a 2-week period to inform and create personalized profiles for improved clinical care in this population.
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http://dx.doi.org/10.1097/AJP.0000000000000750DOI Listing
November 2019

Responsive Asthma Care for Teens (ReACT): development protocol for an adaptive mobile health intervention for adolescents with asthma.

BMJ Open 2019 08 20;9(8):e030029. Epub 2019 Aug 20.

Department of Psychology, Drexel University, Philadelphia, Pennsylvania, USA.

Introduction: Asthma is a leading cause of youth morbidity in the USA, affecting >8% of youth. Adherence to inhaled corticosteroids (ICS) can prevent asthma-related morbidity; however, the typical adolescent with asthma takes fewer than 50% of their prescribed doses. Adolescents are uniquely vulnerable to suboptimal asthma self-management due to still-developing executive functioning capabilities that may impede consistent self-regulation and weaken attempts to use problem solving to overcome barriers to ICS adherence.

Methods And Analysis: The aims of this project are to improve adherence to ICS as an important step towards better self-management among adolescents aged 13-17 years diagnosed with asthma by merging the efficacious behaviour change strategies found in behavioural health interventions with scalable, adaptive mobile health (mHealth) technologies to create the Responsive Asthma Care for Teens programme (ReACT). ReACT intervention content will be developed through an iterative user-centred design process that includes conducting (1) one-on-one interviews with 20 teens with asthma; (2) crowdsourced feedback from a nationally representative panel of 100 adolescents with asthma and (3) an advisory board of youth with asthma, a paediatric pulmonologist and a behavioural health expert. In tandem, we will work with an existing technology vendor to programme ReACT algorithms to allow for tailored intervention delivery. We will conduct usability testing of an alpha version of ReACT with a sample of 20 target users to assess acceptability and usability of our mHealth intervention. Participants will complete a 4-week run-in period to monitor their adherence with all ReACT features turned off. Subsequently, participants will complete a 4-week intervention period with all ReACT features activated. The study started in October 2018 and is scheduled to conclude in late 2019.

Ethics And Dissemination: Institutional review board approval was obtained at the University of Kansas and the University of Florida. We will submit study findings for presentation at national research conferences that are well attended by a mix of psychologists, allied health professionals and physicians. We will publish study findings in peer-reviewed journals read by members of the psychology, nursing and pulmonary communities.
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http://dx.doi.org/10.1136/bmjopen-2019-030029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707700PMC
August 2019

Associations Between Physical Activity and Chronic Pain Severity in Youth With Chronic Abdominal Pain.

Clin J Pain 2019 07;35(7):618-624

Children's Mercy Hospital, Kansas City, MO.

Objectives: The present study aimed to: (1) better understand physical activity levels in youth with chronic abdominal pain and (2) investigate the relationship between day-level physical activity related to next day pain intensity to identify any intraindividual heterogeneity.

Methods: Seventy-one youth (M=13.34 y, SD=2.67 y) with chronic abdominal pain provided reports of pain severity and continuous objective reports of sedentary behavior, moderate-to-vigorous physical activity (MVPA), and total sleep time using accelerometers over 14 days.

Results: Findings revealed that youth with chronic abdominal pain do not meet recommended levels of MVPA per day (M=34.64 min, SD=33.31 min). Further, results indicated a random effect of the previous day's MVPA predicting pain severity. There was a small significant negative effect of within-person total sleep time as a predictor of pain severity.

Discussion: The current study highlights the importance of separating between-person and within-person differences when examining the relationship between physical activity and pain severity. Future studies should explore moderating factors that may help to explain random effects to better understand the types of individuals with positive or negative relationships between physical activity and pain severity.
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http://dx.doi.org/10.1097/AJP.0000000000000716DOI Listing
July 2019

A Systematic Evaluation of Asthma Management Apps Examining Behavior Change Techniques.

J Allergy Clin Immunol Pract 2019 Nov - Dec;7(8):2583-2591. Epub 2019 Apr 4.

Department of Clinical & Health Psychology, University of Florida, Gainesville, Fla.

Background: Mobile health (mHealth) apps have the potential to facilitate asthma self-management by including medication reminders, allowing self-monitoring of symptoms, improving access and quality of information communicated with provider, and providing educational resources to patients and parents. Many apps exist for asthma management; however, the extent to which apps include evidence-based behavior change strategies has not been examined.

Objective: To review the content and quality of mHealth asthma management apps that are available to patients.

Methods: Asthma apps were identified using a systematic search process. Twenty-three apps were coded for presence or absence of behavior change techniques (BCTs) using the taxonomy of BCTs as defined by Abraham and Michie in 2008. Quality ratings were also determined for each app using the Mobile App Rating Scale (MARS).

Results: The number of BCTs each app used ranged from 1 to 11 (mean, 4). BCTs that were most commonly used were instruction, behavior-health link, self-monitoring, feedback, teach to use prompts/cues, consequences, and others' approval. Overall app quality based on MARS scores ranged from 2.45 to 4.50 (mean, 3.32). Two apps, Kiss myAsthma and AsthmaMD, used at least 8 BCTs and had high quality ratings.

Conclusions: Kiss myAsthma and AsthmaMD used at least 8 BCTs and had good quality scores.
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http://dx.doi.org/10.1016/j.jaip.2019.03.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6776707PMC
October 2020

Commentary: Identifying Opportunities for Pediatric eHealth and mHealth Studies: Physical Activity as a Case Example.

J Pediatr Psychol 2019 Apr;44(3):269-274

Center for Children's Healthy Lifestyles and Nutrition, Children's Mercy Kansas City, Missouri.

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http://dx.doi.org/10.1093/jpepsy/jsz005DOI Listing
April 2019

Introduction to the Coordinated Special Issue on eHealth/mHealth in Pediatric Psychology.

J Pediatr Psychol 2019 04;44(3):259-262

National Institutes of Health, Office of Behavioral and Social Sciences Research.

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http://dx.doi.org/10.1093/jpepsy/jsz010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657436PMC
April 2019

Neighborhood built environment associations with adolescents' location-specific sedentary and screen time.

Health Place 2019 03 10;56:147-154. Epub 2019 Feb 10.

Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, United States.

Less is known about how neighborhood environments relate to sedentary time as compared to physical activity. This study examined relations of perceived and objective neighborhood environments with TV time, total screen time, total sedentary time, sedentary time at home, sedentary time in the home neighborhood, and time spent at home, in 524 12-16 year olds. Better perceived aesthetics and a perceived neighborhood environment index were related to less TV and screen time, and greater cul-de-sac density was related to less total and home sedentary time. Greater street connectivity, mixed land use, and an objective neighborhood environmental index were related to more total sedentary time. Findings suggest that some neighborhood environment attributes may not have the same potential influences on limiting sedentary time as they do for supporting physical activity.
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http://dx.doi.org/10.1016/j.healthplace.2019.01.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6477917PMC
March 2019

Parents' Perspectives on the Theoretical Domains Framework Elements Needed in a Pediatric Health Behavior App: A Crowdsourced Social Validity Study.

JMIR Mhealth Uhealth 2018 Dec 21;6(12):e192. Epub 2018 Dec 21.

Clinical Child Psychology Program, University of Kansas, Lawrence, KS, United States.

Background: Most pediatric studies do not include parent stakeholders in the design of the intervention itself and many pediatric mobile health (mHealth) interventions are not meaningfully disseminated after the trial period ends. Consequently, the consumer desire for mobile apps targeting pediatric health behavior is likely to be met by commercial products that are not based in theory or evidence and may not take stakeholder preferences into account.

Objective: The aim was to assess parent preference for mobile app features that map onto specific Theoretical Domains Framework (TDF) elements.

Methods: This study was a crowdsourced social validity study of 183 parents who were asked to rate their preferences for mobile app features that correspond to elements of the TDF. The TDF organizes a large number of theoretical models and constructs into three components: (1) capability, (2) motivation, and (3) opportunity. Parents of children were recruited through Amazon Mechanical Turk.

Results: The majority of participants were Caucasian and mean age was 36.9 (SD 8.0) years. Results revealed broad acceptability of communication, motivation, and opportunity domains. However, the degree to which each domain was valued varied within behavioral category. Parents demonstrated a preference for increasing procedural knowledge for physical activity and diet behaviors over sleep (F=5.18, P=.006). Similarly, parents valued self-monitoring as more important for physical activity than sleep (F=4.04, P=.02). When asked about the value of features to help children develop skills, parents preferred those features for dietary behavior over sleep (F=3.57, P=.03). Parents perceived that goal-setting features would be most useful for physical activity over sleep and diet (F=5.30, P=.005). Incentive features within the app were seen as most useful for physical activity over sleep (F=4.34, P=.01).

Conclusions: This study presents a low-cost strategy for involving a large number of stakeholders in the discussion of how health behavior theory should be applied in a mHealth intervention. Our approach is innovative in that it took a scientific framework (ie, TDF) and made it digestible to parents so that they could then provide their opinions about features that might appear in a future app. Our survey items discriminated between various health behaviors allowing stakeholders to communicate the different health behaviors that they would like a TDF feature to change. Moreover, we were able to develop a set of consumer opinions about features that were directly linked to elements of the TDF.
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http://dx.doi.org/10.2196/mhealth.9808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6320421PMC
December 2018

Dietary Motivation and Hedonic Hunger Predict Palatable Food Consumption: An Intensive Longitudinal Study of Adolescents.

Ann Behav Med 2018 08;52(9):773-786

Clinical Child Psychology Program, Schiefelbusch Institute for Life Span Studies, University of Kansas, Lawrence, KS, USA.

Background: Understanding interactions between stable characteristics and fluctuating states underlying youth's food choices may inform methods for promoting more healthful food intake.

Purpose: This study examined dietary motivation and hedonic hunger as interacting predictors of adolescents' consumption of palatable foods.

Methods: Intensive longitudinal data were collected from 50 adolescents (aged 13-18) over 20 days. Participants completed a measure of dietary motivation at baseline and reported on hedonic hunger and palatable food consumption via a smartphone app at the end of each day.

Results: Results indicated that 66.7% of the variability in hedonic hunger was between-person (BP) and 33.3% was within-person (WP). BP hedonic hunger was positively associated with fatty food consumption (β = 0.28, p < .05), and WP hedonic hunger was positively associated with starchy food consumption (β = 0.38, p < .0001). Autonomous motivation was negatively associated with consumption of fast foods (β = -0.14, p < .05). Significant cross-level interactions were found: WP hedonic hunger and controlled motivation were positively associated with starchy food consumption, and WP hedonic hunger and autonomous motivation were negatively associated with fast food consumption.

Conclusions: Findings indicated that hedonic hunger has the potential to fluctuate, and conceptualization of the variable as both trait and state may be most appropriate. Adolescents with controlled dietary motivation may be vulnerable to the influence of hedonic hunger and prone to eating higher quantities of starchy foods. Adolescents with autonomous dietary motivation may be less vulnerable to hedonic hunger and less likely to consume fast food.
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http://dx.doi.org/10.1093/abm/kax051DOI Listing
August 2018

Initial development and validation of a fecal incontinence-specific quality of life measure.

J Pediatr Surg 2018 Jun 7;53(6):1148-1153. Epub 2018 Mar 7.

Colorectal Center at Cincinnati Children's, Division of Pediatric General & Thoracic Surgery, Cincinnati, OH. Electronic address:

Background/purpose: Fecal incontinence is a prevalent pediatric condition with psychosocial impacts on both children and their caregivers. We sought to develop and validate the Cincinnati Fecal Incontinence Scale (CINCY-FIS) as a psychometrically valid measure to assess the quality of life and caregiver impacts of pediatric fecal incontinence.

Methods: Items were generated through review of previous measures, expert consensus, and pilot testing with feedback from 8 families. Initial study measures were completed by 222 caregivers. Following item reduction, 18 items were subjected to confirmatory factor analysis. Convergent and criterion validity were assessed using correlation. Reliability was established using internal consistency statistics and test-retest reliability at baseline and 2-week follow-up.

Results: A five factor first-order structure with two higher-order factors demonstrated acceptable fit to the data, was consistent with a priori hypotheses, and was more parsimonious than the alternative model. Convergent validity and criterion-related validity were established for all of the CINCY-FIS scales. Reliability was high and consistent across both measurement occasions.

Conclusions: The CINCY-FIS is a reliable and valid assessment of pediatric fecal incontinence-specific quality of life and parenting stress. The score is highly sensitive to patient changes making it suitable for both clinical and research purposes.

Type Of Study: Prospective observational.

Level Of Evidence: Study of Diagnostic Test Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.02.076DOI Listing
June 2018

Goal feedback from whom? A physical activity intervention using an N-of-1 RCT.

Psychol Health 2018 06 9;33(6):701-712. Epub 2017 Oct 9.

f Department of Psychology , Oklahoma State University , Stillwater , OK , USA.

Objective: Adolescents are not meeting the recommended guidelines for physical activity. Social support and self-regulatory skills are two factors known to impact physical activity and sedentary behaviour. The study sought to examine how targeting feedback as part of a self-regulatory process could increase physical activity, and the individual who should be providing the feedback.

Design: The study utilised an aggregated N-of-1 RCT which allows for an iterative process of intervention development, and examines variability within participants to answer the question for whom did the intervention work. Ten adolescents (ages 13-18) set a daily physical activity goal. Adolescents received a SMS text message providing feedback on goal attainment daily from a parent, peer, behavioural health specialist; or no text message (control).

Main Outcome Measures: A bioharness heart rate monitor assessed heart rate as proxy for goal attainment. Adolescents also self-monitored their physical activity in the Calorie Counter and Diet Tracker by MyFitnessPal app (commercially available).

Results: Intervention demonstrated a significant effect for 30% of the sample in increasing MVPA (M = 52 min), with no significant effect on sedentary behaviour.

Conclusion: A single occasion of text messaging from the right person can produce changes, however, careful consideration should be given to who provides the feedback.
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http://dx.doi.org/10.1080/08870446.2017.1385783DOI Listing
June 2018

Mobile Health Interventions for Improving Health Outcomes in Youth: A Meta-analysis.

JAMA Pediatr 2017 05;171(5):461-469

Department of Clinical & Health Psychology, University of Florida, Gainesville.

Importance: Mobile health interventions are increasingly popular in pediatrics; however, it is unclear how effective these interventions are in changing health outcomes.

Objective: To determine the effectiveness of mobile health interventions for improving health outcomes in youth 18 years or younger.

Data Sources: Studies published through November 30, 2016, were collected through PubMed, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, and PsychINFO. Backward and forward literature searches were conducted on articles meeting study inclusion criteria. Search terms included telemedicine, eHealth, mobile health, mHealth, app, and mobile application.

Study Selection: Search results were limited to infants, children, adolescents, or young adults when possible. Studies were included if quantitative methods were used to evaluate an application of mobile intervention technology in a primary or secondary capacity to promote or modify health behavior in youth 18 years or younger. Studies were excluded if the article was an unpublished dissertation or thesis, the mean age of participants was older than 18 years, the study did not assess a health behavior and disease outcome, or the article did not include sufficient statistics. Inclusion and exclusion criteria were applied by 2 independent coders with 20% overlap. Of 9773 unique articles, 36 articles (containing 37 unique studies with a total of 29 822 participants) met the inclusion criteria.

Data Extraction And Synthesis: Of 9773 unique articles, 36 articles (containing 37 unique studies) with a total of 29 822 participants met the inclusion criteria. Effect sizes were calculated from statistical tests that could be converted to standardized mean differences. All aggregate effect sizes and moderator variables were tested using random-effects models.

Main Outcomes And Measures: Change in health behavior or disease control.

Results: A total of 29 822 participants were included in the studies. In studies that reported sex, the total number of females was 11 226 (53.2%). Of those reporting age, the average was 11.35 years. The random effects aggregate effect size of mobile health interventions was significant (n = 37; Cohen d = 0.22; 95% CI, 0.14-0.29). The random effects model indicated that providing mobile health intervention to a caregiver increased the strength of the intervention effect. Studies that involved caregivers in the intervention produced effect sizes (n = 16; Cohen d = 0.28; 95% CI, 0.18-0.39) larger than those that did not include caregivers (n = 21; Cohen d = 0.13; 95% CI, 0.02-0.25). Other coded variables did not moderate study effect size.

Conclusions And Relevance: Mobile health interventions appear to be a viable health behavior change intervention modality for youth. Given the ubiquity of mobile phones, mobile health interventions offer promise in improving public health.
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http://dx.doi.org/10.1001/jamapediatrics.2017.0042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6037338PMC
May 2017

Bidirectional Associations Between Psychological States and Physical Activity in Adolescents: A mHealth Pilot Study.

J Pediatr Psychol 2017 06;42(5):559-568

Clinical Child Psychology Program, University of Kansas, Sunnyside Ave, Lawrence, USA.

Objective: To understand the predictors and consequences of adolescent moderate-to-vigorous physical activity (MVPA) and sedentary behavior in nearly real-time.

Methods: Participants were 26 adolescents ( M age = 15.96, SD  = 1.56) who provided 80 self-reports of subjective states and continuous objective reports of MVPA and sedentary behavior over 20 days.

Results: Random effects were observed for all of the models with affect and feeling variables predicting MVPA. There was a negative fixed effect for within-person positive affect and sedentary behavior and the inverse association for negative affect. Within-person MVPA was a significant positive predictor of positive affect and energy. There was a random effect for within-person MVPA and fatigue. There was a significant random effect for within-person sedentary behavior predicting positive affect. Within-person sedentary behavior was a significant negative predictor of energy.

Conclusions: Findings highlight the importance of the intrapersonal nature of the associations among subjective states and physical activity.
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http://dx.doi.org/10.1093/jpepsy/jsw099DOI Listing
June 2017

The promise of wearable sensors and ecological momentary assessment measures for dynamical systems modeling in adolescents: a feasibility and acceptability study.

Transl Behav Med 2016 12;6(4):558-565

Clinical Child Psychology Program, University of Kansas, 2015 Dole Human Development Center, Lawrence, KS, 66045, USA.

Intervention development can be accelerated by using wearable sensors and ecological momentary assessment (EMA) to study how behaviors change within a person. The purpose of this study was to determine the feasibility and acceptability of a novel, intensive EMA method for assessing physiology, behavior, and psychosocial variables utilizing two objective sensors and a mobile application (app). Adolescents (n = 20) enrolled in a 20-day EMA protocol. Participants wore a physiological monitor and an accelerometer that measured sleep and physical activity and completed four surveys per day on an app. Participants provided approximately 81 % of the expected survey data. Participants were compliant to the wrist-worn accelerometer (75.3 %), which is a feasible measurement of physical activity/sleep (74.1 % complete data). The data capture (47.8 %) and compliance (70.28 %) with the physiological monitor were lower than other study variables. The findings support the use of an intensive assessment protocol to study real-time relationships between biopsychosocial variables and health behaviors.
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http://dx.doi.org/10.1007/s13142-016-0442-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110505PMC
December 2016

Parent illness appraisals, parent adjustment, and parent-reported child quality of life in pediatric cancer.

Pediatr Hematol Oncol 2016 Aug 20;33(5):314-326. Epub 2016 Jul 20.

a Department of Psychology , Oklahoma State University , Stillwater , Oklahoma , USA.

Psychosocial distress is a salient construct experienced by families of children with newly diagnosed cancer, but little is known about parental appraisal of the child's illness and the subsequent impact this may have on child and parent functioning. The goal of the present study was to examine the interrelationships among multiple parent illness appraisals, parent adjustment outcomes, and parent-reported child quality of life in parents of children diagnosed with cancer. Parents completed measures of illness appraisal (illness uncertainty and attitude toward illness), parent adjustment (general distress, posttraumatic stress, parenting stress), and child quality of life (general and cancer-related). Path analysis revealed direct effects for parent illness uncertainty and illness attitudes on all 3 measures of parent adjustment. Illness uncertainty, but not illness attitudes, demonstrated a direct effect on parent-reported child general quality of life; parenting stress had direct effects on general and cancer-related quality of life. Exploratory analyses indicated that parent illness uncertainty and illness attitudes conferred indirect effects on parent-reported general and cancer-related quality of life through parenting stress. Negative parent illness appraisals appear to have adverse impacts on parents' psychosocial functioning and have implications for the well-being of their child with cancer.
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http://dx.doi.org/10.1080/08880018.2016.1198443DOI Listing
August 2016

Health-Related Quality of Life and Parental Stress in Children With Fecal Incontinence: A Normative Comparison.

J Pediatr Gastroenterol Nutr 2016 12;63(6):633-636

*Clinical Child Psychology Program, University of Kansas, Lawrence †Colorectal Center ‡Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, OH.

Objective: The aim of the present study was to describe the quality of life and parenting stress associated with a child with fecal incontinence (FI).

Methods: Female caregivers (n = 170) of children of 3 to 12 years age with FI completed a broad and general measure of quality of life and a measure of parenting stress. Results were compared with proxy reports for a normative sample of healthy children.

Results: Caregivers of children with FI reported significantly impaired quality of life for their children and increased parenting stress in all of the respective domains relative to healthy controls. Impairments reported by caregivers were large in magnitude. Similarly, rates of parenting stress were at or greater than the 98th percentile for caregivers of children with FI.

Conclusions: Children with fecal incontinence and their families are in need of interventions targeting their quality of life and the stress associated with caregiving. FI appears to be particularly stressful for caregivers who may be in need of support beyond medical management of their child's bowel. Moreover, additional refinements in disease-specific quality of life assessment are needed in this population. Such refinement would allow for more precise measurement of the quality of life processes that are unique to FI.
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http://dx.doi.org/10.1097/MPG.0000000000001201DOI Listing
December 2016

Parent Perceptions of Illness Uncertainty and Child Depressive Symptoms in Juvenile Rheumatic Diseases: Examining Caregiver Demand and Parent Distress as Mediators.

J Pediatr Psychol 2016 Oct 19;41(9):941-51. Epub 2016 Feb 19.

Department of Psychology, Oklahoma State University.

Objective: Examine caregiver demand and general parent distress as mediators in the parent illness uncertainty-child depressive symptom association in youth with juvenile rheumatic diseases.

Methods: Children and adolescents completed the Child Depression Inventory; caregivers completed the Parent Perceptions of Uncertainty Scale, the Care for My Child with Rheumatic Disease Scale, and the Brief Symptom Inventory. The pediatric rheumatologist provided ratings of clinical disease status.

Results: Analyses revealed significant direct associations between illness uncertainty and caregiver demand, and between caregiver demand and both parent distress and child depressive symptoms. Results also revealed significant parent uncertainty → caregiver demand → parent distress and parent uncertainty → caregiver demand → child depressive symptom indirect paths.

Conclusions: Results highlight the role of illness appraisals in adjustment to juvenile rheumatic diseases, and provide preliminary evidence that parent appraisals of illness uncertainty impact parent distress and child depressive symptoms indirectly through increased perceptions of caregiver demand.
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http://dx.doi.org/10.1093/jpepsy/jsw004DOI Listing
October 2016

Illness Uncertainty, Global Psychological Distress, and Posttraumatic Stress in Pediatric Cancer: A Preliminary Examination Using a Path Analysis Approach.

J Pediatr Psychol 2016 Apr 30;41(3):309-18. Epub 2015 Sep 30.

Department of Psychology, Oklahoma State University.

Objective: To investigate the relationship of illness uncertainty (IU) to global psychological distress (GPD) and posttraumatic stress symptomatology (PTSS) using a path analysis approach.

Methods: Participants were 105 caregivers (MAge = 36.9 years, standard deviation [SD] = 8.7) of children (MAge = 8.6 years, SD = 5.0) with newly diagnosed cancer. A path analysis model examined the indirect and direct effects of each IU subscale on PTSS through GPD. 

Results:  The final model accounted for 47.30% of the variance in PTSS, and the ambiguity facet of IU had a significant indirect effect on PTSS through GPD. Lack of clarity and unpredictability were not significant predictors. 

Conclusions: Ambiguity experienced by parents may be salient in the development of PTSS. Future research should examine these relationships longitudinally in larger samples to better understand adjustment in parents of children with cancer.
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http://dx.doi.org/10.1093/jpepsy/jsv093DOI Listing
April 2016
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