Child-level Outcomes Research Articles

A Digital Health Model for School-Based Implementation to Improve Parent and Child Outcomes: Comparison of Active Versus Light-Touch Coaching Effects.

Online or app-based parenting interventions have become more widely available in recent years. However, challenges related to poor engagement and high attrition have been noted in the literature, and there are important questions regarding ways to enhance parental engagement and improve treatment outcomes through digital health, including through the addition of therapeutic coaches. The current study evaluated differences in the effects of active versus "light-touch" coaching implementations of an enhanced version of Family Check-Up Online (FCU-O) on parent/family and child-level outcomes from pre-treatment to 2-month follow-up assessments. The enhanced version of the FCU-O was adapted to support families in coping with pandemic-related stressors to prevent youth behavioral and emotional problems during middle school and included app-based modules designed to support effective parenting practices as well as virtual coaching. In the "active-coach" condition, parenting coaches were active in efforts to arrange coaching sessions with parents as they worked through the app-based modules, while in the light-touch intervention, parent-coaches enrolled participants in the context of a one-time support session but did not actively pursue families to schedule additional sessions. Parents in the active-coach condition exhibited greater engagement with both the app and coaching sessions than parents in the light-touch condition. Further, stronger improvements in several aspects of parenting and child functioning were observed in the active-coach versus light-touch conditions. However, parents in the light-touch condition showed reductions in stress and comparable levels of dosage when using the app. Implications for prevention and accessibility of digital health interventions are discussed.

Scaling up healthy eating in early childhood education and care: evaluation of the Appetite to Play capacity-building intervention.

The purpose of this study was to examine the dissemination of the healthy eating component of Appetite to Play at scale using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. The Appetite to Play capacity-building intervention is a set of evidence-informed implementation strategies aimed at enhancing the adoption of recommended practices for promoting healthy eating and active play in early years settings. The evaluation was pragmatic, employing both quantitative (surveys) and qualitative (interviews) data collection. The Appetite to Play intervention was delivered through in-person community-based workshops, virtual workshops, asynchronous e-learning and online resources. We received completed surveys from 1670 in-person workshop participants (96 % female), and twenty-three (all female) survey respondents also participated in a telephone interview. Approximately two-thirds of all participant groups were certified early childhood educators. Results indicated that Appetite to Play had high reach (25 867 individual website visits, 195 workshops delivered), effectiveness (significant increases in care provider's knowledge, confidence (P < 0·05) and high post-intervention intention to implement), adoption (11 % of educators in BC trained) and implementation (good alignment with implementation strategies and current practices), with a significant maintenance plan to support the intervention's future success. An evidence-based capacity-building intervention with an emphasis on training and provision of practical online resources can improve early years providers' knowledge, confidence and intention to implement recommended practices that promote healthy eating. Further research is needed to determine the impact on child-level outcomes and how parents can be supported in contributing to positive food environments.

Supporting a Strong Start: Using Universal Vital Records to Understand the Service Needs of Newborns and their Families

The [Index] is a simple, yet innovative, tool that makes better use of data routinely collected at birth to summarize the assets that exist across and within communities. Comprising 12 health, family, and financial indicators available on standard birth records, the Index offers a strengths-based, cost-effective, holistic, valid, and meaningful characterization of the conditions into which newborns are born at both a state and local level. Given the strong, graded relationship between [Index] scores and the predicted probability of child protection involvement and death before age 5, the Index has become an important tool among policymakers to identify communities who should be prioritized for investment so that supports can be allocated more equitably and earlier in children’s lives. It also has provided an opportunity to develop a representative sample of children born into families with historically high service needs, but low engagement, to whom we would reach out directly to gather their perspectives of service experiences. This information will be augmented with administrative records as children age. This work will fill a major gap in information about the needs and experiences of the entire population of young children and families – not just those who engage in services – and the barriers, benefits, and challenges new parents may face in accessing the supports they need. This session will highlight the [Index], its relationship to child-level outcomes, how communities are using it to facilitate equitable investment, and, given international birth record standardization, how other jurisdictions might implement a similar tool.

Policy, Systems, and Environmental Strategies to Support Healthy Eating Behaviors in Early Childhood: A Scoping Review of Existing Evaluation Tools

BackgroundPolicy, systems, and environmental (PSE) change strategies aimed at supporting healthy eating behaviors work to enhance optimal nutrition by making healthy foods more available and accessible in the community. PSE change strategies can complement and strengthen knowledge, skills, and behaviors obtained through individual-level nutrition education. ObjectiveThis scoping review aimed to identify existing literature evaluating early childhood (ie, children younger than age 5 years) PSE change strategies supporting healthy eating behaviors and to describe the evaluation tools used to assess the identified PSE change strategies. MethodsThree databases (PubMed, Cumulated Index in Nursing and Allied Health Literature, and Web of Science) were used to systematically search for articles published between 2013 and 2023 written in English and conducted in the United States that evaluated PSE change strategies supporting healthy eating behaviors in young children (ie, children younger than age 5 years). Two study members conducted the review, discussing and reconciling discrepancies until a consensus was reached for interobserver reliability. ResultsFindings from this review identified 48 studies evaluating early childhood PSE change strategies supporting healthy eating behaviors, with 36 studies using 25 PSE-focused evaluation tools to evaluate these strategies. Most tools (80%) assessed PSE change strategies supporting access and availability of healthy food and beverage options in early childhood education settings. Studies did not evaluate child-level outcomes (ie, attitudes, preferences, and behaviors) to showcase improvement of early childhood nutrition. Only 60% of the tools reported evidence of validity or reliability. ConclusionsMost of the studies identified in this scoping review were aimed to evaluate healthy eating PSE change strategies focused on improving access to and availability of healthy foods and beverages in early childhood education settings. Future research is needed to develop and validate PSE-focused evaluation tools assessing child-level healthy eating practices and behaviors.

Move Well, Feel Good: Feasibility and acceptability of a school-based motor competence intervention to promote positive mental health.

In response to the adverse impacts of the COVID-19 lockdown measures Move Well, Feel Good (MWFG) was developed as a school intervention using improvement of motor competence as a mechanism for promoting positive mental health. Study objectives were to evaluate the feasibility and acceptability of MWFG and to describe changes in child-level outcomes. Five northwest England primary schools were recruited. MWFG was delivered over 10-weeks through physical education (PE) lessons, which were supplemented by optional class-time, break-time, and home activities. The intervention focused on development of 9-10 year-old children's motor competence in locomotor, object control, and stability skills, and psychosocial skills. Feasibility was evaluated against nine pre-defined criteria using surveys, interviews (teachers), and focus groups (children). Pre- and post-intervention assessments of motor competence, mental health, prosocial behaviour, wellbeing, and 24-hour movement behaviours were also completed. The five recruited schools represented 83% of the target number, 108 children consented (54% of target) with teachers recruited in all schools (100% of target). Intervention dose was reflected by 76% of the 45 scheduled PE lessons being delivered, and adherence was strong (>85% of children attending ≥75% of lessons). Positive indicators of acceptability were provided by 86% of children, 83% of PE teachers, and 90% of class teachers. Data collection methods were deemed acceptable by 91% of children and 80% of class teachers, and children spoke positively about participating in the data collection. Child-level outcome data collection was completed by 65%-97% of children, with a 3%-35% attrition rate at post-intervention, depending on measure. Favourable changes in motor competence (+13.7%), mental health difficulties (-8.8%), and prosocial behaviour (+7.6%) were observed. MWFG is an acceptable and feasible motor competence intervention to promote positive mental health. Content and delivery modifications could inform progression to a pilot trial with a more robust design.

Training and coaching early childhood teachers to foster social, emotional, and behavioral competence of children in Turkey.

A growing evidence base demonstrates the effectiveness of teacher training and coaching interventions to improve teacher- and child-level outcomes in high-income countries. However, more information is needed to show the benefits of these interventions in low- and middle-income countries (LMICs). To provide an evidence base for LMICs, we conducted a cluster-randomized controlled trial examining the efficacy of a teacher training and coaching intervention for promoting children's social, emotional, and behavioral competence, Reaching Educators and Children (REACH) Classroom Check-Up (CCU), on teachers' behaviors, teacher-child relationship quality, and children's social competence and problem behaviors. Participants included 20 early childhood teachers and 175 children (4-6 year olds) in Turkey. Findings indicate that REACH CCU increased teachers' positive behaviors and teacher behaviors that support social, emotional, and behavioral competence of children, while reducing teachers' negative behaviors. Teachers in REACH CCU demonstrated an increased level of closeness and reduced levels of conflict with children in their classrooms. Furthermore, REACH CCU improved teacher-reported social competence and reduced problem behaviors of children. Results provide evidence that REACH CCU is a promising approach for improving teachers' behaviors, teacher-child relationship quality, and children's social, emotional, and behavioral competence, especially in LMICs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Programs to Address Violence for Military Families: a Systematic Review

Abstract Purpose Family violence, encompassing intimate partner violence (IPV) and child maltreatment (CM), is a considerable public health issue affecting a large subset of the U.S. population. Military families may be exposed to unique risk factors for experiencing family violence. Interventions to address family violence that are specific to military and Veteran populations are critical to the military family wellbeing as they address the unique military context as well as military stressors. Though a number of these programs exist, to our knowledge, there has been no systematic effort to describe and evaluate these interventions. To address this issue, the present study employs systematic review methods to explore the following research questions: (1) What military family violence interventions are reported in the peer-reviewed literature? (2) What are the characteristics of these interventions? (3) How effective are these interventions? Methods This study utilized a systematic review following the PROSPERO (the International Prospective Register of Systematic Reviews) protocol, registration code CRD42022296207. Results The initial search returned 3,666 sources. From these, 15 sources evaluating thirteen military family violence interventions were identified. About half of the studies evaluated interventions for Veterans and/or their partners (n = 7), one study was for both Veterans and Active Duty service members and/or their partners, four were solely for Active Duty service members and/or their partners and families, two studies were for Veterans alone, and one study addressed a system-level intervention. Only three studies examined child-level outcomes. All studies reported positive intervention outcomes covering a variety of treatment modalities (i.e., group, couples, individual, online, in-person), which ranged from improved anger management skills, including reduced yelling, reductions in physical and psychological IPV, decreases in parenting practices that could potentially become violent, improvement in overall couples functioning, and increased relationship satisfaction. While all studies reported positive outcomes, their effect sizes ranged from small to large. Conclusion This study had three main findings: (1) The majority of interventions were for Veterans and/or their partners rather than active service personnel; (2) All interventions reported positive outcomes in the reduction of self-reported IPV, with the majority of these outcomes maintained over time; (3) While we intended to assess military family-level interventions that targeted IPV and CM, we only found three studies that targeted or included CM. Future research should explore how different treatment modalities (e.g., couples, individual, group, in-person, online) could affect long-term IPV treatment outcomes and should focus on how to best incorporate children, including documenting if there are children in the household, into IPV treatments/programs for military families.

Specialised Paediatric PAlliativE CaRe: Assessing family, healthcare professionals and health system outcomes in a multi-site context of various care settings: SPhAERA study protocol

BackgroundThe number of children and adolescents living with life-limiting conditions and potentially in need for specialised paediatric palliative care (SPPC) is rising. Ideally, a specialised multiprofessional team responds to the complex healthcare needs of children and their families. The questions of, how SPPC is beneficial, for whom, and under what circumstances, remain largely unanswered in the current literature. This study’s overall target is to evaluate the effectiveness of a SPPC programme in Switzerland with respect to its potential to improve patient-, family-, health professional-, and healthcare-related outcomes.MethodsThis comparative effectiveness study applies a quasi-experimental design exploring the effectiveness of SPPC as a complex intervention at one treatment site in comparison with routine care provided in a generalised PPC environment at three comparison sites. As the key goal of palliative care, quality of life - assessed at the level of the patient-, the family- and the healthcare professional - will be the main outcome of this comparative effectiveness research. Other clinical, service, and economic outcomes will include patient symptom severity and distress, parental grief processes, healthcare resource utilisation and costs, direct and indirect health-related expenditure, place of death, and introduction of SPPC. Data will be mainly collected through questionnaire surveys and chart analysis.DiscussionThe need for SPPC has been demonstrated through numerous epidemiological and observational studies. However, in a healthcare environment focused on curative treatment and struggling with limited resources, the lack of evidence contributes to a lack of acceptance and financing of SPPC which is a major barrier against its sustainability. This study will contribute to current knowledge by reporting individual and child level outcomes at the family level and by collecting detailed contextual information on healthcare provision. We hope that the results of this study can help guiding the expansion and sustainability of SPPC and improve the quality of care for children with life-limiting conditions and their families internationally.Trial registrationRegistered prospectively on ClinicalTrials.gov on January 22, 2020. NCT04236180Protocol versionAmendment 2, March 01, 2021.

Evaluation of Telehealth in Child Behavioral Health Services Delivery During the COVID-19 Pandemic.

The authors quantified the impact of the use of telehealth services on patient-level clinical outcomes among children with complex behavioral and emotional needs in Idaho during the COVID-19 pandemic by comparing data collected in 2020 with data for the same months in 2019. Longitudinal statewide data of Child and Adolescent Needs and Strengths (CANS) assessments were extracted from Idaho's mental and behavioral health system. Prepandemic assessments were matched to midpandemic assessments. A linear mixed-effect model was used to explore four child-level outcomes: psychosocial strengths-building rate, rate of need resolution within a life-functioning domain, rate of need resolution within a behavior-emotional domain, and rate of need resolution within a high-risk behaviors domain. The number of new patients admitted to Idaho's state-funded mental and behavioral health program decreased almost twofold from April-December 2019 to April-December 2020 (N=4,458 vs. 2,794). For most children with complex needs, the use of telehealth was as effective in terms of strengths building and needs resolution as in-person services; for children whose caregivers had issues with access to transportation, availability of telehealth services improved outcomes for the children. The COVID-19 pandemic in 2020 was associated with a dramatic drop in the number of children served by Idaho's mental health program. Telehealth may effectively bridge mental health service delivery while patients and providers work toward the resolution of transportation issues or may serve as a more acceptable permanent format of service delivery for some populations.

How can we measure the developmental impacts of the COVID-19 pandemic on young children?

Objectives • Present a conceptual data model for understanding the impacts of COVID on children 0-5 • Outline administrative datasets with relevant indicators that are commonly collected, integrated at the individual level, and include relevant 2-generation linkages • Provide specific considerations for research using the conceptual model ApproachThis session presents findings from a paper that was collaboratively generated by a workgroup of five integrated administrative data systems (IDS) in communities across the US with expansive data holdings in early education. Contributors have decades of experience in utilizing administrative data for social policy planning and analysis. We started with a thorough literature review, used a national survey data of IDS data holdings collected in 2020, and co-created a conceptual data model for administrative data reuse based upon current practices. Specific care was taken to include community-level changes and adult factors that serve as mediators for children’s outcomes. ResultsThe COVID-19 pandemic made its mark on the entire world, yet little is known about children, aged 0-5, whose lives have been exponentially affected. This conceptual data model presents five developmental resilience pathways (i.e. early learning, safe and nurturing families, health, housing, and financial/employment) that include direct and indirect influencers related to COVID-19 impacts, and the contexts and community supports that can affect child-level outcomes. We then overview commonly available administrative datasets with relevant indicators to be linked at the individual and household level, with discussion of data specific considerations (e.g. access, insufficiency, availability, quality, and linkage). The US response creates a natural experiment of policy and implementation decisions across boundaries, and while US-centric, this approach could be applied internationally. ConclusionThe development and use of IDS for research has great potential to inform solutions to our most pressing social problems. Cross-site research studies and maintaining sustainable capacities for long-term research is paramount to understanding the implications of response interventions and to study impacts on child development over time.

Mental Health Gap Action Programme intervention Guide (mhGAP-IG) for Child and Adolescent Mental Health in Low- and Middle-Income Countries (LMIC): A Systematic Review

BackgroundThe Mental Health Gap Action Programme (mhGAP) supports engagement of non-specialists in mental health services in Low- and Middle-Income countries. Given this aim, assessment of the effectiveness of approaches under its remit is warranted.AimsWe evaluated mhGAP approaches relating to child and adolescent mental health, focusing on provider / child outcomes, and barriers / facilitators of implementation.MethodsThirteen databases were searched for reviews and primary research on mhGAP roll out for child and adolescent mental health.ResultsTwelve studies were reviewed. Provider-level outcomes were restricted to knowledge gains, with limited evidence of other effects. Child-level outcomes included improved access to care, enhanced functioning and socio-emotional well-being. Organisational factors, clients and providers? attitudes and expectations, and transcultural considerations were barriers.ConclusionsFurther attention to the practical and methodological aspects of implementation of evaluation may improve the quality of evidence of the effectiveness of approaches under its remit.

Nature-Based Early Childhood Education and Children's Social, Emotional and Cognitive Development: A Mixed-Methods Systematic Review.

This systematic review synthesised evidence on associations between nature-based early childhood education (ECE) and children’s social, emotional, and cognitive development. A search of nine databases was concluded in August 2020. Studies were eligible if: (a) children (2–7 years) attended ECE, (b) ECE integrated nature, and (c) assessed child-level outcomes. Two reviewers independently screened full-text articles and assessed study quality. Synthesis included effect direction, thematic analysis, and results-based convergent synthesis. One thousand three hundred and seventy full-text articles were screened, and 36 (26 quantitative; 9 qualitative; 1 mixed-methods) studies were eligible. Quantitative outcomes were cognitive (n = 11), social and emotional (n = 13), nature connectedness (n = 9), and play (n = 10). Studies included controlled (n = 6)/uncontrolled (n = 6) before-after, and cross-sectional (n = 15) designs. Based on very low certainty of the evidence, there were positive associations between nature-based ECE and self-regulation, social skills, social and emotional development, nature relatedness, awareness of nature, and play interaction. Inconsistent associations were found for attention, attachment, initiative, environmentally responsible behaviour, and play disruption/disconnection. Qualitative studies (n = 10) noted that nature-based ECE afforded opportunities for play, socialising, and creativity. Nature-based ECE may improve some childhood development outcomes, however, high-quality experimental designs describing the dose and quality of nature are needed to explore the hypothesised pathways connecting nature-based ECE to childhood development (Systematic Review Registration: CRD42019152582).

Associations Between State Laws Governing Recess Policy with Children's Physical Activity and Health.

State-level laws governing recess policies vary widely across the United States. We characterize the presence of such laws and assess their associations with child-level outcomes. The presence of a state recess law was determined using the Classification of Laws Associated with School Students (CLASS) database. Parents of 6- to 11-year-old children reported physical activity, overall health, school absences, school-related problems, and ability to make/keep friends as part of the National Survey of Children's Health (NSCH). Logistic regression was used to compare outcomes in states with and without recess laws cross-sectionally in 2018 and between 2003 and 2011/2012 using a difference-in-differences analysis. In 2018, 20 states had a law recommending or requiring recess. Cross-sectionally, the odds of being physically active every day (odds ratio, 95% confidence interval: 2.8, 1.2-6.5) and having no difficulty making or keeping friends (2.9, 1.2-7.2) were significantly higher for children residing in states with versus without a recess law. There were no significant associations in the difference-in-differences model. Significant cross-sectional associations in 2018 were not confirmed by a difference-in-differences analysis of two waves of the NSCH. Short follow-up time and the apparent weakness of existing state laws warrant further assessment of state-level recess law.

Using a participatory method to test a strategy supporting the implementation of a state policy on screening children for adverse childhood experiences (ACEs) in a Federally Qualified Health Center system: a stepped-wedge cluster randomized trial

BackgroundAdverse childhood experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to violence. ACE screening is increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. To promote ACE screening uptake, the state of California issued the “ACEs Aware” policy that provides Medicaid reimbursement for ACE screening annually for child primary care visits. However, policy directives alone often do not translate into effective screening efforts and greater access to care. Few rigorous studies have developed and tested implementation strategies for ACE pediatric screening policies. This study will fill this gap by testing a multifaceted implementation strategy in partnership with a Federally Qualified Health Center (FQHC) system serving low-income families in Southern California to support the ACE Aware policy.MethodsWe will use Implementation Mapping, with study process and consideration of determinants and mechanisms guided by the EPIS framework, to co-create and refine an implementation strategy. The proposed strategy is comprised of online training videos, a customized algorithm and use of technology to improve workflow efficiency, implementation training to internal FQHC personnel, clinic support and coaching, and written implementation protocols. A hybrid type 2, stepped-wedge cluster randomized trial design with five primary care clinics will test whether a multifaceted implementation strategy improves (a) fidelity to the ACE screening protocol, (b) reach defined as the proportion of eligible children screened for ACEs, and (c) the impact of the ACE policy on child-level mental health referrals and symptom outcomes. The study will use mixed methods with data to include electronic health records, surveys, and interviews with clinic personnel and caregivers.DiscussionThis study is designed to increase the capacity of FQHCs’ inner context to successfully implement an outer context-initiated ACE policy designed to benefit pediatric patients. It capitalizes on a rare opportunity to use a co-creation approach to develop, adapt, refine, and pilot test an implementation strategy to maximize the impact of a new state-wide policy intended to improve ACE assessment and subsequent care to improve child health, particularly those from underserved communities.Trial registrationTrial # NCT04916587 registered at ClinicalTrials.gov on June 4, 2021.

Sand Play for 0–8-Year-Old Children’s Health and Development: A Systematic Review Protocol

Sand play may be a significant determinant of health and development in early childhood, but systematically synthesised evidence is absent in the literature. The main objective of this study was to present a planned methodology to systematically review, and synthesise, the evidence regarding sand play and its associations with 0–8-year-old children’s health and development. The systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement was registered to PROSPERO (CRD42021253852). Literature searches will be conducted using information from eight electronic databases. Studies will be included when participating children were aged 0–8 years, settings provided children with exposure to sand environments and/or materials, and child-level outcomes related to physical, cognitive, and/or social–emotional health and development. The search results will be imported to software; duplicates will be removed; and independent double screening, and study quality assessments using appropriate tools, will be conducted. Synthesis without meta-analysis will be conducted for quantitative studies similar in exposure, outcome, and content analysis to qualitative studies. Our overall confidence in each review finding will be assessed. The findings of this systematic review can inform policy makers and early childhood education teachers about the associations between sand play and children’s health and development, and its impact in practice.

An Initial Investigation of the CIRCLE Infant-Toddler Teacher Training for Toddler Teachers

ABSTRACT This pilot study conducted an initial evaluation of the Center for Improving the Readiness of Children for Learning and Education (CIRCLE) Infant-Toddler Teacher Training program. The program is unique in three ways: 1) use of an online platform with courses that explain social-emotional, language, and literacy development in young children (infants and toddlers) and teaching strategies to support development across these areas; 2) use of child progress monitoring measures (milestones checklists) to identify children who need additional support; and 3) use of remote coaching to support toddler teachers’ professional learning within the program. The purpose of the pilot study was to examine the impact of the CIRCLE Infant-Toddler Teacher Training on the quality of toddler teachers’ instruction and interactions with toddlers and toddlers’ language and social-emotional/behavioral skills. In this study, we utilized a randomized control design, with 38 toddler teachers and 229 toddlers (ages 24–36 months) participating in the pilot study. Research Findings: Findings suggested that toddler teachers who participated in the CIRCLE Infant-Toddler Teacher Training had improved interactions with toddlers. There were no main intervention effects on child-level outcomes. Practice or Policy: Taken together, these findings suggest that providing coaching-based professional development opportunities for toddler teachers may be an important way to improve early learning environments.

Addressing challenging behaviors in challenging environments: Findings from Ohio's early childhood mental health consultation system.

Early childhood mental health consultation (ECMHC) has been promoted by the federal government as a promising model for reducing early childhood expulsions and suspensions and is now implemented by numerous states. Despite growing ECMHC proliferation, this study is only the second randomized controlled trial of ECMHC, extending the methodologies of the first to include assessment of effects on random peers. Classrooms were assigned randomly to treatment or waitlist-control condition (n = 51 classrooms, 57 preschool teachers, and 190 preschoolers). Evaluation measures were collected at both pretreatment and posttreatment, following approximately six consultation visits. Classroom and teacher outcomes were evaluated with ordinary least squares regressions, while hierarchical linear modeling was used to evaluate child-level outcomes, accounting for the nested study design. Treatment children (both the target children who prompted the referral for ECMHC and random peers) evidenced significant improvements in social and emotional skills. Promising trend findings were noted for child behavior problem reduction and teacher pedagogical approach and locus of control. No significant effects were found on likelihood of expulsion and classroom mental health climate. This is the first ECMHC to demonstrate effects on nontarget peers in a rigorous randomized controlled trial. Programmatic and methodologic limitations and implications are discussed.

From policy to practice: Examining the role of recess in elementary school

ObjectivesTo examine the relationship between school recess policies, the quality of the recess environment and body mass index (BMI) among elementary school children. Study designObservational. MethodsData were collected at 23 schools across four geographically distinct regions of the United States. Measures included recess observations using the Great Recess Framework-Observational Tool (GRF-OT), recess policies were collected with the School Physical Activity and Policy Assessment, and BMI was obtained through height and weight measurements among 429 students in third and fifth grade. ResultsResults showed that school policies related to recess access significantly predicted children’s BMI, and school policies related to investment in recess significantly predicted recess quality as measured by the GRF-OT. ConclusionsResults from this study can be used to help inform future research regarding how school recess policies can impact child-level outcomes and the recess environment.

ADHD Symptoms do not Moderate Outcomes to Behavioral Parent Training Delivered in the Voluntary Sector

The purpose of the study was to determine the moderating role of baseline levels of attention-deficit/hyperactivity disorder symptoms on parent- and child-level outcomes following the Caring in Chaos behavioral parent training intervention at immediate post-intervention and follow-up assessment. One-hundred sixty-one children between the ages of 3–9 (Mean age = 7.6; 73% male) with parental concerns of attention-deficit/hyperactivity disorder were randomly assigned to the Caring in Chaos behavioral parent training intervention, a task-shifted intervention delivered by a volunteer workforce across 12 community-based settings in Denmark, or to a wait-list control condition. Parent report of parenting behavior, sense of competence, stress, depressive symptoms as well as child attention-deficit/hyperactivity disorder symptoms and child noncompliance were collected at baseline, immediate post-intervention and at follow-up assessment points. Analyses indicated no moderating effect of baseline attention-deficit/hyperactivity disorder symptoms on parent- and child-outcomes, with no to large effects at post-treatment with maintenance of effects at follow-up assessment. The results of these analyses suggest that the Caring in Chaos behavioral parent training intervention can be utilized with young children with varying levels of attention-deficit/hyperactivity disorder symptoms. These findings further support that community-based interventions delivered by nonprofessionals may serve as a beneficial option to increase availability and access to behavioral parent training for the treatment of attention-deficit/hyperactivity disorder.

Outcomes of a Community-Wide Health Intervention in a Low-Income, Primarily Hispanic Community: The Go! Austin/Vamos! Austin (GAVA) Initiative.

To describe outcomes of a 4-year physical activity (PA) and nutrition intervention (2013-2017) in Dove Springs, a low-income urban community in Texas. Go! Austin/Vamos! Austin is a place-based intervention targeting the built and social environments of PA and nutrition. Baseline and follow-up measures related to PA and nutrition were obtained from 357 parent-child dyads (final n = 236) in the intervention community and a control community. A three-level dose of exposure measure was created to indicate the amount of exposure to intervention activities across the 4 years. Pre-post changes in key outcomes by level of exposure and contrasts across "high exposure" and "no exposure" categories were obtained using repeated-measures regression, adjusting for important confounders. "High exposure" adult participants showed consistently more favorable changes than "no exposure" participants across a variety of indicators, including positive perceptions and utilization of community PA resources, amount of moderate PA, utilization of retail outlets offering fresh produce, and measures of healthy eating. Few improvements were seen in child-level outcomes. Community interventions can successfully improve health-promoting behaviors provided they ensure sufficient dose of exposure.