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OBJECTIVE—This study examined the relationships between parent-child mealtime interactions and dietary adherence and glycemic control in young children with type 1 diabetes. It was hypothesized that young children who exhibited disruptive mealtime behaviors would have more dietary deviations (poorer dietary adherence) and poor glycemic control. It was also hypothesized that parents of young children who used ineffective/coercive parenting strategies at mealtimes would have children with more dietary deviations and poor glycemic control. RESEARCH DESIGN AND METHODS—A total of 35 families of children (aged 2.2–7.9 years) with type 1 diabetes were recruited from a pediatric hospital. Families had at least three meals videotaped in their home, which were coded for parent, child, and eating behaviors, using the Dyadic Interaction Nomenclature for Eating. Children’s dietary adherence was assessed according to deviations from the prescribed number of carbohydrate units per meal. Children’s average glycemic excursion was assessed prospectively for 2 weeks, using a standardized home blood glucose meter. RESULTS—Findings demonstrated significant positive relationships between children’s mealtime behavior, dietary deviations, and glycemic control. An examination of parent behaviors revealed significant positive correlations between parents’ use of ineffective/coercive parenting strategies and children’s dietary deviations and glycemic control. CONCLUSIONS—This was the first study to examine the relationship between parent-child mealtime interactions and health outcomes in young children with type 1 diabetes. The mealtime problems examined can be improved through specific behavioral interventions. Future research is needed to examine how parent-child interactions at mealtimes relate to children’s health outcomes to inform clinical care.

Objective. To conduct a randomized clinical trial comparing a behavioral and nutrition intervention (BEH) with a usual care control condition (CTL) for children (ages 18 months to 4 years) with cystic fibrosis (CF) and pancreatic insufficiency. This trial was designed to (1) evaluate a randomized comparison of BEH with CTL over 8 weeks, (2) provide a replication of the impact of BEH by inviting the CTL group to receive BEH after 8 weeks, and (3) examine the maintenance of BEH at 3- and 12-month follow-up.Methods. Of 14 eligible children, 10 were randomly assigned and initiated treatment (71% recruitment rate). Four participants were randomly assigned to BEH, and 6 were assigned to CTL (5 of whom chose to crossover to BEH). BEH included nutrition counseling to increase energy intake (via types of foods and addables/spreadables) and child behavioral management training to teach parents differential attention and contingency management skills. CTL was consistent with the 2002 CF Foundation Consensus Conference Guidelines for nutritional care.Results. BEH led to greater increases in energy intake pre- to posttreatment than CTL as measured by calories per day (842 kcal/day vs −131 kcal/day change). On receiving BEH, the change in energy intake was replicated with the CTL group (892 kcal/day change). At 3- and 12-month follow-up, energy intake was maintained (672 kcal/day increase from baseline and 750 kcal/day increase from baseline, respectively). Children in this study met or exceeded normal weight and height velocities from pretreatment to the 3-month follow-up (mean weight: 1.4 kg/6 months; mean height: 5.1 cm/6 months) and from posttreatment to the 12-month follow-up (mean weight: 2.5 kg/12 months; mean height: 8.3 cm/12 months).Conclusions. Toddlers and preschoolers who have CF and received BEH were able to meet the energy intake recommendations for this disease and maintain these gains up to 12 months after treatment. In addition, these children demonstrated weight and height velocities from pretreatment to 12-month follow-up, consistent with the goal of normal growth. BEH is a promising, evidence-based, early nutritional intervention for children with CF. An upcoming multisite clinical trial will test BEH versus an attention control condition using a larger sample (N = 100), providing additional evidence about the efficacy of this treatment for energy intake and growth in young children with CF.

Objective.—To evaluate the sensitivity of the new International Classification of Headache Disorders-2nd edition (ICHD-II) criteria in the diagnosis of childhood migraine and to propose specific criteria for the diagnosis of childhood migraine. Background.—In 2004, ICHD-II was adopted by the International Headache Society. The prior version had been criticized for its lack of sensitivity in diagnosing childhood headaches. ICHD-II is felt to be an improvement as it provides for some differences between pediatric and adult migraine diagnosis in its footnotes, however, has yet to be validated. Clinically, it is the impression of many pediatric headache specialists that children's migraines are of shorter duration, tend to be bilateral rather than unilateral, and that children more often report either photophobia or phonophobia, rather than both. Methods.—The characteristics of headache in 260 patients, ages 18 and under, clinically diagnosed with migraine at two large pediatric headache centers were compiled using standard intake questionnaires. Inter-rater reliability in clinical diagnosis was determined by consensus of the clinical diagnosis. These data were analyzed applying the International Classification of Headache Disorders-1st edition (ICHD-I) and ICHD-II criteria for migraine to determine sensitivity of migraine diagnosis in comparison with clinical impression. Each headache characteristic in ICHD-II was analyzed individually to determine its effect on sensitivity of diagnosis. Results.—183/260 patients (70.4%) met ICHD-I criteria. 161/260 patients (61.9%) met the ICHD-II criteria with a 4- to 72-hour range. When the footnoted allowance of ICHD-II for short duration (2 hours) was utilized, 187/260 patients (71.9%) met criteria, while this improved to 192/260 patients (73.9%) with 1-hour duration. If duration was excluded, 210/260 patients (80.8%) met criteria. The most common reasons for patients not meeting the standard criteria were the requirement of unilateral location, headache duration and number of associated symptoms. Based on these observations, modified criteria were empirically derived and the sensitivity increased to 84.4%. Data were reanalyzed using the criteria of focal head pain, either bilateral or unilateral, shortened duration, and modified associated symptoms, which resulted in an improved sensitivity in migraine diagnosis of 84.4%. Conclusions.—Modification of ICHD-II criteria to include bilateral headache, headache duration of 1 to 72 hours, and nausea and/or vomiting plus two of five other associated symptoms (photophobia, phonophobia, difficulty thinking, lightheadedness, or fatigue), in addition to the usual description of moderate to severe pain of a throbbing or pulsating nature worsening or limiting physical activity, improved sensitivity of migraine diagnosis to 84.4%.

Objective.—To assess the long-term effectiveness and outcome of multidisciplinary treatment of childhood headaches 1, 2, and 5 years after initial treatment. Background.—Headaches are a common problem for children and adolescents and for many patients continue into adulthood. Outcome research for pediatric migraine headaches is limited, thus restricting knowledge of the effectiveness of long-term management and outcome. Methods.—Headache characteristics were assessed at the initial visit and were reevaluated 1, 2, and 5 years later in independent sub-groups of consecutive patients. These characteristics included headache frequency, severity, average duration, school absences, and overall perceived response to treatment. Results.—At 1 year, 96 patients were evaluated (mean age = 11.0 ± 3.4, 59% females), 69 patients at 2 years (mean age = 10.6 ± 3.4, 48% females), and 32 at 5 years (mean age = 10.5 ± 3.9, 66% females). The headaches were reported as better in 94% at 1 year, 85% at 2 years, and 94% at 5 years. The initial frequency was at 13.4 ± 10.8 headaches per month, 4.9 ± 7.0 at 1 year (P < .001), 4.7 ± 7.6 at 2 years (P < .001), and 4.5 ± 7.5 at 5 years (P < .001). The severity decreased from 6.8 ± 1.8 to 5.1 ± 2.3 at 1 year (P < .001), to 5.0 ± 2.4 at 2 years (P < .001), and to 4.6 ± 2.5 at 5 years (P < .01). The school days missed per month showed a marked decrease from 4.5 ± 9.5 at initial visit to 1.55 ± 2.8 at 5 years (P < .001). Patients that were only seen at their initial visit and did not choose to return for follow-up had less frequent and shorter duration headaches on initial visit when compared with the rest of the sample and continued to be doing well at the 1-, 2-, and 5-year assessments. Conclusions.—Multidisciplinary treatment was found to be effective for children and adolescents with improvement of multiple outcome variants of pediatric migraine care, including frequency, severity, and school days missed. Patients who did not return to follow-up evaluation were more likely to have less frequent and shorter duration headaches at initial presentation. Regular follow-up care is needed for those children with more severe initial headache presentation.

Headache is a common condition among children and adolescents, and it can result in considerable pain, distress, and functional disability. Lacking proper care, many children will continue to experience headaches into adulthood. These considerations point to the importance of prompt, effective, and early intervention for pediatric headache. Biobehavioral treatments are central to such intervention. From promotion of adherence to optimal use of abortive and prophylactic medications to health behaviors that reduce headache activity to biofeedback-assisted relaxation training, the addition of biobehavioral treatment components to a comprehensive pediatric headache care plan can lead to better initial clinical outcomes, may lessen the need for medication, and may help maintain effects over the long term. Attention to the effects of headache and the accompanying psychological distress is an equally important part of treatment. Indeed, outcomes should be measured in terms of pain parameters (headache frequency, duration, severity) and effect on functional disability and quality of life (school absences, mood, satisfaction with pain relief). Optimal care for children and adolescents with headache can be realized with collaboration among primary care practitioners and headache specialists such as child neurologists and pediatric behavioral medicine experts. Biobehavioral treatment is a foundation for provision of such care.

We describe a new measure of dietary intake in cystic fibrosis (CF): the CF Individualized NuTritional Assessment of Kids Eating (CF INTAKE). Ninety-one children (49 boys, M = 4.5 ± 3.2 years) participated. Four scores measured Missed Opportunities to maximize calorie intake: Meal, Enzyme, Calorie, and Food Choice Scores. Power Scores measured high-fat food/addables intake. Recommended meals were omitted 10% and enzymes were omitted 15% of the time. More than half of all foods consumed were low-fat foods. Calorie intake was maximized in only one third of foods eaten. The CF INTAKE can identify specific areas to target through individualized nutritional counseling.

Headache occurs across the lifespan, but limited attention has been devoted to children and adolescents. This article discusses pertinent methodological considerations when conducting behavioral research with pediatric populations. Issues needing special consideration when working with children and adolescents involve ethics, sample characterization, headache diagnosis, treatment administration, and outcome measurement. Available literature is reviewed and specific recommendations are offered when possible.

Trials that compare drug and behavior therapies or evaluate combination therapy raise special methodological issues. This article reviews these methodological issues and, where possible, offers guidelines for addressing them. Sources of bias in the selection and recruitment of participants and in the measurement of treatment outcomes are discussed. In addition, methodological problems presented by the differing structures of behavior and drug therapy, by confounding variables, such as allegiance effects, differential expectations and preferences for drug or behavior therapy, and differential adherence with drug or behavior therapy also are reviewed. Issues in the selection of appropriate control groups are also discussed.

Guidelines for design of clinical trials evaluating behavioral headache treatments were developed to facilitate production of quality research evaluating behavioral therapies for management of primary headache disorders. These guidelines were produced by a Workgroup of headache researchers under auspices of the American Headache Society. The guidelines are complementary to and modeled after guidelines for pharmacological trials published by the International Headache Society, but they address methodologic considerations unique to behavioral and other nonpharmacological treatments. Explicit guidelines for evaluating behavioral headache therapies are needed as the optimal methodology for behavioral (and other nonpharmacologic) trials necessarily differs from the preferred methodology for drug trials. In addition, trials comparing and integrating drug and behavioral therapies present methodological challenges not addressed by guidelines for pharmacologic research. These guidelines address patient selection, trial design for behavioral treatments and for comparisons across multiple treatment modalities (eg, behavioral vs pharmacologic), evaluation of results, and research ethics. Although developed specifically for behavioral therapies, the guidelines may apply to the design of clinical trials evaluating many forms of nonpharmacologic therapies for headache.

Clinical outcome studies have established cognitive-behavioral therapy (CBT) as an efficacious treatment for children and adolescents presenting with a variety of problems, such as anxiety and maladaptive behaviors. Findings to date are also very promising for the use of CBT techniques with children and adolescents who have chronic medical illnesses, including obesity, encopresis, severe and persistent feeding problems, recurrent headache, recurrent abdominal pain and acute procedural pain. This article provides an overview of behavioral/cognitive-behavioral theory, intervention and the important role outcome-based research plays in the development of this treatment modality. CBT interventions utilized with various pediatric populations are described, and the results of outcome-based research employing these techniques are examined. The Chambless criteria are used to determine the efficacy of specific interventions based upon the number, size and outcomes of studies utilizing CBT treatments with pediatric populations. Case examples are included to further illustrate the effectiveness of these interventions for children and adolescents with chronic medical conditions.

Objectives To compare the food group variety and nutritional adequacy of the diet between toddlers with cystic fibrosis (CF) and age-matched controls. Subjects A clinical sample of 22 toddlers with CF (mean age = 21.3 ± 7.2 months) matched to a community sample of 22 healthy peers. Main outcome measures The variety index for toddlers (VIT) and the mean adequacy ratio (MAR). Results Fruit group scores were highest for children with CF (0.95 ± 0.13; possible range 0.00–1.00), and dairy group scores were highest for controls (0.90 ± 0.18). All children earned the lowest scores for vegetables (CF: 0.15 ± 0.12; controls: 0.26 ± 0.22). No significant differences were found when comparing VIT and MAR scores by sample (P > 0.05). A moderate positive relationship was found between total VIT scores and MAR scores for all children (r = 0.38, P

This study examined family functioning at mealtime, a context relevant to the management of cystic fibrosis (CF). Thirty-three families of children with CF and a control sample of 33 families of children without a chronic illness were assessed. Family functioning was rated during a videotaped dinner using the McMaster Mealtime Interaction Coding System (MICS), and mealtime behavioral problems were assessed using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS). Ratings for families of children with CF were lower than for control families on overall functioning and five of six MICS dimensions (Communication, Interpersonal Involvement, Behavior Control, Affect Management, Roles). In families of children with CF, better family functioning was related to less frequently occurring mealtime behavioral problems (BPFAS); however, family functioning was not related to the child's weight status or the child's caloric intake. Data support that nutritional intervention may be maximized if dietary adherence is promoted in the context of positive parent-child and family interactions.

The aim of this study was to measure quality of life (QOL) across a broad age range of paediatric migraine patients. Children and adolescents ( n = 686) with migraine completed the Pediatric Quality of Life Inventory, version 4.0 (PedsQL 4.0) and a standardized headache assessment at an initial clinic visit. The sample size for each PedsQL age group was: age 2-4 = 21, age 5-7 = 86, age 8-12 = 298, and age 13-18 = 281. Mean total score was 72.7 ± 14.8, significantly less than healthy norms ( P < 0.01). Teens reported lower School Functioning than older and young children ( P < 0.05) and young children reported lower Social Functioning than older children and teens ( P < 0.001). A moderate relation was found between self and parent report. Age-related effects on QOL have implications for the evaluation and management of migraine in paediatric practice. The self and parent report forms of the PedsQL can be used in a practice setting.

This pilot study examined a behavioral treatment to increase calorie intake in toddlers with cystic fibrosis. Eight toddlers were randomly assigned to behavioral plus nutrition (BEH) or nutrition intervention (NTR) conditions. Calorie intake and weight were measured at pre- and posttreatment. The BEH group showed a trend for changes in calorie intake pre- to posttreatment (p = .07; 40% increase). Results for the BEH and NTR groups did not differ significantly. Most participants achieved weight gains consistent with normal growth. Seventy-five percent had not shown this pattern during the year prior to intervention. These results support the feasibility and potential for behavioral interventions in this age group.

Objective. Despite the high prevalence of headaches in youths, quality of life (QOL) has not been well examined. We examined QOL in a clinical sample of children with headaches and compared it with children with other chronic diseases. Methods. A survey study was conducted of 572 consecutive patients (mean age, 11.4 ± 3.6 years) who presented with headaches to a children’s headache center. Children and parents completed the Pediatric Quality of Life Inventory, Version 4.0 and a standardized headache assessment. Results were compared with established norms for healthy and chronically ill children. Results. Most patients (99%) had a clinical diagnosis of migraine: 85% met the International Headache Society migraine criteria, and 40% had chronic daily headaches. Total Pediatric Quality of Life Inventory, Version 4.0 score was lower for the entire group (73.1 ± 14.4) compared with healthy norms (83.0 ± 14.8) and lowest for children with chronic daily headaches (70.5 ± 15.5). The impact on QOL of children with migraine was similar to that of children with arthritis and cancer. Conclusions. QOL of children with headaches is significantly affected by their health condition. The impact of headaches on QOL is similar to that found for other chronic illness conditions, with impairments in school and emotional functioning being the most prominent.

Background.—Migraine headache is common and has multiple etiologies. A number of mitochondrial anomalies have been described for migraine, and mitochondrial dysfunction has been implicated as one potential pathophysiological mechanism. Carnitine is used by mitochondria for fatty acid transportation; its deficiency, however, has not been implicated in migraine pathophysiology. Methods and Results.—Two adolescent girls presented to the Headache Center at Cincinnati Children's Hospital Medical Center with frequent headaches and were diagnosed with migraine by the International Headache Society (IHS) criteria. Both girls had a history of recurrent fatigue, muscle cramps, and multiple side effects from their prophylactic treatment. Carnitine levels were measured and found to be low. Carnitine supplementation was initiated. Both patients had a reduction in headache frequency, as well as an improvement in their associated symptoms and other complaints. A skin and muscle biopsy obtained from one patient revealed a partial carnitine palmityltransferase II deficiency in the muscle only. Conclusion.—Carnitine palmityltransferase II deficiency may represent another etiology for migraine headache, and may be useful in further defining the pathophysiology of migraine. When properly recognized, supplementation with carnitine may improve the outcome of the migraine as well as the carnitine-associated symptoms.

BACKGROUND Migraine is a significant problem for many children. Topiramate has been suggested to be effective for the prophylaxis of migraine in adults, but has not yet been examined in children. The drug has been demonstrated to be safe and effective for childhood seizure disorders. The objective of this study was to demonstrate the safety and efficacy of topiramate for the prevention of pediatric migraine. METHODS Children with frequent migraine were prescribed topiramate for headache prevention. Dosages, serum levels, and Serum Glutamic Oxalacetic Transaminase (SGOT) levels were monitored. Changes in frequency, severity, and duration of headaches were recorded and changes in headache-related disability using PedMIDAS also were measured. RESULTS Ninety-seven children were treated with topiramate, and 75 were reevaluated 88.7 +/- 35.7 days later, 41 were seen at a second follow-up, and 17 were seen at a third follow-up evaluation. The daily dose reached at second evaluation was 84.0 +/- 38.6 mg/day or 1.42 +/- 0.74 mg/kg/day. This corresponded to a mean serum level of 2.8 +/- 1.6 micro g/mL. The mean headache frequency was reduced from 16.5 +/- 10.0 to 11.6 +/- 10.2 days per month (P

Objective. To conduct intensive pain management skills training (IST) in children with sickle cell disease (SCD) and their parents and to comprehensively evaluate pain, coping, and daily functioning in children pre, immediately post, and 3 months following treatment. Methods. Three children who received IST in nonpharmacological and pharmacological pain management strategies completed a Coping Strategies Questionnaire (CSQ) at pre, post, and follow-up assessments, and daily pain and activity diaries for 18 weeks, spanning from 1 week pretreatment to 11 weeks posttreatment. Results. From pre- to posttreatment, 1 child receiving IST indicated increased report of active coping attempts and all 3 children indicated decreased report of negative thinking on the CSQ. Participants in IST used coping skills on 90% of days with pain and reported the skills to be moderately helpful on the daily diaries. For daily activities such as eating dinner, playing with friends, and hours slept, children participated similarly on days with pain and days without pain during the posttreatment period. Given the small number of participants in this study, individual cases are discussed to highlight similarities and differences in how participants responded to the treatment and during the 3-month follow-up period. Conclusions. In this pilot study, each participant showed improvement in coping and daily functioning after completing the IST program. Individual differences in response to treatment indicate the need for more targeted intervention programs that incorporate pharmacological and nonpharmacological components. The results of this study highlight both the promise and the complications of conducting comprehensive pain intervention and functional outcome studies in children with SCD.

Objective To review and critically evaluate the extant research literature pertaining to adherence in youth and adults with headache and to provide recommendations for future research. Background This article provides the first systematic review of pediatric headache adherence and updates a previous review of treatment adherence in adults with headache. Design Systematic review of empirical literature. Methods A literature search with no date restriction was conducted using PubMed and PsycINFO electronic databases and bibliographies of relevant articles. Results Adherence rates in adults with headache range considerably from 25% to 94% across treatment, assessment method, and definition of adherence utilized. Methods to assess adherence included retrospective prescription claims data, paper or electronic diaries, follow-up appointment attendance, written and verbal self-report of general adherence, verbal self-report of adherence over a specific amount of time via in person interview or telephone, validated adherence measures, adherence questionnaires without validation, and counselor ratings of homework. Each methodology and assessment tool demonstrated strengths and weaknesses. No studies have systematically examined medication adherence in children with headache, and the few available studies examining adherence to behavioral treatment have documented adherence rates ranging from 52% to 86%. Conclusions Adherence research in adults with headache is growing, but studies demonstrate a number of methodological shortcomings. Adherence research in children with headache, and adherence intervention research in both adults and children, is scant. Future research should use objective measures of adherence, consider over-the-counter medications and medication overuse, examine demographic, psychological, and behavioral correlates of adherence, assess adherence to botulinum toxin type A, and examine the efficacy of adherence interventions in individuals with headache.

Background The purpose of this study was to evaluate the efficacy of a self-guided CD-ROM program (“Headstrong”) containing cognitive-behavioral self-management strategies versus an educational CD-ROM program for treating headaches, headache-related disability, and quality of life. Methods Participants were 35 children ages 7–12 years with migraine recruited from one university medical center and two children’s hospital headache clinics. Participants were randomly assigned to complete the Headstrong or educational control CD-ROM program over a 4-week period. Data on headache frequency, duration, and severity, migraine-related disability, and quality of life (QOL) were obtained at baseline, post-intervention, and 3-months post-intervention. Results At post-intervention, Headstrong resulted in lower severity (on a 10-point scale) than the control group by child report (5.06 ± 1.50 SD vs. 6.25 ± 1.92 SD, p = 0.03, ES = 0.7). At 3-months post-intervention, parents reported less migraine-related disability (on the PedMIDAS) in the Headstrong group compared to the control group (1.36 ± 2.06 SD vs. 5.18 ± 6.40 SD; p = 0.04, ES = 0.8). There were no other group differences at post treatment or at 3-months post-intervention. Conclusions When compared to an educational control, Headstrong resulted in lower pain severity at post-treatment and less migraine-related disability at 3-months post-intervention, by child and parent report respectively. Headache frequency and quality of life did not change more for Headstrong versus control. Additional research is needed on the Headstrong Program to increase its efficacy and to test it with a larger sample recruited from multiple centers simultaneously.

OBJECTIVE: This prospective longitudinal study examined the long-term physical and psychosocial outcomes of adolescents with juvenile-onset fibromyalgia (JFM), compared with healthy control subjects, into early adulthood. METHODS: Adolescent patients with JFM initially seen at a pediatric rheumatology clinic (n = 94) and age- and gender-matched healthy control subjects (n = 33) completed online measures of demographic characteristics, pain, physical functioning, mood symptoms, and health care utilization at ∼6 years’ follow-up (mean age: 21 years). A standard in-person tender-point examination was conducted. RESULTS: Patients with JFM had significantly higher pain (P < .001), poorer physical function (P < .001), greater anxiety (P < .001) and depressive symptoms (P < .001), and more medical visits (P < .001)than control subjects. The majority (>80%) of JFM patients continued to experience fibromyalgia symptoms into early adulthood, and 51.1% of the JFM sample met American College of Rheumatology criteria for adult fibromyalgia at follow-up. Patients with JFM were more likely than control subjects to be married and less likely to obtain a college education. CONCLUSIONS: Adolescent patients with JFM have a high likelihood of continued fibromyalgia symptoms into young adulthood. Those who met criteria for fibromyalgia in adulthood exhibited the highest levels of physical and emotional impairment. Emerging differences in educational attainment and marital status were also found in the JFM group. JFM is likely to be a long-term condition for many patients, and this study for the first time describes the wide-ranging impact of JFM on a variety of physical and psychosocial outcomes that seem to diverge from their same-age peers.

I worked in a basic science biology laboratory throughout my undergraduate years. But I was not trained in genomics, systems biology, neurophysiology, or modern molecular aspects of medicine. I conducted behavioral intervention studies for my master’s thesis and doctoral dissertation (Powers, Blount, Bachanas, Cotter, & Swan, 1993; Powers & Roberts, 1995). But I did not learn about the phases of clinical trials that are common language in pharmacological studies, data and safety monitoring boards, or what a data coordinating center is or does. I learned to help children and families via delivery of evidence-based care as an intern and fellow. But I was not exposed to the principles of health outcomes research, health care delivery system improvement, epidemiology, or the discipline of informatics and “big data.” It is true that some of these terms and entities did not exist during my training or early career as an assistant professor. In addition, advances in pediatric behavioral medicine, clinical child and adolescent psychology, cognitive and neuroscience, social psychology, among other areas of psychological science have been many since the 1990s. Today, I am not an expert—in fact very much an evolving student—of all of these integral aspects of academic medicine, behavioral neuroscience, and pediatric behavioral medicine. What I do know, and what I try to integrate into my programs of research, I learned from my colleagues. My point is that going forward, excellence in pediatric psychology investigation, clinical care, training, and leadership is a team sport. Team Science is the now, and the future (and it probably has always been a key to successful, high-impact research). It is an honor to be asked to provide commentary as the 2013 Logan Wright Distinguished Research Award recipient. I would like to reflect on the concepts of Team Science, Team Care, Team Training, and Team Leadership. I will discuss my experiences with the application of these principles in the areas of —(1) Programmatic, Integrated Clinical Care and Research; (2) Training and Mentorship; and (3) Administration and Leadership. I will also offer some thoughts about getting started as an early career scientist–practitioner.

Context. Mothers are in an important position to prevent obesity in their children by shaping early diet and activity patterns. However, many mothers of overweight preschool children are not worried about their child's weight. Objective. To explore mothers' perceptions about how they determine when a child is overweight, why children become overweight, and what barriers exist to preventing or managing childhood obesity. Design. Three focus groups with 6 participants in each. Participant comments were transcribed and analyzed. Themes were coded independently by the 6 authors who then agreed on common themes. Setting. A clinic of the Special Supplemental Nutrition Program for Women, Infants, and Children in Cincinnati, Ohio. Participants. Eighteen low-income mothers (13 black, 5 white) of preschool children (mean age of 44 months) who were at-risk for later obesity. All but 1 mother had a body mass index (BMI) ≥25 kg/m2, and 12 mothers had a BMI ≥30 kg/m2. All but 1 child had a BMI ≥85th percentile for age and sex, and 7 had a BMI ≥95th percentile. Results. Mothers did not define overweight or obese in their children according to how height and weight measurements were plotted on the standard growth charts used by health professionals. Instead, mothers were more likely to consider being teased about weight or developing limitations in physical activity as indicators of their child being overweight. Children were not believed to be overweight if they were active and had a healthy diet and/or a good appetite. Mothers described overweight children as thick or solid. Mothers believed that an inherited tendency to be overweight was likely to be expressed in the child regardless of environmental factors. In trying to shape their children's eating, mothers believed that their control over the child's diet was challenged by other family members. If a child was hungry, despite having just eaten, it was emotionally difficult for mothers to deny additional food. Conclusions. Health professionals should not assume that defining overweight according to the growth charts has meaning for all mothers. Despite differing perceptions between mothers and health professionals about the definition of overweight, both groups agree that children should be physically active and have healthy diets. Health professionals may be more effective in preventing childhood obesity by focusing on these goals that they share with mothers, rather than on labeling children as overweight.

Background: Chronic daily headaches (CDH) occur in >4% of the adult population. The criteria for CDH, however, are controversial. In children, the characterization of frequent headaches and CDH is limited. Methods: A Headache Center to characterize headaches in children (3 to 18 years old) was established. Over 34 months, 577 children have been evaluated. With use of a definition of ≥15 headaches per month, 200 (34.6%) children had CDH. Results: The average age at the first headache in these children was 9.3 ± 3.6 years, whereas the average age at presentation to the Headache Center was 12.5 ± 3.1 years. Sixty-eight percent were girls, 88% were Caucasian, and 11% were African American. Ninety-two percent clinically had migraine headaches, whereas 60.5% met the International Headache Society migraine criteria. The pain was pulsatile in 79%, 63.5% had nausea with or without vomiting, and 59.5% had photophobia and phonophobia. Three subcategories emerged, with 37% having frequent headaches but not daily, 43.5% having episodic daily headaches, and 19.5% having a continuous headache. Conclusion: The features of CDH in children most closely match those of migraine. A clear division of these children using frequency identifies three groups: frequent headaches (15 to 29), daily intermittent, and daily continuous. The daily continuous group is the most unique; however, the nature of these headaches continues to remain migrainous.

Obwohl bereits eindeutig gezeigt wurde, dass kognitive Verhaltenstherapie (CBT) die Funktionsbeeintrachtigung chronischer Schmerzzustande bei Jugendlichen mit Fibromyalgie signifikant verbessert, profitieren doch nicht alle Behandelten davon. Daruber hinaus bedeutet nicht jede Funktionsverbesserung auch einen klinisch relevanten Vorteil.

Study Objective. To investigate calorie intake, behavioral eating styles, and parent perception of eating behavior of school-age children with cystic fibrosis (CF) compared with healthy peers.Design. A two-group comparison study.Setting. A clinical sample of 28 school-age children with CF and a community sample of 28 healthy peers matched for age (6 to 12 years) and socioeconomic status.Measurements and Main Results. The children with CF consumed more calories per day (2175 cal/d) than the control children (1875 cal/d) and achieved a significantly higher recommended daily allowance (RDA) of energy (128% of the RDA) than the control children (91.61% of the RDA). Fifty-four percent of the CF sample were achieving the CF dietary recommendations of 120% of the RDA. Despite this energy intake, the CF sample was significantly below the control sample on weight (24.56 vs 31.23 kg), height (125.48 vs 133.06 cm), andz score for weight (−0.811 vs 0.528) and height (−0.797 vs 0.371). On measures of behavioral eating style, the CF sample had significantly longer meals (23.90 min) than the control sample (17.34 min) and had a significantly slower pace of eating (43.27% 10-second intervals with bites) than the control sample (51.29% 10-second intervals with bites) but did not differ significantly on the number of calories consumed during dinner. On a measure of parent report of mealtime behaviors, parents of the children with CF rated mealtime behavior problems of “dawdles” and “refuses food” as more intense (mean, 3.46) than did the parents of control children (mean, 2.67). For the CF sample, a significant correlation was found between the parent intensity ratings of problem behavior in general and meal duration (r = .48), and a significant negative correlation was found between the parent intensity ratings of problem mealtime behaviors and the percentage of intervals with bites (pace of meal) (r = −.533).Conclusions. Although the school-age children with CF were consuming more calories per day than their healthy peers, and more than 50% of the children in the CF sample were at or above the CF dietary recommendations, the children in the CF sample were significantly below the control children on measures of weight and height. The behavioral data suggest that increased caloric intake is not without cost, because the CF sample spent an additional 7 minutes per day at dinner and ate their meals at a slower pace than their healthy peers. These data were associated with higher intensity ratings of mealtime behaviors by parents of children with CF. These findings point to the need for individualized assessment of energy needs for school-age children with CF and comprehensive programs that teach parents behavioral strategies to motivate their children to meet these higher energy requirements in an adaptive manner.

Early, safe, effective, and durable evidence-based interventions for children and adolescents with chronic migraine do not exist.To determine the benefits of cognitive behavioral therapy (CBT) when combined with amitriptyline vs headache education plus amitriptyline.A randomized clinical trial of 135 youth (79% female) aged 10 to 17 years diagnosed with chronic migraine (≥15 days with headache/month) and a Pediatric Migraine Disability Assessment Score (PedMIDAS) greater than 20 points were assigned to the CBT plus amitriptyline group (n = 64) or the headache education plus amitriptyline group (n = 71). The study was conducted in the Headache Center at Cincinnati Children's Hospital between October 2006 and September 2012; 129 completed 20-week follow-up and 124 completed 12-month follow-up.Ten CBT vs 10 headache education sessions involving equivalent time and therapist attention. Each group received 1 mg/kg/d of amitriptyline and a 20-week end point visit. In addition, follow-up visits were conducted at 3, 6, 9, and 12 months.The primary end point was days with headache and the secondary end point was PedMIDAS (disability score range: 0-240 points; 0-10 for little to none, 11-30 for mild, 31-50 for moderate,50 for severe); both end points were determined at 20 weeks. Durability was examined over the 12-month follow-up period. Clinical significance was measured by a 50% or greater reduction in days with headache and a disability score in the mild to none range (20 points).At baseline, there were a mean (SD) of 21 (5) days with headache per 28 days and the mean (SD) PedMIDAS was 68 (32) points. At the 20-week end point, days with headache were reduced by 11.5 for the CBT plus amitriptyline group vs 6.8 for the headache education plus amitriptyline group (difference, 4.7 [95% CI, 1.7-7.7] days; P = .002). The PedMIDAS decreased by 52.7 points for the CBT group vs 38.6 points for the headache education group (difference, 14.1 [95% CI, 3.3-24.9] points; P = .01). In the CBT group, 66% had a 50% or greater reduction in headache days vs 36% in the headache education group (odds ratio, 3.5 [95% CI, 1.7-7.2]; P .001). At 12-month follow-up, 86% of the CBT group had a 50% or greater reduction in headache days vs 69% of the headache education group; 88% of the CBT group had a PedMIDAS of less than 20 points vs 76% of the headache education group. Measured treatment credibility and integrity was high for both groups.Among young persons with chronic migraine, the use of CBT plus amitriptyline resulted in greater reductions in days with headache and migraine-related disability compared with use of headache education plus amitriptyline. These findings support the efficacy of CBT in the treatment of chronic migraine in children and adolescents.clinicaltrials.gov Identifier: NCT00389038.

Objective The objective of this article is to determine the monthly variation of emergency department (ED) visits for pediatric headache. We hypothesized youth have increased headache-related ED visits in the months associated with school attendance. Methods Using a United States representative sample of ED visits in the National Hospital Ambulatory Medical Care Survey from 1997 to 2009, we estimated number of visits associated with ICD-9 codes related to headache, migraine, status migrainosus, or tension-type headache in 5- to 18-year-olds. Age-stratified multivariate models are presented for month of visit (July as reference). Results There was a national estimate of 250,000 ED visits annually related to headache (2.1% of total visits) in 5- to 18-year-olds. In 5- to 11-year-olds, the adjusted rate of headache-related visits was lower in April (OR 0.42, 95% CI 0.20, 0.88). In 12- to 18-year-olds, there were higher rates in January (OR 1.92, 95% CI 1.16, 3.14) and September (OR 1.64, 95% CI 1.06, 2.55). Conclusions In adolescents we found higher ED utilization in January and September, the same months associated with school return from vacation for a majority of children nationally. No significant reduction in the summer suggests that school itself is not the issue, but rather changes in daily lifestyle and transitions.

Children from low socioeconomic status (SES) and ethnic minority backgrounds are at heightened risk for overweight, yet are underrepresented in the pediatric obesity literature. This article describes strategies employed to minimize barriers to recruitment and retention of African American families receiving Women, Infants, and Children services in a longitudinal study examining caregiver feeding and child weight. Seventy-six families enrolled in the study over 3½ years, and 50% of the families completed the study. Despite effortful planning, unanticipated barriers likely contributed to lengthy recruitment and a modest retention rate. Future research should incorporate lessons learned to modify and develop effective strategies for increasing engagement of low-SES and ethnic minority families in research.

Background Retrospective and cross-sectional studies have suggested a bidirectional relationship between migraine and mood disturbance. Objective The present prospective daily diary study examined the prevalence and temporal associations between migraine and daily mood, mood and next-day headache, and headache and next-day mood. Methods Sixty-nine children (50 females, 19 males) between the ages of 7 and 12 years and their parents attending neurology clinic appointments and having a diagnosis of migraine as defined by International Headache Classification 2nd edition criteria completed measures on the quality of life, headache disability, child emotions, and child behaviors. Children and parents then recorded children's headache occurrence, headache duration, headache severity, mood, daily hassles, and medication use on paper diaries once a day for 2 consecutive weeks. “Mood” was defined using the Facial Affective Scale, which is a visual representation of negative and positive affect. Data were analyzed using multilevel models. Results Controlling for age, sex, quality of life, headache disability, and medication use, worse mood was associated with same-day occurrence, longer duration, and more severe headache in both child and parent report. Today's mood was not consistently associated with next-day headache, and today's headache was not associated with next-day mood in either child or parent report. Conclusions Results of this study lend support to a complex relationship between mood and headache in children with migraine. More research is needed to further elucidate the temporal nature of this relationship within a given day and over an extended period of time.

To quantitatively assess cortical dysfunction in pediatric migraine, 31 adolescents with acute migraine and age- and gender-matched controls were studied using a magnetoencephalogra- phy (MEG) system at a sampling rate of 6,000 Hz. Neuromagnetic brain activation was elicited by a finger-tapping task. The spectral and spatial signatures of magnetoencephalography data in 5 to 2,884 Hz were analyzed using Morlet wavelet and beamformers. Compared with controls, 31 migraine subjects during their headache attack phases (ictal) showed significantly prolonged latencies of neuromagnetic activation in 5 to 30 Hz, increased spectral power in 100 to 200 Hz, and a higher likelihood of neuromagnetic activation in the supplementary motor area, the occipital and ipsilateral sensorimotor cortices, in 2,200 to 2,800 Hz. Of the 31 migraine subjects, 16 migraine subjects during their headache-free phases (interictal) showed that there were no significant differences between interictal and control MEG data except that interictal spectral power in 100 to 200 Hz was significantly decreased. The results demonstrated that migraine subjects had significantly aberrant ictal brain activation, which can normalize interictally. The spread of abnormal ictal brain activation in both low- and high-frequency ranges triggered by movements may play a key role in the cascade of migraine attacks. Perspective: This is the first study focusing on the spectral and spatial signatures of cortical dysfunction in adolescents with migraine using MEG signals in a frequency range of 5 to 2,884 Hz. This methodology analyzing aberrant brain activation may be important for developing new therapeutic interventions for migraine in the future.

This study examined mealtime behaviors in families of young children with type 1 diabetes (T1DM) on intensive insulin therapy. Behaviors were compared to published data for children on conventional therapy and examined for correlations with glycemic control. Thirty-nine families participated and had at least three home meals videotaped while children wore a continuous glucose monitor. Videotaped meals were coded for parent, child, and child eating behaviors using a valid coding system. A group difference was found for child request for food only. There were also associations found between children's glycemic control and child play and away. However, no associations were found between parent and child behaviors within meals and children's corresponding post-prandial glycemic control. Results reinforce existing research indicating that mealtime behavior problems exist for families of young children even in the context of intensive therapy and that some child behaviors may relate to glycemic control.

Diet is an important component of diabetes treatment and integral to successful management. While intensive insulin therapy can allow patients to eat more freely, it is not known how the rapid uptake of intensive therapy in young children with type 1 diabetes has impacted their diet and if diet and healthful eating in young children correlates with mealtime behaviors and glycemic control. This study examined diet, mealtime behaviors, and glucose control in a sample of 39 young children on intensive therapy. This was a one-sample, cross-sectional study . Children had a mean age of 5.1±1.1 years. Children's 3-day diet diaries were assessed using a deviation scale (measure of adherence) and a healthy eating index. Mealtime behaviors were assessed using the Behavioral Pediatric Feeding Assessment Scale . Children's glucose control was measured using continuous glucose monitoring. Children's mean carbohydrate intake was 72%±24% of the recommended levels based on their age, sex, size, and activity level, and children exceeded national guidelines for percentage of calories from fat and saturated fat. A more healthful diet correlated with fewer child mealtime behavior problems, but better dietary adherence correlated with more parent mealtime behavior problems. Even in the context of intensive management, diet can be problematic for young children with type 1 diabetes. Parent-reported problems with mealtime behaviors seem to correlate with healthy eating and dietary adherence.

The cerebral cortex serves a primary role in the pathogenesis of migraine. This aberrant brain activation in migraine can be noninvasively detected with magnetoencephalography (MEG). The objective of this study was to investigate the differences in motor cortical activation between attacks (ictal) and pain free intervals (interictal) in children and adolescents with migraine using both low- and high-frequency neuromagnetic signals. Thirty subjects with an acute migraine and 30 subjects with a history of migraine, while pain free, were compared to age- and gender-matched controls using MEG. Motor cortical activation was elicited by a standardized, validated finger-tapping task. Low-frequency brain activation (1∼50 Hz) was analyzed with waveform measurements and high-frequency oscillations (65–150 Hz) were analyzed with wavelet-based beamforming. MEG waveforms showed that the ictal latency of low-frequency brain activation was significantly delayed as compared with controls, while the interictal latency of brain activation was similar to that of controls. The ictal amplitude of low-frequency brain activation was significantly increased as compared with controls, while the interictal amplitude of brain activation was similar to that of controls. The ictal source power of high-frequency oscillations was significantly stronger than that of the controls, while the interictal source power of high-frequency oscillations was significantly weaker than that of controls. The results suggest that aberrant low-frequency brain activation in migraine during a headache attack returned to normal interictally. However, high-frequency oscillations changed from ictal hyper-activation to interictal hypo-activation. Noninvasive assessment of cortical abnormality in migraine with MEG opens a new window for developing novel therapeutic strategies for childhood migraine by maintaining a balanced cortical excitability.

(1995). Simulation training with parents of oppositional children: Preliminary findings. Journal of Clinical Child Psychology: Vol. 24, No. 1, pp. 89-97.

Study objective. To investigate calorie intake, behavioral eating styles, and parent perception of eating behavior of preschool children with cystic fibrosis (CF) compared with healthy peers. Design. A two group comparison study. Setting. A clinical sample of 32 preschool children with CF (aged 2 to 5 years) and a community sample of 29 healthy peers matched for age and socioeconomic status. Measurements and main results. The two groups did not differ on the total number of calories consumed per day or the percentage of calories derived form fat. The CF sample achieved a significantly higher percent of the recommended daily allowance (RDA) of energy (95% RDA) than the control group (84% RDA), P < .05, but did not achieve the CF dietary recommendations of 120% RDA. On measures of behavioral eating style, the CF sample had significantly longer meals (24.63 min) than the control group (18.57 min), P < .01, but did not differ on pace of eating or calories consumed per bite. On a measure of parent report of mealtime behavior, parents of the CF sample identified mealtime behaviors of "dawdles" and "refuses food" as more problematic (M = .93) than parents of control children (M = .22), P < .05. Conclusions. While preschool children with CF consume as much or more than healthy peers, they are not achieving the CF dietary recommendations. Furthermore, there appear to be behavioral differences in eating and parent perception of CF children's eating that may contribute to the failure to achieve dietary recommendations.

Objectives: The objectives of this study were to assess comorbid psychiatric diagnoses in youth with chronic daily headache (CDH) and to examine relationships between psychiatric status and CDH symptom severity, as well as headache-related disability. Methods: Standardized psychiatric interviews (Kiddie Schedule for Affective Disorders and Schizophrenia, KSADS) were conducted with 169 youth ages 10–17 diagnosed with CDH. Participants provided prospective reports of headache frequency with a daily headache diary and completed measures of symptom severity, headache-related disability (PedMIDAS) and quality of life (PedsQL). Results: Results showed that 29.6% of CDH patients met criteria for at least one current psychiatric diagnosis, and 34.9% met criteria for at least one lifetime psychiatric diagnosis. No significant relationship between psychiatric status and headache frequency, duration, or severity was found. However, children with at least one lifetime psychiatric diagnosis had greater functional disability and poorer quality of life than those without a psychiatric diagnosis. Discussion: Contrary to research in adults with chronic headaches, most youth with CDH did not appear to be at an elevated risk for comorbid psychiatric diagnosis. However, patients with a comorbid psychiatric diagnosis were found to have higher levels of headache-related disability and poorer quality of life. Implications for treatment are discussed.

This study looks for differences in mealtime characteristics and glycemic control for young children with type 1 diabetes who either eat with television (TV) viewing or without TV viewing. Sample size is 24 families (mean child age = 5.2, SD = 1.0 years). Meals with TV lasted 6 minutes longer than meals without TV. Meals with TV were associated with greater fat intake and higher average glucose levels, but not with greater intake of calories, carbohydrates, or more child bites. This study suggests relations between TV viewing and some negative outcomes for young children, but more research is needed to determine causation.

Exacerbation of migraine with menses is common in adolescent girls and women with migraine, occurring in up to 60% of females with migraine. These migraines are oftentimes longer and more disabling and may be related to estrogen levels and hormonal fluctuations.This study identifies the unique genomic expression pattern of menstrual-related migraine (MRM) in comparison to migraine occurring outside the menstrual period and headache-free controls.Whole blood samples were obtained from female subjects having an acute migraine during their menstrual period (MRM) or outside of their menstrual period (non-MRM) and controls (C)--females having a menstrual period without any history of headache. The messenger RNA was isolated from these samples, and genomic profile was assessed. Affymetrix Human Exon ST 1.0 (Affymetrix, Santa Clara, CA, USA) arrays were used to examine the genomic expression pattern differences between these 3 groups.Blood genomic expression patterns were obtained on 56 subjects (MRM = 18, non-MRM = 18, and controls = 20). Unique genomic expression patterns were observed for both MRM and non-MRM. For MRM, 77 genes were identified that were unique to MRM, while 61 genes were commonly expressed for MRM and non-MRM, and 127 genes appeared to have a unique expression pattern for non-MRM. In addition, there were 279 genes that differentially expressed for MRM compared to non-MRM that were not differentially expressed for non-MRM. Gene ontology of these samples indicated many of these groups of genes were functionally related and included categories of immunomodulation/inflammation, mitochondrial function, and DNA homeostasis.Blood genomic patterns can accurately differentiate MRM from non-MRM. These results indicate that MRM involves a unique molecular biology pathway that can be identified with a specific biomarker and suggest that individuals with MRM have a different underlying genetic etiology.

Background A combined behavior–nutrition approach is recommended for children with CF with growth deficits. The present study aimed to use a qualitative approach to 1) understand families' experiences using behavior–nutrition intervention strategies and 2) identify the challenges with CF management families experienced during the developmental transition between toddlerhood and early school-age. Methods Eight families (mean age of children=8.2years) participated in a semistructured interview. Themes were independently identified by three coders, confirmed via consensus, and compared to a reliability coder. Results Parents discussed behavior and nutrition strategies, ongoing challenges with nutrition and behavior, new challenges, and protective factors. Challenges included transition to school, transfer of treatment responsibility, picky eating, and parental stress. Conclusions Ongoing assessment and recommendations to address parent stress and child behavior are warranted. Providing families with anticipatory guidance can better prepare families for challenging developmental transitions including starting school and the transfer of treatment responsibility.

Objective: To evaluate the efficacy of Coenzyme Q10 (CoQ10) supplementation in the prevention of migraine in children using a placebo-controlled, double-blinded, crossover, add-on trial. Background: CoQ10 has been demonstrated to have efficacy in migraine prevention in adults but lacks pediatric research with more rigorous methodology. CoQ10 has been observed to be deficient in a significant number of children and adolescents presenting to tertiary headache centers. CoQ10 has the potential to modify both the inflammatory changes that occur during recurrent migraine and the alteration of mitochondrial function. A deficit of CoQ10 could thus affect the response to treatment and clinical characteristics of migraine in children and adults. Methods: One-hundred-and-twenty children and adolescents with migraine headache were randomized in a crossover, double-blind, placebo-controlled, randomized, add-on study to receive a placebo or CoQ10 (100 mg) supplement for 224 days. Data for 76 patients were available at the crossover point and 50 were analysed at the endpoint. Response to treatment, overall headache improvement, and headache disability were assessed. Results: Both the placebo and CoQ10 groups showed reduced migraine frequency [ F(1, 60) = 15.68, p 0.05], severity [ F(1, 54) = 0.06, p > 0.05], or duration [ F(1, 45) = 0.14, p > 0.05]. Conclusions: Overall, results of the study demonstrate that children and adolescents with migraine improved over time with multidisciplinary, standardized treatment regardless of supplementation with CoQ10 or placebo. There was no difference in headache outcomes between the CoQ10 and placebo groups at day 224. Due to the improvements seen in weeks 1–4, CoQ10 may lead to earlier improvement in headache severity, but given the sample size this conclusion warrants further investigation with a larger sample.

Acute migraine could be associated with neurophysiological and cognitive changes. This study evaluates the neurophysiological changes in auditory information processing in adolescents with acute migraine by means of magnetoencephalography. The multifeature sound mismatch negativity (MMN) paradigm was used to study nine adolescents with an acute migraine and nine age- and gender-matched healthy controls. Latencies and amplitudes of M100, M150, M200, and MMNm responses were evaluated. Migraine subjects had smaller M150 amplitudes than healthy subjects. The latencies of MMNm response for the frequency change were delayed in both hemispheres in migraine subjects, as compared with healthy controls. Our results indicate that the function of neural substrates, responsible for different stages of auditory information processing, is impaired during the acute migraine. The identification of underlying cortical dysfunction during an acute migraine can lead to future identification of neurophysiological biomarkers for studying acute migraine and response to treatment.

Patton SR, Williams LB, Eder SJ, Crawford MJ, Dolan L, Powers SW. Use of continuous glucose monitoring in young children with type 1 diabetes: implications for behavioral research. Objective: This study presents data on the use of continuous glucose monitoring (CGM) in young children with type 1 diabetes mellitus (T1DM). CGM provides moment-to-moment tracking of glucose concentrations and measures of intra- and interday variability, which are particularly salient measures in young children with T1DM. Methods: Thirty-one children (mean age = 5.0 yr ) with T1DM wore the Medtronic Minimed CGM for a mean of 66.8 h. The CGM was inserted in diabetes clinics, and parents were provided brief training. Results: Few difficulties were experienced and families cited the acceptability of CGM. Participants' CGM data are compared with self-monitoring blood glucose (SMBG) data as well as data from older children with T1DM to illustrate differences in methodology and variability present in this population. CGM data are used to calculate glucose variability, which is found to be related to diabetes variables such as history of hypoglycemic seizures. Conclusions: CGM is an acceptable research tool for obtaining glucose data in young children with T1DM and has been used previously in older children and adults. CGM may be particularly useful in young children who often experience more glucose variability. Data obtained via CGM are richer and more detailed than traditional SMBG data and allow for analyses to link blood glucose with behavior.

Three mildly malnourished children with cystic fibrosis and their parents participated in a behavioral group-treatment program that focused on promoting and maintaining increased calorie consumption. Treatment included nutritional education, gradually increasing calorie goals, contingency management, and relaxation training, and was evaluated in a multiple baseline design across four meals. Children's calorie intake increased across meals, and total calorie intake was 32% to 60% above baseline at posttreatment. Increased calorie consumption was maintained at the 96-week follow-up (2 years posttreatment). The children's growth rates in weight and height were greater during the 2 years following treatment than the year prior to treatment. Increases in pace of eating and calories consumed per minute were also observed 1 year posttreatment. These findings replicated and extended earlier research supporting the efficacy of behavioral intervention in the treatment of malnutrition in children with cystic fibrosis.

(Headache 2010;50:1005-1016) Objective.— To investigate the functional abnormalities of the motor cortices in children with migraine using magnetoencephalography (MEG) and a finger-tapping task. Background.— Cortical hyperexcitability has been reported in adults with migraine using MEG. Many children with migraine report difficulty with motor functioning. There is no report on motor-evoked magnetic activation in children with migraine using MEG and the latest signal processing methods. Methods.— Ten children with migraine (all female, 9 right-handed and 1 left-handed, aged 13-17 years) and 10 age- and gender-matched healthy children were studied with a 275-channel MEG system. After hearing a unilateral, randomly presented sound cue (500 Hz, 30 milliseconds square tone), each subject immediately performed a brisk index finger tapping with either the right or the left index finger. The auditory stimuli consisted of 200 trials of square tone, 100 trials per ear, randomly distributed. The latency and amplitude of neuromagnetic responses were analyzed with averaged waveforms. Neuromagnetic sources were estimated using synthetic aperture magnetometry (SAM). SAM images were normalized for each participant for group comparison. Results.— In comparison with healthy children, children with migraine had prolonged latency of motor-evoked magnetic response in the right hemispheres during left finger movement (62.33 ± 34.55 milliseconds vs 34.9 ± 17.29 milliseconds, P

Inadequate intake and suboptimal growth are common problems for patients with CF and a critical target for intervention. The purpose of this study was to compare the growth outcomes of children with CF who participated in a randomized clinical trial to improve energy intake and weight to children with CF receiving standard of care during the same time period. Our primary outcome was change in body mass index z-score (BMI z-score) over 2 years. An exploratory outcome was forced expiratory volume at 1-sec (FEV1) over 2 years. Participants were children ages 4–12 with CF, who participated in a randomized clinical trial of behavior plus nutrition intervention versus nutrition education alone, and a matched Comparison Sample receiving standard of care drawn from the Cystic Fibrosis Foundation (CFF) Registry. Children in the Clinical Trial Group (N = 67) participated in a 9-week, nutrition intervention and were followed at regular intervals (3, 6, 12, 18, and 24 months) for 2 years post-treatment to obtain anthropometric and pulmonary function data. For each child in the Comparison Sample (N = 346), these measures were obtained from the CFF Registry at matching intervals for the 27-month period corresponding to the clinical trial. Over 27 months, children in the Clinical Trial Group (the combined sample of the behavior plus nutrition and the nutrition alone) demonstrated significantly less decline in BMI z-score, −0.05 (SD = 0.68, CI = −0.23 to 0.13), as compared to children in the Comparison Sample, −0.21 (SD = 0.67, CI = −0.31 to −0.11). No statistically significant differences were found for decline in FEV1 between children in the Clinical Trial Group and the Comparison Sample. The key implication of these findings is that intensive behavioral and nutritional intervention is effective and needs to be adapted so that it can be broadly disseminated into clinical practice.

Objective To describe school absences in adolescents with Juvenile Primary Fibromyalgia Syndrome (JPFS) and examine the relationship between school absenteeism, pain, psychiatric symptoms, and maternal pain history. Methods Adolescents with JPFS (N ¼ 102; mean age 14.96 years) completed measures of pain and depressive symptoms, and completed a psychiatric interview. Parents provided information about the adolescents’ school absences, type of schooling, and parental pain history. School attendance reports were obtained directly from schools. Results Over 12% of adolescents with JPFS were homeschooled. Those enrolled in regular school missed 2.9 days per month on average, with one-third of participants missing more than 3 days per month. Pain and maternal pain history were not related to school absenteeism. However, depressive symptoms were significantly associated with school absences. Conclusion Many adolescents with JPFS experience difficulties with regular school attendance. Long-term risks associated with school absenteeism and the importance of addressing psychological factors are discussed.

Preschool children (n=30) undergoing routine immunizations at a health department were taught to use distraction prior to the medical procedure and to use a party blower, as an age appropriate version of deep breathing, just prior to and during the injection. Parents were taught to coach their children. A no-treatment control group (n=30) was used to evaluate effectiveness. Results indicated that trained parents engaged in more prompting of their child to use the blower than untrained parents. Trained children engaged in more blower usage than untrained children. Child distress was lower on two of three observational measures for the trained children. Parents of trained children reported that both they and their children were less distressed when compared to how they normally would be during the procedures. Staff, who were not trained nor instructed to change their behavior, engaged in significantly more coaching of trained than of untrained children to use the blower, suggesting generalization of the behavior from parents to staff. Suggestions for future research are included.

Better growth and nutritional status is strongly associated with better pulmonary function and survival in children with CF. Behavioral intervention is an efficacious treatment approach for improving calorie intake and weight gain in children with CF; and recently has been shown to facilitate maintenance of daily energy intake at 120% of the healthy population over a 2-year period. However, no study to date has examined factors that predict outcome with behavior intervention to promote weight gain in CF. The objectives of this study were to examine the influence of nutritional status, mealtime behavior problems, and maternal depressive symptoms on calorie intake and weight gain following participation in a randomized trial to improve nutritional status in cystic fibrosis. Sixty-seven children, aged 4-12 years with cystic fibrosis participated in a clinical trial targeting calorie and weight increases. Participants completed baseline measures of mealtime behavior problems, maternal depression, and fat absorption, and baseline and post-treatment caloric intake and weight. Assignment to behavioral group (R(2) change = 0.17), lower frequency of mealtime behavior problems (R(2) change = 0.11), and higher maternal depression (R(2) change = 0.06) predicted greater calorie increase baseline to post-treatment. Assignment to behavioral group (R(2) change = 0.09), higher baseline weight (R(2) change = 0.10), fat absorption (R(2) change = 0.02), and lower frequency of mealtime behavior problems (R(2) change = 0.06) predicted greater weight gain baseline to post-treatment. Less frequent mealtime behavior problems led to better calorie intake and weight gain in a 9-week clinical trial of behavior intervention and nutrition education to improve nutritional status in cystic fibrosis. The key implication from these findings is that early referral to behavioral intervention as soon as growth deficits become a concern will likely yield the best nutritional outcomes.