Parental behaviors shape children’s obesity risk, yet little is known about family-level implications of caregiver glucagon-like peptide-1 (GLP-1) use. This cross-sectional study surveyed caregivers who started GLP-1 medication for weight management within the past 6 months and lived with at least one child aged ≤18 years ( n = 58). Guided by the Family Ecological Model, the survey assessed caregiver perceptions of family health behaviors since starting GLP-1 medication. Nearly half of caregivers reported offering healthier foods to children (46.6%) and increased focus on managing children’s nutrition and physical activity (50.0%). About one-quarter of caregivers reported healthier child eating (27.6%) and physical activity (24.1%). Most caregivers reported no change in child eating (67.2%) and physical activity (72.4%). Caregivers were more likely to report healthier foods offered following GLP-1 initiation when concern about a child’s weight had been raised by pediatrician ( p = 0.02). Caregiver GLP-1 initiation may provide an opportunity to support family-centered obesity prevention.

Abstract Clinical chart abstraction extracts structured patient variables from longitudinal clinical notes but is labor-intensive and difficult to scale. We evaluated LLM agents for question-guided chart review using lung cancer molecular testing guideline concordance as a use case. Two configurations were compared: (1) sequential note review using metadata and chronology, and (2) the same framework augmented with keyword-based note search. Gold-standard labels were established by human annotators. The search-enabled agent achieved higher accuracy (92.4% vs. 83.5%) and reduced errors by more than half (41 vs. 89) by retrieving evidence from long, heterogeneous note histories. In guideline concordance evaluation, most determinate patient–rule assessments were concordant (80.7%), while most apparent non-concordance reflected missing molecular testing documentation rather than documented care deviations. These results suggest tool-augmented LLM agents can approximate key aspects of human chart review and support scalable information extraction from longitudinal clinical documentation.

OBJECTIVE:Caregivers of children with a chronic illness often experience stress that can impact their child's health and influence the parent-child relationship dynamic through changes in communication patterns. Within a pediatric asthma sample, we examined the associations between medical factors and caregiver stress on parent-child communication patterns and youth quality of life (QOL). METHODS:Youth with asthma (n = 70; Mage = 13.99; 43% female) and their caregivers (94% female; 46% White) were recruited from a pediatric pulmonary clinic. Hierarchical regression models examined the unique contributions of medical factors and caregiver stress (Pediatric Inventory for Parents, PIP) on caregiver-child communication patterns (Revised Family Communication Pattern Instrument, RFCP; openness vs. conforming to family ideals) and youth QOL (Pediatric Asthma Quality of Life Questionnaire, PAQLQ). RESULTS:On a scale of 42-210, in which higher scores indicate greater frequency or difficulty of problems contributing to caregiver stress, caregivers reported an average frequency score of 83.91 (SD = 30.226) and an average difficulty score of 79.00 (SD = 32.767). More emergency room visits in the past 12 months (B = .327, p = 0.006) were related to greater endorsement of parent-child communication conformity orientation, explaining 21.1% of variance, F(3,61) = 5.45, p = 0.002; caregiving stress was only associated at the bivariate level. Higher caregiving stress difficulty (B = -0.389, p = 0.001) was related to lower youth QOL, explaining 17.0% of variance, F(2,64) = 6.55, p = 0.003. CONCLUSIONS:Caregivers of youth with asthma reported low-moderate caregiving stress in both frequency and difficulty of problems faced. Nevertheless, caregiving stress difficulty was a predictor of their child's QOL above and beyond medical factors. Healthcare providers should screen for caregiving stress and continue to monitor caregiver well-being throughout the illness trajectory.

Background:Adolescent asthma is a significant contributor to youth morbidity and is known to be best managed through consistent medication use and symptom management. However, adolescents often struggle to perceive their symptoms accurately and consistently use their medication at the recommended rate, risking worsened symptoms and impaired quality of life. The Responsive Asthma Care for Teens (ReACT) system is a project aimed at identifying and and providing supporting for several barriers adolescents may face in asthma management. By integrating both software and hardware to monitor medication adherence, ReACT provides a personalized support plan to improve asthma management and, subsequently, quality of life. Objective:The objective of this study is to conduct a proof-of-concept assessment of the ReACT system following an initial pilot study and adjusting for the feedback received. In addition to assessing the acceptability and usability of the current version, this study aims to assess whether the proposed ReACT system leads to indications of improvement in medication adherence because of the personalized support plans. Methods:Participants in the study were 5 adolescents aged 15 to 17 years recruited using a combination of consent-to-contact forms delivered via an in-person asthma clinic and Qualtrics panels. As a part of this study, participants met with the study team 3 times over 1 month. After completing initial surveys on stress, problem-solving, and asthma-related quality of life, we oriented the participants to the ReACT platform and asked them to interact with it as normal. After the month, the participants were interviewed, and they discussed the system and completed surveys assessing their opinions on acceptability and usability. Results:On a 4-point scale, participants reported high acceptability of ReACT (mean score 3, SD 0.32), willingness to use it again (mean score 4, SD 0.89), and willingness to recommend it to a friend (mean score 3.75, SD 0.55), and they considered it to be helpful (mean score 3.2, SD 0.84). Conclusions:Our findings suggest that ReACT is an acceptable and usable mobile health intervention to improve asthma self-management among adolescents, and it had promising results for improving self-regulation, problem-solving, and asthma control. The system continues improving based on feedback from a larger sample size of participants, and we hope that ReACT will aid adolescent development while delivering highly personalized support for each user.

OBJECTIVE:There is a need for a systematic review on social functioning and peer relationships among adolescents with chronic pain (ACP) given the high prevalence of chronic pain in adolescence and integral role of peer relationships in adolescent development. This review aims to examine the methods used to evaluate social functioning, the types and extent of peer relationship difficulties, and pain characteristics and sociodemographic factors related to social functioning in ACP. METHODS:A systematic literature search of PubMed, PsycINFO, CINAHL, Web of Science, and Cochrane databases was performed. Included studies were written in English, presented original, quantitative, peer-reviewed research, had a primary focus on social functioning or peer relationships in ACP, and included study participants between the ages of 10 and 18 years. The review was registered in PROSPERO (No. CRD42022364870). RESULTS:Twenty-eight articles were included in the review. All studies used self-, parent-, or peer-report questionnaires to evaluate social functioning. Most (89%) of the studies were cross-sectional. Findings suggest that ACP experience social difficulties frequently characterized by loneliness, social anxiety, withdrawal, and peer victimization. Studies examining the associations between social functioning and sociodemographic variables, pain location, and pain-related characteristics yielded mixed findings. Study quality was mixed, with 57.14% rated as "good." CONCLUSIONS:Findings from this review emphasize the increased risk of reduced social connectedness and the complexity of underlying mechanisms associated with poorer social functioning among ACP. Additional research utilizing longitudinal methodologies is needed to understand potential moderators and directionality of associations between chronic pain and social functioning.

Background:An adaptive text messaging intervention to promote adolescent physical activity has demonstrated feasibility, acceptability, and preliminary efficacy in a recent proof-of-concept study. To inform future intervention development, a secondary analysis of the data examined how physical activity is influenced by mood, environment, and physical feelings of energy and fatigue. Objective:This study aims to understand how both macro- and microtemporal variables (eg, psychological and environmental variables at both levels) influence the efficacy of a brief mobile health intervention (ie, NUDGE) for physical activity. Methods:Using a matched control design, we evaluated the effect of daily positive and negative affect, perceptions of the weather, energy, and fatigue as moderators of the effect of the intervention on 21 intervention participants and 21 matched controls. Results:Consistent with study hypotheses, macrotemporal (levels of the variable on a 3-week timescale) moderators of intervention effectiveness were observed for positive affect (P<.001), negative affect (P=.03), energy (P<.001), fatigue (P<.001), and perceived weather barriers (P<.001) for moderate-to-vigorous physical activity. These effects were observed more consistently for moderate-to-vigorous physical activity than for sedentary behavior, which was only significant for energy (P<.001). No effects for microtemporal variables (at the day level) were observed. Conclusions:There appears to be an optimization opportunity for mobile health physical activity interventions that can be achieved by personalizing intervention features and content based on approximately monthly assessments of affect, physical feeling states, and perceived weather barriers.

Objective: Caregivers' self-efficacy for managing their child's asthma appears to influence their success with managing their child's disease. We examined how caregiver self-efficacy operates in the context of multilevel social-environmental support factors to shape asthma outcomes. Method: Caregivers of children (<18 years old) with asthma completed surveys at baseline (T1) and 3 months later (T2). At T1, caregivers (n = 814) rated health care provider communication, family collaboration, community resources, socioeconomic status (SES), objective numeracy, caregiver global health, and caregiver self-efficacy for managing their child's asthma. At T1 and T2 (n = 401), caregivers rated their asthma management behaviors and their child's asthma-related morbidity and quality of life. We used structural equation models to test whether caregiver self-efficacy mediated the associations between support factors and outcomes. Results: For T1 caregiver asthma management behavior, we observed positive indirect effects through self-efficacy for community resources and caregiver global health, and an unexpected negative indirect effect for SES. For T2 caregiver asthma management behavior, we observed no indirect effects. For T1 child asthma-related morbidity, we found positive indirect effects through self-efficacy for community resources and caregiver global health, and a negative indirect effect for SES. For child asthma-related morbidity at T2, the indirect effects found at T1 remained significant. Conclusions: Social-environmental factors may be an underrecognized driver of caregiver self-efficacy and its consequent child asthma outcomes. Interventions focused on building resources at the community level and strategies that promote caregiver health could empower caregivers with greater self-efficacy and improve asthma outcomes.

OBJECTIVE:Parent-child communication is integral to pediatric asthma management. This review evaluates parent-child communication among youth with asthma and their caregivers. It aims to characterize the type of communication according to a unifying framework (Murphy, L. K., Murray, C. B., & Compas, B. E., Guest Editors: Cynthia A. Gerhardt, Cynthia A. Berg, Deborah J. Wiebe and Grayson N. Holmbeck (2017). Topical review: Integrating findings on direct observation of family communication in studies comparing pediatric chronic illness and typically developing samples. Journal of Pediatric Psychology, 42, 85-94. https://doi.org/10.1093/jpepsy/jsw051), assess sociodemographic factors associated with communication, and examine the relationship between parent-child communication and youth psychosocial and health-related outcomes. METHODS:A systematic literature search was conducted using PubMed, PsycINFO, CINAHL, Web of Science, Cochrane Library, and Embase databases (June 2021; updated May 2024). Included studies reported original, peer-reviewed research on the relationship between parent-child communication and youth psychosocial or health outcomes among pediatric patients (mean age <18 years) with asthma and their primary caregiver(s). Study quality was evaluated using the Study Quality Assessment Tools of the NHLBI. RESULTS:Sixty-six articles were included with data from 5,373 youth with asthma. Studies assessed both positive (warm and structured) and negative (hostile/intrusive and withdrawn) communication. Most studies used questionnaires and cross-sectional designs. Associations between sociodemographic and communication variables were largely nonsignificant. Greater positive and less negative communication was associated with better youth psychosocial and asthma outcomes overall. CONCLUSION:Parent-child communication may be an important target for interventions aimed at improving youth outcomes. More research is needed to develop communication-focused interventions that aim to enhance parents' and youths' communication skills (i.e., increase their use of positive communication approaches and/or reduce their use of negative communication approaches) and evaluate their impact on youth outcomes. Future research should also use more discussion tasks and longitudinal designs.

BackgroundThere is a longstanding gap between national asthma guidelines and their implementation in primary care. Primary care providers (PCPs) endorse numerous provider and practice or clinic-related barriers to providing guidelines-based asthma care. To reduce asthma morbidity in primary care, PCPs need access to tools that facilitate adherence to national guidelines, which can be delivered at the point of care, are minimally burdensome, and fit within the clinic workflow. Clinical decision support (CDS) tools are health IT systems that can be housed in the electronic health record (EHR) system. ObjectiveThis study aimed to follow user-centered design principles and describe the formative qualitative work with target stakeholders (ie, PCPs and IT professionals) to inform our design of an EHR-embedded CDS tool that adheres to recent, significant changes in asthma management guidelines. MethodsPurposive sampling was used to recruit three separate subgroups of professionals (n=15) between (1) PCPs with previous experience using a paper-based CDS tool for asthma management, (2) PCPs without previous experience using CDS tools for asthma management, and (3) health care IT professionals. The PCP interview guide focused on their practice, familiarity with national asthma guidelines, and how a CDS tool embedded in the EHR might help them provide guideline-based care. The health care IT professional guide included questions on the design and implementation processes of CDS tools into the EHR. Qualitative data were audio-recorded, transcribed, and then analyzed using an inductive approach to develop themes. ResultsThemes were organized into 2 domains, current practice and CDS tool development. The themes that emerged from PCPs included descriptions of assessments conducted to make an asthma diagnosis, previous attempts or opportunities to implement updated national asthma guidelines, and how a CDS tool could be implemented using the EHR and fit into the current asthma management workflow. The themes that emerged from health care IT professionals included processes used to design CDS tools and strategies to collect evidence that indicated a tool’s value to a practice and the broader health system. ConclusionsIn this study, user-centered design principles were used to guide a qualitative study on perceived barriers and facilitators to a primary care–based, EHR-integrated asthma CDS tool. PCPs expressed their interest in adopting an asthma CDS tool that was low burden and efficient but could help them adhere to national asthma guidelines and improve clinic workflow. Similarly, health care IT professionals perceived an asthma CDS tool to be useful, if it adhered to EHR design standards. Implementation of a CDS tool to improve adherence of PCPs to recently updated national asthma guidelines could be beneficial in reducing pediatric asthma morbidity.

Background: An adaptive text messaging intervention to promote adolescent physical activity has demonstrated encouraging feasibility, acceptability, and preliminary efficacy in a recent proof-of-concept study. To inform future intervention development, a secondary analysis of the data examined how physical activity is influenced by mood, environment, and physical feelings of energy and fatigue. Objective: To understand how both macro- and microtemporal variables (e.g.., psychological and environmental variables at both levels) influence the efficacy of a brief mHealth intervention (i.e., NUDGE) for physical activity. Methods: Using a matched control design, we evaluated the effect of daily positive and negative affect, perceptions of the weather, energy, and fatigue as moderators of the effect of the intervention on 21 intervention participants and 21 matched controls. Results: Consistent with study hypotheses, macrotemporal (levels of the variable on a three-week timescale) moderators of intervention effectiveness were observed for positive affect (p < .001), negative affect (p = 0.031), energy (p < .001), fatigue (p < .001), and perceived weather barriers (p < .001) for moderate-to-vigorous physical activity. These effects were more consistently observed for moderate-to-vigorous physical activity than for sedentary behavior, which was only significant for energy (p < .001). No effects for microtemporal (variables at the day level) were observed. Conclusions: There appears to be an optimization opportunity for mHealth physical activity interventions that can be achieved by personalizing intervention features and content based on approximately monthly assessments of affect, physical feeling states, and perceived weather barriers.

Adolescent asthma is a significant contributor to youth morbidity and is known to be best managed through consistent medication use and symptom management. However, adolescents often struggle to accurately perceive their symptoms and consistently use their medication at the recommended rate, risking worsened symptoms and impaired quality of life. The Responsive Asthma Care for Teens (ReACT) system is a project directed at identifying and supporting the various reasons adolescents may be struggling with asthma management. By integrating both software and hardware elements to monitor medication adherence, ReACT provides a personalized support plan to eventually increase asthma management and subsequently, quality of life. The objective of this study is to conduct a proof-of-concept assessment of the ReACT system following an initial pilot study and adjusting for the feedback received. In addition to assessing the acceptability and usability of the current version, this study aims to assess whether the proposed ReACT system shows indication of improvement in medication adherence as a result of the personalized support plans. Participants in the study were five 15-17 year-old adolescents recruited using a combination of consent-to-contact forms delivered via an in-person asthma clinic and Qualtrics panels. As a part of this study, participants were asked to meet with the study team three times over the course of the month. After completing initial surveys on stress, problem solving, and asthma related quality of life, participants were oriented on the ReACT platform and asked to interact with it as normal. After the month, participants conducted an interview discussing the system and completed surveys assessing their opinions on acceptability and usability. On a four-point scale, participants reported high acceptability (mean 3), would use ReACT again (mean 4), recommend it to a friend (mean 3.75), and that ReACT was helpful (mean 3.5). At post-intervention adolescents demonstrated pre-post changes in problem-solving ability (Cohen d=0.43), motivation (Cohen d=0.84), and asthma-related stress (school Cohen d=0.91; leisure Cohen d=0.67; responsibility Cohen d=0.56). Our findings suggest ReACT is an acceptable and usable mHealth intervention to improve adolescent asthma self-management through promising results for improving self-regulation, problem-solving, and ultimately asthma control. As the system continues improving from participant feedback and a larger sample size, ReACT hopes to aid adolescent development while delivering highly personalized support to best aid each individual user.

BACKGROUND:Youth with sickle cell disease (SCD) often experience low health-related quality of life (HRQOL). Engagement in resilience-promoting processes, such as secondary control engagement (SCE) coping, or adapting to stressors, may be linked to contextual risk factors (e.g., poverty status). This study aims to illuminate relationships between a cumulative risk index (CRI), SCE coping, and HRQOL in youth with SCD and test whether SCE coping moderates the relationship between CRI and HRQOL.PROCEDURE:Participants in this cross-sectional study included 63 youth ages 8-18 with SCD. Participants completed measures to assess SCE coping use (Responses to Stress Questionnaire) and HRQOL (PedsQL SCD Module). Six variables from the electronic medical record were compiled in a CRI. Correlational and regression analyses examined relationships between primary variables and moderating effects of SCE coping, respectively.RESULTS:Model results show that SCE coping and CRI explain variation in HRQOL (p = .001), and a significant interaction exists between SCE and CRI (β = -.29, p = .02), with a stronger inverse relationship between CRI and HRQOL for higher SCE values. This suggests that lower CRI is associated with greater HRQOL for those with higher SCE coping relative to lower SCE coping.CONCLUSIONS:SCE coping may selectively benefit children with SCD experiencing lower cumulative risk, warranting encouragement of this strategy in clinical settings. Findings do not support SCE coping benefits for youth with higher risk, suggesting that the strategy may not be useful when risk-related stressors are especially pervasive; alternative protective factors should be identified for this risk group.

ObjectivePediatric asthma management is challenging for parents and guardians (hereafter caregivers). We examined (1) how caregivers mentally represent trigger and symptom management strategies, and (2) how those mental representations are associated with actual management behavior.MethodsIn an online survey, N = 431 caregivers of children with asthma rated 20 trigger management behaviors and 20 symptom management behaviors across 15 characteristics, and indicated how often they engaged in each behavior.ResultsPrincipal components analysis indicated 4 dimensions for trigger management behaviors and 3 for symptom management behaviors. Bayesian mixed-effects models indicated that engagement in trigger management behavior was more likely for behaviors rated as affirming caregiver activities. However, trigger management behavior did not depend on how highly the behavior was rated as challenging for caregiver, burdensome on child, or routine caregiving. Engagement in symptom management behavior was more likely for behaviors rated as affirming and common and harmless to the child, but was unrelated to how highly a behavior was rated as challenging for caregivers.ConclusionThese results suggest that interventions might be particularly useful if they focus on the affirming nature of asthma management behaviors. However, such interventions should acknowledge structural factors (e.g. poverty) that constrain caregivers' ability to act.

OBJECTIVE:Suboptimal nutritional adherence in adolescents with cystic fibrosis (awCF) has been associated with lower lung function. AwCF often have more independence in dietary decisions than younger children, yet little research has examined how adolescent decision-making relates to nutritional adherence. This study explored whether components of adolescent decision-making involvement facilitate enzyme and caloric adherence in awCF. METHODS:37 families participated and completed study procedures. AwCF and caregivers completed electronic surveys, including the Decision-Making Involvement Scale (DMIS). The DMIS evaluated awCF behaviors during nutrition-related decision-making/discussions with caregivers using DMIS subscales: Child Seek (asking for help/advice from caregivers), Child Express (awCF stating opinions) and Joint/Options (awCF participating in joint decision-making or caregiver providing options). AwCF completed 2, 24-hr diet recalls via videoconferencing/phone to estimate adherence. Chart reviews collected medical information. DMIS subscales were regressed onto enzyme and caloric adherence. RESULTS:43% of awCF met calorie recommendations; 48.6% took all enzymes as prescribed. Caloric adherence was positively correlated with adolescent- and parent-reported Child Seek (r = 0.53; r = 0.36) and adolescent-reported Joint/Options (r = 0.41). Per adolescent-report, the caloric adherence regression model was significant, with Child Seek contributing unique variance in caloric adherence (β = .62, p = .03). Parent-reported adolescent-decision-making involvement significantly predicted caloric adherence, but none of the subscales contributed unique variance. No other regressions were significant. CONCLUSIONS:When awCF participated in nutrition-related discussions with a caregiver, especially with questions, caloric adherence was better. Future research should examine whether family factors influence these results. AwCF are encouraged to ask questions in nutrition discussions.

BackgroundPediatric asthma is a heterogeneous disease; however, current characterizations of its subtypes are limited. Machine learning (ML) methods are well-suited for identifying subtypes. In particular, deep neural networks can learn patient representations by leveraging longitudinal information captured in electronic health records (EHRs) while considering future outcomes. However, the traditional approach for subtype analysis requires large amounts of EHR data, which may contain protected health information causing potential concerns regarding patient privacy. Federated learning is the key technology to address privacy concerns while preserving the accuracy and performance of ML algorithms. Federated learning could enable multisite development and implementation of ML algorithms to facilitate the translation of artificial intelligence into clinical practice. ObjectiveThe aim of this study is to develop a research protocol for implementation of federated ML across a large clinical research network to identify and discover pediatric asthma subtypes and their progression over time. MethodsThis mixed methods study uses data and clinicians from the OneFlorida+ clinical research network, which is a large regional network covering linked and longitudinal patient-level real-world data (RWD) of over 20 million patients from Florida, Georgia, and Alabama in the United States. To characterize the subtypes, we will use OneFlorida+ data from 2011 to 2023 and develop a research-grade pediatric asthma computable phenotype and clinical natural language processing pipeline to identify pediatric patients with asthma aged 2-18 years. We will then apply federated learning to characterize pediatric asthma subtypes and their temporal progression. Using the Promoting Action on Research Implementation in Health Services framework, we will conduct focus groups with practicing pediatric asthma clinicians within the OneFlorida+ network to investigate the clinical utility of the subtypes. With a user-centered design, we will create prototypes to visualize the subtypes in the EHR to best assist with the clinical management of children with asthma. ResultsOneFlorida+ data from 2011 to 2023 have been collected for 411,628 patients aged 2-18 years along with 11,156,148 clinical notes. We expect to complete the computable phenotyping within the first year of the project, followed by subtyping during the second and third years, and then will perform the focus groups and establish the user-centered design in the fourth and fifth years of the project. ConclusionsPediatric asthma subtypes incorporating RWD from diverse populations could improve patient outcomes by moving the field closer to precision pediatric asthma care. Our privacy-preserving federated learning methodology and qualitative implementation work will address several challenges of applying ML to large, multicenter RWD data. International Registered Report Identifier (IRRID)DERR1-10.2196/57981

The American Academy of Pediatrics calls for patient participation in medical encounters but data suggests that child involvement remains low. Providers play a major role in facilitating patient involvement; however, there is little research on youth involvement and factors hindering or facilitating participation in food allergy (FA) encounters. Allergy providers (N=162) completed an online survey through listserv and Facebook postings that assessed their practices and perspectives regarding inclusion of pediatric patients in FA visits based on child age. Providers also identified barriers and facilitators to including pediatric patients in medical encounters. One-way repeated-measures analyses of variance examined differences in provider practices and perspectives among three age groups. Provider report of their practices [F(1.48, 237.16)=239.93, p<.01] and their perspectives [F(1.34, 215.21)=275.40, p<.01] varied by child age such that providers were least likely to include younger patients and their involvement was rated as least important. Providers reported that barriers to including children in medical encounters were caregivers responding for the child (67.9%), it was more efficient to communicate with caregivers (66.7%), and that caregivers provide more accurate information (63.6%). Facilitators to including children in medical encounters were caregivers providing space for children to speak (84.1%), children wanting to be involved (84.6%), and asking questions directly to children (74.1%). FA providers are not uniformly including patients in medical encounters which is counter to pediatric guidelines and may lead to missed opportunities for patient-centered care. Educating caregivers on the importance of patient involvement may be helpful in overcoming barriers and facilitating pediatric patient involvement.