Objectives: We sought to examine associations between area-level socioeconomic deprivation and: (1) hospitalization length; (2) severity; and (3) clinical outcomes in adolescents hospitalized for atypical anorexia nervosa or anorexia nervosa (AN). We hypothesized that more socioeconomic deprivation would be associated with longer length of hospitalization, greater illness severity, and poorer clinical outcomes. Methods: We conducted a study of individuals aged 11-18 years with AN who were admitted for medical instability. Tract-level socioeconomic deprivation was characterized by using a deprivation index (range 0-1, higher scores indicating more deprivation). Outcomes of interest included (1) hospitalization length defined as duration in days between admission and discharge, (2) illness severity defined as percentage of goal weight at admission and global Eating Disorder Examination Questionnaire (EDE-Q) score and (3) clinical outcomes defined as re-admission rate, 3- and 6-month follow up percentage goal weight, and 3- and 6-month weight restoration status. We used multivariate regression to assess associations between deprivation index and outcomes of interest. Results: A total of 121 adolescents were included. The mean age was 15.4 years (range 11.0-17.9 years). Higher deprivation was associated with a lower percent of target goal weight achieved at 3-month follow up (Estimate= -19.8; p-value = 0.029; 95% CI= -37.5 to -2.1). Contrary to our initial hypothesis, higher deprivation index scores were associated with shorter hospitalization lengths (Estimate = -15.4; p < 0.001; 95% CI = -22.6 to -8.2). Conclusions: Higher deprivation was associated with a lower percent of target goal weight achieved at 3-month follow up and shorter length of hospitalization. This study adds to the extant literature by using a novel method, geocoding, to examine the relationship between socioeconomic deprivation and eating disorder outcomes. Future studies with more diverse samples (including Spanish speakers) are needed.

ABSTRACT:Self-report is the gold standard for assessing pain intensity, although the method of acquiring pain reports may influence the ratings obtained. Retrospective reports of pain intensity are often found to be elevated relative to daily diary reports, possibly due to recall bias and the influence of psychosocial factors on memory. In this study, we sought to examine differences between retrospective reporting of average pain intensity in the past week vs averaged daily diary reporting of pain intensity in a sample of adolescents with juvenile fibromyalgia (JFM). We also sought to determine the predictive effects of pain catastrophizing, functional disability, and depressive symptoms on discrepancies between retrospective and daily diary report. As part of a randomized controlled trial, 317 adolescents with JFM (Mage = 15.7, SD = 1.6, 88.4% female) completed daily diary and one-week retrospective pain intensity measures, the Children's Depression Inventory-2, Functional Disability Inventory, and Pain Catastrophizing Scale at baseline, post-treatment, and 3-month follow-up. We examined the predictive effects of psychosocial factors on mean differences between averaged daily and one-week retrospective reports of pain intensity. Retrospective reports of pain intensity were significantly higher than diary reports across time. A longitudinal multiple linear regression model showed that the magnitude of discrepancies between daily diary and retrospective reports was not significantly predicted by functional disability, depressive symptoms, or pain catastrophizing. These findings raise the possibility that other factors such as cognitive biases (eg, threat interpretation, saliency, recency bias) may play a larger role than psychosocial factors in explaining pain reporting discrepancies.

Migraine is one of the most common chronic health problems in children and adolescents, resulting in high levels of functional disability. Symptoms frequently persist into and impact the course of adulthood for affected individuals. Current practice recommendations include a combined therapy approach of preventive medication and cognitive behavioral therapy (CBT); however, no trials have systematically assessed whether a combined therapy approach is superior to a cognitive behavioral monotherapy intervention. The REACH (Responding With Evidence and Access for Childhood Headaches) trial will compare the impact of a CBT monotherapy to a combined treatment for prevention of migraine in youth, while addressing barriers to CBT access by utilizing a teletherapy approach. The study will include youth with migraine between the ages of 10 and 17 years from 15 sites across the United States, who will be randomly assigned to a CBT + pill (amitriptyline) group or CBT-alone group. Both groups will complete six sessions of telehealth CBT, as well as three booster sessions, over the course of 6 months. Participants will report on headache and migraine frequency and related disability via a daily headache diary before (28-day baseline), during, and after completion of the intervention (the last 28 days on the protocol). The CBT + pill group will also undergo a dose titration of clinically prescribed amitriptyline throughout the active treatment phase. Primary treatment outcomes are a ≥50% reduction in headache days and reduction in migraine-related disability (i.e., Pediatric Migraine Disability Assessment score ≤20). Findings of the REACH study may confirm current practice guidelines or provide evidence of comparable effectiveness of combined therapy and CBT monotherapy for prevention of migraine. This trial is designed to reinforce current guidelines for preventive headache management strategies in youth with migraine. The study will also advance knowledge by determining whether CBT alone, without the potential side effects of medication, is sufficient.

Objectives:For youth with gastrointestinal (GI) conditions, mental health symptoms can exacerbate GI symptoms. In a cyclical fashion, experiencing GI symptoms at school can contribute to depression, anxiety, and embarrassment. This study evaluated the impact of school instruction type on mental health and GI symptoms for youth with GI conditions during the COVID-19 pandemic.Method:Data were collected from caregivers and patients aged 8 to 17 years with inflammatory bowel disease, celiac disease, and irritable bowel syndrome (N = 146) from September to December 2020. Patients completed measures of depression, anxiety, anger, and GI symptoms; caregivers provided their child's school instruction type (online, hybrid, or in-person). Analyses were conducted to examine the relations of mental health symptoms, GI symptoms, and school instruction type.Results:Participants generally had mild levels of depressive symptoms (T = 55.50), and anxiety (T = 53.02) and anger (T = 49.92) symptoms were within normal limits. Anxiety and GI symptoms were positively related (b = 0.14, p < 0.01), and if participants were attending school online, they had worse GI symptoms (b = 0.46, p < 0.05). However, there was no significant interaction between anxiety and instruction type. Depression and anger were not significantly related to GI symptoms and there were no significant interactions.Conclusion:For children with GI conditions during the pandemic, as their anxiety symptoms increased, so did their GI symptoms. Further research should examine the long-term effects of virtual learning for those with GI conditions.

ABSTRACT:Juvenile fibromyalgia (JFM) is a complex and disabling chronic pain condition for which treatment options are limited. The objective of this randomized controlled trial was to compare the relative efficacy of 3 group-based interventions: cognitive-behavioral therapy (CBT) alone, graded aerobic exercise (GAE) alone, or CBT combined with specialized neuromuscular exercise (Fibromyalgia Integrative Training [FIT] Teens), in reducing pain-related disability for adolescents with JFM. Patients with JFM (ages 12-17) who experienced moderate-to-severe pain and pain-related disability were eligible. A total of 317 adolescents (86.4% girls, 84.2% White, mean age 15.8 years) were randomized to receive 8 weeks (16 sessions) of CBT (N = 110), GAE (N = 104), or FIT Teens (N = 103), followed by 4 booster sessions. Our primary hypothesis that the FIT Teens intervention would be superior to CBT or GAE was not supported. Rather, participants in all treatments showed significant reduction in disability with no differences between groups at the 3-month primary endpoint (main effect estimate = -3·94 [95% CI: -6·62 to -1·26]) and at 6-, 9-, and 12-month follow-up (main effect estimate = -4·52 [95% CI: -7·35 to -1·68]; -4·21 [95% CI: -7·13 to -1·29]; and -4·76 [95% CI: -7·84 to -1·68], respectively). Pain intensity was significantly improved at 9- and 12-month follow-up. Although the overall magnitude of improvement in disability was small, approximately 1 in 4 patients in the FIT and CBT groups had clinically remarkable improvement. Cognitive-behavioral and exercise-based treatments are promising for the management of JFM. Further research is needed to examine the characteristics of treatment responders and the mechanisms of improvement.

The present study examined the relationship between food insecurity (FI) and loss of control eating (LOC) in adolescents treated for cardiometabolic conditions, and inter-connections among week-to-week variations in receipt of SNAP benefits, FI, and LOC. Forty-one adolescents presenting to cardiometabolic clinics completed validated surveys of FI and LOC. A subset of 20 adolescents experiencing FI completed 4 weekly e-surveys, over 1 month. Overall, 56% reported public assistance, 39% reported FI, and 37% reported LOC. FI related to greater LOC (β = 0.17, p < 0.01). Among those with FI, receipt of SNAP related to greater within-person FI within the same week (β = 0.60, p < 0.05) but not the following week (β = -0.48, p = 0.20). FI related to greater LOC in the same week (β = 0.17, p < 0.001) and in the following week (β = 0.20, p < 0.001). In adolescents treated for cardiometabolic conditions, FI is prevalent and related to greater LOC. SNAP benefits might dampen FI week-to-week, but the effect of FI on LOC and cardiometabolic health should be explored causally.

Poor disease self-management is a significant issue in migraine in children and adolescents. Comprehensive treatment for migraine may include pharmacological, non-pharmacological, and biobehavioral interventions as well as engagement in healthy habits. With the annual cost of nonadherence in US health care exceeding $300 billion, self-management of chronic conditions is critical to reducing morbidity. Although barriers to self-management are amenable to behavioral intervention/CBT, many adolescents lack the self-management skills to overcome them on their own, and clinic-based self-management efforts have proven inadequate. Additionally, the reach of this treatment is restricted due to limited access (e.g., lack of available trained providers, distance between patient homes and treatment facility). We have addressed these accessibility issues by iteratively developing the first migraine-specific digital therapeutic self-management tool, Migraine Manager. We describe a randomized controlled clinical trial of Migraine Manager on headache frequency, health-related quality of life (HRQOL), and migraine-related disability in 160 adolescents with migraine compared to an attention control arm. We anticipate that participants in the Migraine Manager arm will demonstrate a statistically significant improvement in headache frequency, HRQOL, and migraine-related disability at post-treatment and 3-, 6-, 9-, and 12-month follow-up compared to participants in the attention control arm. If efficacious, Migraine Manager could have a significant impact on public health by providing greater access to evidence-based care in a large proportion of patients who otherwise would not receive treatment, thereby reducing health care disparities for families that have limited access to services and serving as a model for self-management intervention across pediatric populations.

OBJECTIVE:This preliminary study analyzed existing data from a larger study to characterize fatigue subtypes (general, cognitive, and sleep-related) across 14 days in adolescents with chronic musculoskeletal (MSK) pain and pain-free controls. A secondary exploratory aim was to determine whether fatigue subtypes were associated with next-day pain intensity, pain interference, sleep quality, or positive or negative affect. METHODS:Participants were 26 adolescents with chronic MSK pain and 26 pain-free controls matched on age and sex who completed a daily diary assessing fatigue subtypes, pain intensity, pain interference, sleep quality, and affect for 14 consecutive nights. Data were aggregated across all nights for between-group comparisons, and dynamic structural equation models were used to determine how fatigue subtypes were associated with pain, sleep, and affect from one day to the next. RESULTS:Averaging across 14 days, participants in the MSK group reported greater total fatigue and fatigue subtypes than participants in the control group (all p's < .001). Averaging across days, participants in the MSK group reported higher general fatigue than cognitive (p = .03) or sleep-related fatigue (p = .053). In the exploratory within-person analysis, previous day's cognitive fatigue (-0.10, p < .01) and general fatigue (-0.08, p < .01) were associated with worse next-day sleep quality in the MSK pain group. In the control group, cognitive fatigue was associated with greater next-day pain intensity (.04; p < .01) but lower next day pain interference (-0.03; p < .001). CONCLUSIONS:Results preliminarily suggest fatigue subtypes are prevalent and impactful in adolescents with chronic MSK pain. Future replication of results is needed.

Introduction: Long-glances away from the roadway-those that exceed 2 s-contribute significantly to driving risk among teen drivers with Attention Deficit/Hyperactivity Disorder (ADHD). In a randomized controlled trial, teen drivers with ADHD assigned to a driver training program (enhanced FOcused Concentration and Attention Learning; FOCAL +) to reduce long-glances away from the roadway demonstrated significantly reduced rates of long-glances and improved simulated driving performance up to 6-months post training compared to teens in a modified conventional driver's training curriculum (control). Additionally, FOCAL + reduced real-world crash risk by 40 % in the year following training. The present study investigates whether age, executive function, IQ, and clinical comorbidities moderated response to FOCAL + training. Method: This is a secondary analysis of the randomized control trial data. Differential response to FOCAL + training among the 152 teens with ADHD (M age = 17.4; 94 % male) randomly assigned to FOCAL + or control was assessed using generalized estimating equations examining the interaction between each moderator variable, randomized group assignment, and time. Outcome variables included count of long-glances and lane position variability assessed during driving simulation at baseline and 1-month and 6-months post-training, and rates of long-glances and crashes/near-crashes during 1-year of naturalistic driving. Results: Teens who were younger and had better executive functioning benefited most from FOCAL + training as evidenced by greater reductions in long-glances and lane variability during simulated driving. No baseline characteristic moderated FOCAL + impact on naturalistic driving outcomes. Conclusions: Baseline moderator variables did not predict naturalistic driving outcomes and, thus, the impact of the FOCAL + training is a broad based one with wide applicability. However, some moderator variables did predict simulator driving outcomes. Findings suggest that FOCAL + offered at a young age may maximize impact, and that booster sessions might be necessary to maintain training effects for teens with worse executive functioning.

Background Functional abdominal pain disorders (FAPD) are the most common chronic pain conditions of childhood and are made worse by co-occurring anxiety. Our research team found that the Aim to Decrease Pain and Anxiety Treatment (ADAPT), a six-session coping skills program using cognitive behavioral therapy strategies, was effective in improving pain-related symptoms and anxiety symptoms compared to standard care. In follow-up, this current randomized clinical trial (RCT) aims to test potential neural mechanisms underlying the effect of ADAPT. Specifically, this two-arm RCT will explore changes in amygdalar functional connectivity (primary outcome) following the ADAPT protocol during the water loading symptom provocation task (WL-SPT). Secondary (e.g., changes in regional cerebral blood flow via pulsed arterial spin labeling MRI) and exploratory (e.g., the association between the changes in functional connectivity and clinical symptoms) outcomes will also be investigated. Methods We will include patients ages 11 to 16 years presenting to outpatient pediatric gastroenterology care at a midwestern children’s hospital with a diagnosis of FAPD plus evidence of clinical anxiety based on a validated screening tool (the Generalized Anxiety Disorder-7 [GAD-7] measure). Eligible participants will undergo baseline neuroimaging involving the WL-SPT, and assessment of self-reported pain, anxiety, and additional symptoms, prior to being randomized to a six-week remotely delivered ADAPT program plus standard medical care or standard medical care alone (waitlist). Thereafter, subjects will complete a post assessment neuroimaging visit similar in nature to their first visit. Conclusions This small scale RCT aims to increase understanding of potential neural mechanisms of response to ADAPT. Trial registration ClinicalTrials.gov registration: NCT03518216.

Objective: Despite varying opinions, little research has examined how to best write pediatric neuropsychology reports. Method: This study gathered input from 230 parents on how text difficulty (reading level) and visual emphasis (bullets, underline, italics) affect report readability and utility. We focused on the most-read report section: summary/impressions. Each parent rated the readability and usefulness of a generic summary/impressions section written in four different styles. The four styles crossed text difficulty (high school-vs-collegiate) with use of visual emphasis (absent-vs-present). Results: Parents found versions with easier text to be more clearly written, easier to follow, and easier to find information (p<.001). Parents rated those with harder text to be overly detailed, complex, hard to understand, and hard to read (p<.001). Visual emphasis made it easier to find key information and the text easier to follow and understand - but primarily for versions that were written in difficult text (interaction p <=.026). After rating all four styles, parents picked their preference. They most often picked versions written in easier text with visual emphasis (p<.001). Conclusions: Findings support writing styles that use easier text difficulty and visual emphasis.

Objective: Examine patterns and predictors of skill learning during multisession Enhanced FOrward Concentration and Attention Learning (FOCAL+) training. Background: FOCAL+ teaches teens to reduce the duration of off-road glances using real-time error learning. In a randomized controlled trial, teens with ADHD received five sessions of FOCAL+ training and demonstrated significant reductions in extended glances (>2-s) away from the roadway (i.e., long-glances) and a 40% reduced risk of a crash/near-crash event. Teens' improvement in limiting long-glances as assessed after each FOCAL+ training session has not been examined. Method: Licensed teen (ages 16-19) drivers with ADHD (n = 152) were randomly assigned to five sessions of either FOCAL+ or modified standard driver training. Teens completed driving simulation assessments at baseline, after each training session, and 1 month and 6 months posttraining. Naturalistic driving was monitored for one year. Results: FOCAL+ training produced a 53% maximal reduction in long-glances during postsession simulated driving. The number of sessions needed to achieve maximum performance varied across participants. However, after five FOCAL+ training sessions, number of long-glances was comparable irrespective of when teens achieved their maximum performance. The magnitude of reduction in long-glances predicted levels of long-glances during simulated driving at 1 month and 6 months posttraining but not naturalistic driving outcomes. FOCAL+ training provided the most benefit during training to teens who were younger and had less driving experience. Conclusion: FOCAL+ training significantly reduces long-glances beginning at the 1st training session. Application Providing five FOCAL+ training sessions early on during teen driving may maximize benefit.

Background and ObjectivesThis cross-sectional observational study retrospectively examined clinical data collected from adolescents and young adults (AYAs) seeking care in a specialty headache clinic. We characterized participants' headache characteristics and psychological functioning and examined the association between self-reported anxiety and depressive symptoms and headache frequency, severity, and disability.MethodsDuring their clinic visit, AYAs (M age = 18.36; range = 14-32, 79.5% female) completed an intake questionnaire and reported about their headache characteristics (i.e., frequency, severity, and duration of symptoms in months), mental health history (i.e., previous diagnosis of an anxiety or depressive disorder), and utilization of emergency department (ED) services for migraine. AYAs also completed psychometrically validated screening tools for anxiety and depressive symptoms (i.e., the GAD-7 and PHQ-9). We computed descriptive statistics and examined associations among scores on psychological measures and headache characteristics, including migraine-related disability. We also tested whether individuals with clinically elevated GAD-7 and PHQ-9 scores had higher levels of disability relative to those with fewer/subclinical levels of anxiety and depressive symptoms.ResultsParticipants (N = 283) reported more than 19 headache days per month on average, with more than 90% describing their average headache intensity as moderate or severe. Nearly half of AYAs reported severe headache-related disability. Approximately one-quarter of AYAs reported a previous diagnosis anxiety or depressive disorder diagnosis, and more than one-third scored above clinical cutoffs on the PHQ-9 and GAD-7. Higher scores on both psychological screening instruments were associated with greater headache frequency. More than 10% of patients endorsed current suicidal ideation; this was not related to headache-related disability. Participants reported a high degree of ED utilization for headache; these rates were unrelated to endorsement of psychological comorbidities.DiscussionIn this sample of AYAs, headache characteristics were generally unrelated to scores on measures on psychological functioning. However, the observed rates of clinically elevated anxiety/depressive symptoms and suicidality in this sample of AYAs underscore the importance of screening for psychological comorbidities in neurology clinics that serve this age group, irrespective of self-reported disability. Results also emphasize the need to expand access to behavioral health services for AYAs with headache disorders and the importance of incorporating a biopsychosocial perspective to the transition of health care from pediatrics to adult neurology practice.