A multi-modal lifestyle intervention program in routine clinical care for children with mental disorders.

Unhealthy lifestyle is frequently seen among children in the Netherlands. Most common forms of unhealthy lifestyle in this population include the consumption of a diet rich in saturated fats and sugar, inactivity, excessive gaming and distorted sleep patterns. Currently, there is a substantial evidence that unhealthy lifestyle is related to higher risk of various chronic disorders such as overweight, obesity, diabetes mellitus, cardiovascular diseases and sleeping problems. Unfortunately, unhealthy lifestyle and poor physical health are even more frequently seen among children with mental health illness such as autism, ADHD, depression and anxiety disorders. Research into lifestyle-related factors in children and their families in the Netherlands is increasing. However, children with mental health disorders are almost always excluded from these lifestyle programs because of the complexity of care in these often multi-problem families. Data of lifestyle interventions for children with mental health problems and their caregivers are therefore not available. Vice versa, treatment expertise of lifestyle factors in child mental health hospitals is lacking and meaningful psychological determinants of these intervention in this vulnerable group are unknown. As a result, there are currently no guidelines, treatment programs or equipped treatment centers where children with mental health problems and poor lifestyle quality can receive proper treatment. Our goal is to develop and implement a multi-modal lifestyle intervention program in routine clinical care for children with mental health disorders. This intervention involves family-based education of healthy lifestyle in combination with the following elements depending on which lifestyle factors need to be improved or a combination of treatment: (1) optimization of sleep based behavioral therapy by a sleep expert, (2) physical activation/sport activity supervised by a psychomotor therapist, (3) dietary treatment provided by a dietician following national guidelines for a healthy diet according to age and sex, and/or (4) restoration of a balanced use of 'screen time' according to age specific guidelines. To generalize healthy behavior in the family a home coach will be involved to visit the families at their homes, schools and sport clubs of the child to give education of healthy lifestyle. The home coach will also contact the family doctor and local coordinator of the municipality to maintain a healthy lifestyle. The primary objective of this study is to test the effectiveness of a multi-modal lifestyle intervention program in routine clinical care compared to care as usual (CAU) for children (6-12 years) with mental health problems in increasing their Quality of Life (QoL). Additional objectives are (1) to investigate the effectiveness of the program compared to CAU on mental health, (2) to investigate the effectiveness of the program compared to CAU on physical health, (3) to identify potential moderators and mediators of the response to the lifestyle program and (4) to assess cost-effectiveness of the lifestyle program for these specific children. This study uses a mixed method design combining a randomized controlled trial (RCT) with a qualitative study using a subsample. After intake, children will have a standardized medical examination to determine physical health. Furthermore, we will use a checklist assessing lifestyle items including unhealthy diet and eating habits, sleeping problems, inactivity, sedentary lifestyle and screen time use. Based on the results of the checklist and medical examination, children and their family will be referred to the multi-modal lifestyle intervention. To assess the added value of the intervention, children will be randomized in two groups: intervention and care as usual group. The effects on quality of life, health resource use and health parameters will be assessed after 3, 6 and 12 months. For the qualitative study, the study population consists of three groups: Children (6 to 12 year), caregivers, the team members of the multi-modal lifestyle intervention. Approximately 10 participants (each group) will be invited to participate in an individual semi-structured in-depth interview. The team members of the multi-modal lifestyle intervention will be interviewed to describe and evaluate the infrastructure and implementation processes, whereas the children and their caregivers will be asked about their expectations, experiences and knowledge on the lifestyle intervention. As the study aims to identify barriers and facilitators of its implementation we will triangulate both qualitative and quantitative methodologies by using an embedded mixed-methods methodology. The RCT will be embedded with qualitative interviews to evaluate the effectiveness the lifestyle intervention. The results will enable us to devise strategies for future implementation of lifestyle interventions for these vulnerable children and their families.