Research Projects
Current Projects
Application Digital Accessibility and Primary Care Teamwork to increase WIC Engagement: ADAPT- WIC
In Ohio, only 42% of eligible women and families participate in WIC, and only 34% of eligible children ages 1-4 receive WIC benefits. Our county’s WIC Outreach Committee has identified a lack of collaboration and buy-in from primary care offices as a critical barrier to improving WIC enrollment. There is a significant need for increasing WIC enrollment and outreach in Ohio, as evidenced by only 42% of eligible Ohioans enrolling (160,145 participants). There are currently inequities in access to application and enrollment materials, with forms only available in English and Spanish. Within the non-English speaking population in the CCHMC primary care clinics, 52% speak Spanish, 11% speak French, and 7% speak Arabic. Expanding non-English form options can increase the capture of WIC-eligible children living in households with a preferred language other than English or Spanish. Far too often, the WIC offices are unable to obtain the information needed to enroll families, and families face the administrative burden and difficulty of navigating the application and eligibility verification process. Funded by the USDA through FRAC, our team, led by pediatrician Dr. Chidiogo Anyigbo and clinical psychologist Dr. Cathy Stough, will establish a system for WIC referral and enrollment for English and non-English-speaking families. In collaboration between Cincinnati Children’s Hospital Medical Center, Hamilton County WIC, and University of Cincinnati, we will develop a system that facilitates communication between healthcare providers and WIC to support families in enrolling in WIC benefits will help reduce these demands for families. Additionally, we will develop standard operating procedures for WIC and primary care clinic collaborations that will be then piloted at offices in communities with the lowest WIC enrollment.
Reducing Health Disparities through an Adaptive Healthy Eating Program for Underserved Infants in a Home Visiting Program (1R21NR019126-01A1)
Obesity disproportionately affects youth from low-income or underrepresented racial and ethnic backgrounds. Youth who go on to develop severe obesity begin to deviate from their normal-weight peers in their growth trajectories by 4-6 months of age, making infancy and early childhood an ideal time for intervention. In collaboration with a home visiting program, Every Child Succeeds (ECS), and faculty from Cincinnati Children’s Hospital Medical Center, we will be developing an infant obesity prevention program, Healthy Eating for My Infant (HEMI). In order to create an intervention that is culturally and contextually relevant, meaningful, and useful for families, we will be working with families and the community to develop the intervention content. HEMI will target healthy eating among infants who are at risk for health disparities and obesity through behavioral and educational strategies. HEMI will consist of 6 adaptive home visit treatment sessions that promote problem-solving, healthy behaviors, readiness to change, goal setting, and self-monitoring. Families participating in HEMI are able to choose which treatment sessions they wish to receive based on their individual needs, and peer counselors will also be involved in delivery of sessions to help families utilizing their lived experience. We hope this intervention is the first step towards reducing obesity among at-risk youth by promoting development of healthy eating in infancy.
Current Student projects
Mealtime Challenges from the Perspectives of Adolescents with Anorexia Nervosa and Atypical Anorexia Nervosa and their Caregivers
Family mealtimes are a critical component in family-based therapy (FBT) for the treatment of restrictive eating disorders (EDs) like anorexia nervosa (AN) and atypical anorexia nervosa (AAN). During the initial phase of treatment, caregivers are allocated the management of adolescents’ meals; this shift in mealtime responsibilities can exacerbate mealtime stress, making mealtimes uniquely challenging and emotionally intense for FBT-enrolled families. However, little is known about the subjective experience of these challenges from adolescents with both AN and AAN and their caregivers. Therefore, in collaboration with psychologists Dr. Claire Aarnio-Peterson and Dr. Kristen Jastrowski-Mano, and under the mentorship of Dr. Stough, graduate student Francesca (Frenchy) St. Pe is exploring specific mealtime challenges, emotions elicited by these challenges, and differences in theme endorsement between diagnoses from joint meal debrief interviews through qualitative thematic and content analyses. Understanding mealtime challenges from the perspectives of both AN and AAN families enrolled in FBT can help providers understand additional support families may need to address challenges related to caregiver self-efficacy, disordered cognitions, and emotion regulation strategies.
Predictors of Treatment Responsiveness and Clinic Attendance Among Children with Early-Onset Severe Obesity in a Weight-Management Clinic
Severe obesity is a known health epidemic, with the prevalence of severe obesity in children being estimated to be around 3.8 to 5.4 million children. One subgroup of children with severe obesity that are known to be at particular risk to experience negative health and psychosocial outcomes are children with early-onset severe obesity (EOSO). EOSO refers to when children ≤ 5-years-old have a body mass index (BMI) that is at or above 120% of the 95th percentile or a BMI ³ 35 kg/m2 . Although research has demonstrated that weight management treatments for severe obesity have been successful, research has also identified that weight-management treatments are not a one-size fits all approach. Identification of factors associated with treatment responsiveness among children with severe obesity is particularly critical given children with severe obesity may be less responsive to current obesity treatments than their peers with moderate obesity. Additionally, retention to weight management treatment is a critical factor that can impact the success and outcomes of treatment, and there are many contextual factors that can impact retention and attendance to weight management treatment. Research has yet to explore factors associated with treatment responsiveness and treatment attendance within tertiary care EOSO weight management clinics. Therefore, in collaboration with endocrinologist, Dr. Nancy Crimmins, and under the mentorship of Dr. Stough, graduate student Taylor Gates is exploring what sociodemographic and contextual factors are associated with treatment responsiveness and treatment attendance in a tertiary care EOSO weight management clinic. Findings from this project may have clinical implications for identifying patients with EOSO in weight management clinics who are at-risk for poorer treatment responsiveness or attendance.
Development and Validation of a Measure to Assess Parent Anxiety about Complementary Feeding
Timely introduction of complementary foods (foods other than breastmilk or formula) is necessary for infants to meet growth targets, increase future diet variety, and reduce risk for feeding problems in childhood. Many parents experience anxiety about introducing complementary foods to their infant which can impact parent quality of life and proper nutrition for their infant. Currently, there is no way to measure parent anxiety about introducing complementary foods to their infant. Graduate student Isabella Pallotto is using a community-engaged approach to develop this measure in collaboration with Dr. Ashley Devonshire, a pediatric allergist, Dr. Adam Carle, a psychometrician, and under the mentorship of Dr. Cathy Stough. The development of this measure will allow pediatric primary care providers and allergists to screen parents for this type of anxiety and connect them to support networks.
Fear of Negative Evaluation among College Students during the COVID-19 Pandemic: The Role of Adverse Childhood Experiences and Anxiety Sensitivity in a Mediation Model
Fear of negative evaluation (FNE) can impact college students’ wellbeing. Despite the importance of FNE, little research has examined predictors of FNE in young adults. Graduate students Francesca St. Pe, Isabella Pallotto, and Jacquana Smith under the mentorship of Dr. Stough are currently exploring predictors of FNE, such as adverse childhood experiences and anxiety sensitivity, among college students during the COVID-19 pandemic.
Experiences of rejection partially mediate Adult Borderline Personality Disorder and adolescent Attention Deficit/Hyperactivity Disorder
Children with ADHD are more likely to be diagnosed with BPD in adulthood, and childhood ADHD symptom severity predicts adult BPD symptom severity. People with ADHD have a higher probability of experiencing rejection due to symptom-related difficulties in social functioning. This increased likelihood of experiencing rejection leads people with ADHD to develop rejection sensitivity at a faster rate, since increased exposure to rejection does not promote resilience. Encompassing some of the key attributes of borderline personality—fear of abandonment, affective instability, impaired interpersonal functioning—rejection sensitivity is experienced within BPD, however also exists independently outside of BPD pathology. ADHD symptom severity predicts later BPD symptom severity, and rejection sensitivity scales are significantly positively correlated with ADHD and BPD symptoms. Under the mentorship of Dr. Cathy Stough, research assistants Zack Streit and Taylor Gates are investigating the role of rejection sensitivity as a potential mediator between childhood ADHD and adult Borderline Personality Disorder (BPD).
Past Projects
The Healthy Start to Feeding (HSF) Intervention
Introduction of complementary foods (i.e., foods besides formula or breast milk) represents a major dietary milestone for infants, but guidelines for how parents should introduce solid foods to their infants are lacking. This is significant given that timing and manner of introduction of solid foods have implications for later obesity-risk throughout childhood, adolescence, and adulthood. Therefore, our team, including pediatrician Dr. Christopher Bolling and occupational therapist Dr. Krystin Turner, have developed an intervention to promote healthy and safe introduction of solid foods and weight gain among infants using a responsive feeding (RF) approach. This project is a collaboration between Cincinnati Children’s Hospital Medical Center, the University of Cincinnati, and Pediatric Associates PSC of Northern Kentucky. The HSF intervention consists of 3 treatment sessions that include education and training on topics such as infant hunger and satiety cues, self-feedings, safety, and healthy foods to introduce. If the HSF intervention is effective, it will reduce early obesity-risk, improve development of infant satiety cues, and increase infant preference for food variety. Given obesity is related to poor long-term health and psychosocial outcomes, financial burden, and reduced quality of life, an early life obesity prevention program could have a significant impact across multiple domains.
MedMentor
MedMentor is a community non-profit mentoring program for children with a serious health condition or chronic illness. The program matches children with an adult mentor who also lives with a chronic or serious health condition, oftentimes the same condition as the child. The program aims to support children and improve their quality of life. Our lab consults with MedMentor regarding assessment of program outcomes and appropriate research design.
Development and Functioning in Infants with High Weight-for-Length
Prior research has demonstrated that toddlers, preschoolers, school-aged children, and adolescents with obesity experience a range of current negative psychosocial outcomes (e.g., poorer quality of life, self-esteem, behavioral problems, social functioning, physical functioning). However, research has not identified whether infants with excess weight also experience current negative consequences, but research has already found that these infants are at increased risk for poorer long-term health outcomes. Understanding if there are immediate negative sequelae of excess weight in infancy is important because it may mean we need to treat this condition earlier, rather than waiting to see whether infant weight improves over time before intervening. Therefore, this study examined whether infants with high weight-for-length experienced delayed development in communication, gross motor skills, fine motor skills, problem solving, and personal/social functioning. Through a collaboration with Cincinnati Children’s Hospital Medical Center, we used a longitudinal design to examine whether infants with high weight-for-length at 6 months of age showed delayed developmental milestones at 9 and 18 months. This study utilized medical records from a primary care clinic that provides services for an ethnically diverse and predominantly lower income population including infants at greater risk for both obesity and developmental delays. Infant weight-for-length category at 6 months was not related to developmental outcomes at 9 or 18 months. This suggests that infants with high weight-for-lengths may not differ during infancy. Future research should examine when the impact of pediatric obesity on behavior and development begins.
Pediatric Patient Experience with Nonalcoholic Fatty Liver Disease
Similar to the rising obesity epidemic, nonalcoholic fatty liver disease (NAFLD) is also emerging as one of the most chronic liver diseases among children and adolescents. Currently, the most successful intervention for NAFLD is weight loss, however, this is a difficult challenge. Including families in these weight loss interventions, along with modifying the intervention to meet the needs of the family, has shown to be an effective way to help children and adolescents with NAFLD lose weight. However, minimal is known about the experiences of patients with this disease. We are collaborating with Cincinnati Children’s Hospital Medical Center psychologist Dr. Sanita Hunsaker to analyze qualitative data from focus groups to better understand the experience of patients with NAFLD. A series of focus groups were held for youth (12-18 years-old) living with NAFLD. Through these focus groups, were able to better understand the overall experience of living with NAFLD, including day-to-day life challenges, difficulties in treatment, and thoughts and suggestions on NAFLD care. We hope this study will improve the care of adolescents living with NAFLD.
Victimization and Bullying Among Youth Who Are Overweight or Obese
Children with overweight or obesity are at greater risk for being the victim of bullying than their normal-weight peers. Further, children that are bullied face many lifelong negative consequences such as behavior problems, depression, anxiety, maladaptive eating. Therefore, in collaboration with faculty in the School of Human Services at the University of Cincinnati (Dr. Laura Nabors and Dr. Ashley Merianos), our lab analyzed a national dataset, the National Survey of Children’s Health (2016), to examine bullying behaviors and victimization among children and adolescents with overweight and obesity. Further, we examined factors that may predict victimization among overweight/obese children, such as school engagement, neighborhood safety and support, family sharing, difficulty making friends, along with demographic factors (e.g., age, sex, race). We found that that youth who were overweight were more likely to be victimized, but not more likely to be a bully. We identified protective factors such as school engagement and neighborhood safety and risk factors such as difficulty making friends and living in a family where information was shared. This study shed light onto the individual, family, and contextual factors related to bullying and victimization among youth who were overweight.
Intuitive Eating Project
Traditional approaches to weight loss have shown to be largely ineffective. Therefore, research has begun to shift their attention to prevention efforts, with one technique being intuitive eating. Intuitive eating involves listening to your body’s own physiological cues when eating, rather than listening to your emotional or situational cues. Intuitive eating has been linked to lower BMI and healthier eating habits. Therefore, accurate assessment of intuitive eating may be important. Therefore, we explored the validity and psychometric properties of the Intuitive Eating Scale-2 for use among a predominantly low-income, African American sample in collaboration with faculty at Cincinnati Children’s Hospital Medical Center and Nationwide Children’s Hospital. Exploratory Factor Analysis (EFA) results showed that a six-factor, twenty-three item measure consisting of the following subscales was a better fit for our sample: Avoiding Forbidden Foods, Permission to Eat, Avoiding Emotional Eating, Avoiding Food-Related Coping Strategies, Reliance on Hunger and Satiety Cues, and Body-Food Choice Congruence. Therefore, using a modified IES-2 factor structure may be a better measure of intuitive eating in low-income Black populations.
Influences on Diet and Weight Gain in College Freshmen
Parent feeding practices are known to have a strong influence on child eating and obesity-risk during childhood and adolescence. Further, research has demonstrated that retrospective recall of parental feeding practices and family mealtimes during childhood is related to eating behavior and weight gain even into young adulthood. However, the examination of weight gain during the first-year of college and how it relates to early parent feeding practices has not yet been explored. In addition, research has led us to believe that other factors such as residential status (i.e., dorms versus commuters living with parents, or off-campus living without parents), depression, and/or adjustment could influence weight gain in college freshmen. Therefore, we explored potential factors that could contribute to weight gain during the first-year of college, with a specific emphasis on childhood feeding experiences. Results showed a trend between BMI at the beginning of college and participant recall of their parent’s level of concern about their weight in early childhood and the frequency of family dinners during early childhood. We also found a negative relationship between college adjustment and depressive symptoms. Understanding these relationships are important given the high rates of overweight and obesity among late adolescents and the fact that the transition to college is a period in which late adolescents may be at risk for gaining weight and mental health problems.
Past student projects
Predictors of Medication Adherence During the Transition to College
College can be a challenging time for many students, but can add unique challenges for students with a chronic medical condition (e.g., IBD, migraine, epilepsy, sickle cell disease) or psychiatric condition (e.g., anxiety, depression, ADHD). One of these unique challenges is medication adherence, or how well a student is able to take their medication as prescribed. Previous studies have explored individual factors associated with medication adherence in youth such as self-efficacy, healthcare transition responsibility, stress, and attitudes toward their illness. However, there is little known about how these individual factors collectively are associated with medication adherence during the college years. Therefore, in collaboration with psychologists Dr. Avani Modi and Dr. Kristen Jastrowski Mano, and under the mentorship of Dr. Stough, graduate student Angela Combs is exploring whether these individual factors are associated with medication adherence in a sample of undergraduate students at the University of Cincinnati with previously diagnosed chronic health or psychiatric conditions for her master’s thesis. Adherence will be measured using the Medication Event Monitoring System (MEMS): electronic caps that will be attached to study bottles that students will be instructed to dispense their medication from for 30 days. Students will complete surveys and be asked questions regarding their medical regimen before their 30-day medication monitoring begins. Understanding the individual factors that may be influencing medication adherence may offer valuable information to inform potential intervention strategies for young adults with a chronic health or psychiatric condition during their college career.
The Impact of Pediatric Disorders of Gut-Brain Interaction on the Family
Pediatric disorders of gut-brain interaction (DGBIs), formerly called functional gastrointestinal disorders (FGIDs), are a complex set of disorders accompanied by chronic and painful gastrointestinal (GI) symptoms (e.g., constipation, vomiting, nausea) that are considered to have a biopsychosocial basis. The unique challenges that accompany DGBIs (e.g., unclear diagnosis, intensive and expensive evaluations, stigmatization) can have a debilitating impact on caregivers and families. Identifying factors that can be modified to reduce the negative impact of the child’s illness on caregivers and families could have important treatment implications. Therefore, graduate student Katie Garr, in collaboration with psychologist Dr. Ashley Kroon Van Diest at Nationwide Children’s Hospital, and under the mentorship of Dr. Stough is examining how caregiver mental, child mental health, and child somatic symptoms influence the impact of the child’s illness on the family, including caregiver health-related quality of life and family functioning. The sample will consist of approximately 50 children with a DGBI diagnosis and their primary caregivers. This study is a multi-informant, cross-sectional design, where caregivers and youth complete questionnaires before their initial clinic appointment. Questionnaires assess a range of factors such as sociodemographic information, child and caregiver mental health, child somatic and GI symptoms, and the impact of the child’s illness on caregiver and family functioning. This study is warranted to better understand the influence of pediatric DGBIs on caregiver and family outcomes, which could be used to inform treatment efforts.
The Relationship between Psychopathic Traits and Aggression Styles in Children At-Risk for ADHD
Higher psychopathy ratings in childhood are predictive of Antisocial Personality Disorder, criminal behavior, and imprisonment. Psychopathy is comprised of 3 main dimensions: callous-unemotional (CU) traits (e.g., lack of remorse, guilt, empathy, and emotions), impulsivity (e.g., sensation-seeking and poor behavioral control), and narcissism (e.g., brags, shallow emotions). These three dimensions correlate with both proactive (behavior that anticipates a reward) and reactive aggression (aggressive response to provocation). However, there are conflicting findings concerning those relationships. Some studies have found both types of aggression are highly correlated with psychopathy ratings; other studies support that high psychopathy ratings are associated with proactive aggression only. Additionally, there are mixed findings regarding which of the 3 psychopathy dimensions are most associated with aggression subtypes. Attention-Deficit/Hyperactivity Disorder (ADHD) populations are of particular interest because they present with high rates of both proactive and reactive aggression, and are also at risk for criminal behavior and Antisocial Personality Disorder. Therefore, under the mentorship of Dr. Stough and in collaboration with Dr. Leanne Tamm and Dr. Stephen P. Becker, undergraduate research assistant, Veronica Mehl, is analyzing data from a previous study conducted at the Cincinnati Children’s Hospital Medical Center at the Center for ADHD. Veronica is examining the relationship between ratings of psychopathic traits and ratings of aggression style in a clinical sample of children at-risk for ADHD. Understanding the relationship between psychopathy and aggression in a high-risk sample of children could provide insight about appropriate treatment options for these children.
The Association Between Childhood Experiences, Anxiety Sensitivity, Fear of Negative Evaluation, and Social Avoidance
Prior research has examined anxiety sensitivity, fear of negative evaluation, social avoidance, and mood and anxiety disorders, but has yet to examine how anxiety sensitivity, fear of negative evaluation, and social avoidance relates to adverse childhood experiences. Therefore, under the mentorship of Dr. Cathy Stough and graduate student, Angela Combs, research assistant, Zoey Bass is examining the associations between past adverse childhood experiences and anxiety sensitivity, fear of negative evaluation, and social avoidance behaviors. Zoey is analyzing data from a previous Healthy Kids Lab study. The current study will allow us to better understand how these variables may exacerbate or maintain trauma symptoms following adverse childhood experiences among emerging adults.
The Relationship Between Locus of Control and Depressive Symptoms in Undergraduate Students During the COVID-19 Pandemic
Locus of control is a psychological construct that is designed to measure an individual’s perception of how much control they have over conditions in their lives. Those with an external locus of control tend to attribute their life outcomes to environmental circumstances, whereas those with an internal locus of control tend to attribute life outcomes to their own personal factors. Research findings indicate that individuals with an external locus of control have a greater risk of experiencing depression, especially in response to stressful life events. With the recent occurrence of the COVID-19 pandemic, many individuals were required by state-orders to quarantine and/or follow shelter-in-place procedures, which resulted in significant changes to one’s daily life. The predisposition of locus of control, in conjunction with the tendency of individuals with depression to have more negative responses to change and stressful life events, may influence an increase in depressive symptoms due to the COVID-19 pandemic. Additionally, because of the influence that personality traits have on behavior, an individual’s locus of control may impact perceived importance for taking recommended precautionary measures (e.g., social distancing, wearing a mask) during COVID-19. Therefore, under the mentorship of Dr. Stough, undergraduate research assistant, Julianne Origlio, is conducting a retrospective study to examine the relationships between locus of control, depressive symptoms, and precautionary behaviors in a college sample at the University of Cincinnati within the context of COVID-19. This data may provide insight into how personality traits influence an individual’s response to major life events and identify potential targets for clinical interventions for at-risk individuals.
The Relationship Between Maternal Internalizing Symptoms and Pediatric Obesity
Family factors (e.g., family environment, parental mental health) may play a critical role in the development of obesity and effective weight management treatment. Previous research has suggested that maternal psychopathology may influence child weight. Therefore, in collaboration with psychologists, Dr. Jessica Woo and Dr. Nany Crimmins, and under the mentorship of Dr. Stough, graduate student, Katie Garr, analyzed data from the Biorepository of Environment, Activity and Nutrition to Prevent Obesity-related Disorders (BEANPOD) study at Cincinnati Children’s Hospital Medical Center for her master’s thesis. The BEANPOD study investigated how the interaction of environment and genetics may increase the risk for obesity-related disorders. From this study, Katie examined the association between maternal depressive and anxiety symptoms on child weight (BMI percentile), child quality of life (health-related and obesity-specific), and maternal recognition and concern about child health and weight status in a sample of youth with obesity who were enrolled in a weight management program. We found that mothers with clinical-level symptoms of anxiety and depression had children with poorer quality of life and marginally higher BMI percentiles at baseline. These findings demonstrate the necessity for identifying and treating caregiver mental health symptoms, as it would likely improve child quality of life and weight management efforts.
The Association Between Mental Health, Adverse Childhood Experiences, and Drunkorexia
Prior research has thoroughly examined anxiety, depression, and adverse childhood experiences and their relationships with both alcohol use and disordered eating. However, research regarding these mental health disorders and adverse childhood experiences (ACEs) and how they are associated with the combination of both disordered eating behaviors and alcohol misuse is sparse. This dangerous combination of caloric restriction, binge drinking, and often times frequent exercising is known as Drunkorexia. Prior drunkorexia research has focused on the relationships of disordered eating, alcohol use, and physical activity, the role of emotion regulation and motivators in drunkorexia behaviors, and the demographics of those that engage in drunkorexia behaviors. Therefore, under the mentorship of Dr. Stough, while she was as an undergraduate research assistant, Taylor Gates, explored drunkorexia amongst a college sample, since research has shown that the college transition is often associated with social norms and pressures, particularly related to alcohol consumption in college. Understanding the possible association between drunkorexia behaviors and anxiety, depression, and ACEs may help future researchers better understand the possible predictors of drunkorexia behaviors. Overall study findings revealed that participants who experienced a greater number of ACEs and a greater number of internalizing symptoms such as depression and anxiety were more likely to engage in drunkorexia behaviors. In conclusion, evaluating and addressing college student’s mental health (e.g., depression and anxiety) and trauma history and providing access to mental health care may help prevent future drunkorexia behaviors from occurring in a college student population. This study identified the importance of understanding the role of trauma and mental health in the development and maintenance of drunkorexia behaviors.