ISPAD Clinical Practice Consensus Guidelines 2018: Psychological care of children and adolescents with type 1 diabetes

Prevalence of diabetes distress and depression and their association with glycemic control in adolescents with type 1 diabetes in Dubai, United Arab Emirates

OBJECTIVE

Diabetes distress and depression have been shown to be prevalent among adolescents with type 1 diabetes and screening for these parameters should be a routine part of diabetes care. To assess the prevalence of diabetes distress and depression and their association with glycemic control in a sample of adolescents with type 1 diabetes attending a diabetes center in Dubai, United Arab Emirates. All adolescents aged 13 to 18 years with type 1 diabetes that were seeking treatment at the Dubai Diabetes Center from the period of September 1, 2018 to May 1, 2019. A total of 72 participants completed the study.

RESEARCH DESIGN AND METHODS

Adolescents were asked to fill in questionnaires assessing diabetes distress and depression. Multivariate linear regression analysis was used to assess the relationships between the subsets of socio-demographic and clinical characteristics, and the scores of the questionnaires.

RESULTS

The mean HbA1c of the study sample was 9.61% [82 mmol/mol] with higher levels found in females as compared with males (p<0.05). Females showed significantly greater levels of distress as compared with males. Although adolescents with HbA1c≥7.5% scored higher for diabetes distress and depression, the difference was not statistically significant to those with an HbA1c of <7.5%. Higher levels of diabetes distress were highly correlated with depressive symptoms, with distress and depression both being significant predictors of one another.

CONCLUSIONS

Our results highlight the importance of implementing and sustaining psycho-educational interventions to aid in alleviating diabetes distress and depression in this subgroup of the population.

Comprehensive psychosocial screening in a pediatric diabetes clinic

OBJECTIVE

The ISPAD recommends routine, comprehensive psychosocial screening for adolescents with diabetes. However, few clinics have implemented procedures consistent with these guidelines. This study describes the results of a universal, comprehensive psychosocial screening program in an integrated pediatric diabetes clinic located within an academic medical center.

RESEARCH DESIGN AND METHODS

Participants included 232 ethnically diverse adolescents with type 1 diabetes (55.5% female; M age = 14.85; 58.5% Hispanic; 20% Black). Adolescents completed screening measures on iPads in the waiting room before their medical visit. The proportion of adolescents screening positive on each psychosocial measure was assessed, and regression analyses evaluated how psychosocial variables accounted for variance in insulin non-adherence and glycemic control (measured by A1c).

RESULTS

Psychosocial concerns were common and ranged from 7% of adolescents screening positive for disordered eating and suicide risk to 52% screening positive for low motivation to manage diabetes. A1c and insulin non-adherence were positively correlated with suicide risk, depressive symptoms, anxiety, disordered eating, diabetes stress, blood glucose monitoring stress, family conflict, and total number of elevations, and negatively correlated with intrinsic motivation. Insulin non-adherence, disordered eating, diabetes stress, and family conflict uniquely predicted A1c. Age, motivation, and family conflict uniquely predicted insulin non-adherence. Eighty-three percent of eligible youth completed the screener. Referrals by physicians to the team psychologist increased by 25% after the screening program was implemented.

CONCLUSIONS

Comprehensive psychosocial screening can be effectively implemented as part of routine pediatric diabetes care and can identify adolescents in need of additional supports.

Integrated Behavioral Health in Pediatric Subspecialty Clinics

Millions of children and adolescents are living with a chronic condition. It is common for mental and behavioral health challenges to arise during their courses of illness. With the complexity of care needed, pediatric subspecialty providers have recognized the need to integrate behavioral health interventions into practice. Continued research in this area has allowed for focused behavioral interventions, particularly in diabetes and asthma. Adult congenital heart programs have adapted a similar model of care and have shown promising success in promotion of health. More established programs have been in existence for childhood cancer and cystic fibrosis.

The Synergistic Effects of a Complementary Physiotherapeutic Scheme in the Psychological and Nutritional Treatment in a Teenage Girl with Type 1 Diabetes Mellitus, Anxiety Disorder and Anorexia Nervosa

Type 1 diabetes mellitus (T1DM) is a chronic disease that can affect the physical and mental health of children and adolescents, often leading to anxiety disorders with chronic activation of the hypothalamic axis (HPA). Moreover, a great proportion of adolescents with T1DM also demonstrate anorexia nervosa (AN), due to the increased preoccupation with food and the need to have an acceptable body image. Herein is described the first case study of an adolescent patient diagnosed with T1DM, anxiety disorder (AD), and AN. A 14-year-old girl with T1DM since the age of 12 years presented weight loss at age 13 years and 3 months and low body mass index (BMI), which did not improve despite dietary recommendations and adequate disease control. Additionally, she presented menstrual disorders at the age of 12 years and 11 months (menstrual age 12 years and 1 month). A psychological evaluation of the teenager was conducted using a semi-structured interview that assessed perceived stress, health status, quality of life, and depression. AD and AN were diagnosed and the patient initiated an intervention focusing on psychological health and nutrition and which incorporated physiotherapeutic relaxation sessions and breathing exercises. After 3 months of treatment, the patient’s BMI was increased, and a normal menstrual cycle was apparent. These results have since remained consistent. Stress leads to the appearance of AN and menstrual disorders. Therefore, physiotherapeutic programs could reduce stress and effectively ameliorate AN and AD.

Disordered Eating Behaviors Among Italian Adolescents with Type 1 Diabetes: Exploring Relationships with Parents' Eating Disorder Symptoms, Externalizing and Internalizing Behaviors, and Body Image Problems

The purpose of this study is to examine associations of disordered eating behaviors (DEBs) with body image problems, parents' eating disorder symptoms, and emotional and behavioral problems among adolescents with type 1 diabetes (T1D). 200 adolescents (M age = 15.24 ± 1.45 years) with T1D completed a self-report measure of DEBs and body ideal internalization, and their parents completed self-report measures of parents' eating problems and child's psychological symptoms. Seventy-three (36.5%) adolescents were DEPS-r-positive (scores ≥ 20), with higher rates among girls (χ² = 9.034, p = .003). Adolescents with T1D and DEBs reported lower SES, worse metabolic control, higher zBMI (p < .001), more eating disorder symptoms, more body image problems, and more emotional and behavioral problems than adolescents with T1D but no DEBs (all p < .05). Parents of adolescents with DEBs showed higher levels of bulimia (p = .028) than parents of adolescents without DEBs. In both genders, pressure to conform to societal norms about body image (p < .01) and externalization symptoms (p < .05) emerged as significant predictors of DEBs. Findings suggest that adolescents with T1D and DEBs showed an alarming psychological condition, with higher level of body image and more emotional and behavioral problems.

The Role of Trust in the Care of Young Children with Type 1 Diabetes

Using the theoretical framework of Guido Möllering conceptualising trust as a mental process composed of three elements—expectation, interpretation and suspension—we examined the role of trust in relation to young children’s (age ≤ 7 years) psychosocial needs when diagnosed with type 1 diabetes. Based on qualitative interviews with health care professionals (HPCs) from paediatric diabetes clinics in all regions of Denmark, we identified four main themes: trust through meaningful interaction, trust as a key factor at the time of diagnosis, trust in a long-term perspective and caregivers as the bridge to trust. We conclude that trust between young children and HCPs is central to children’s psychosocial experience, as well as a primary need, when children are diagnosed with type 1 diabetes. Trusting relationships counteract children’s experience of fear, anxiety and needle phobia and reinforce HCPs’ experience of providing good psychosocial as well as medical care. The present study offers insights into how trust can positively affect young children’s experience of diagnosis. This study also points out some key barriers to and facilitators of creating trusting relationships. This research is a first step towards a greater understanding that can inform collective future guidelines on the psychosocial care of young children.

Validation Study and Outcomes of the Diabetes Quality of Life in Youth Instrument in Haitian Youth With Type 1 Diabetes Residing in Haiti

OBJECTIVES

Health-related quality of life (HRQL) in type 1 diabetes is a critical health outcome but has not been studied in many low-income countries. In this study we evaluated the validity of 2 HRQL instruments, measured the HRQL and explored the association between HRQL and glycemic control.

METHODS

This was a cross-sectional study of Haitian youth with diabetes between 0 and 25 years of age and living in Haiti. We administered the 51-item Diabetes Quality of Life in Youth (DQOLY) questionnaire and the EuroQol Visual Analogue Scale (EQ-VAS). Psychometric analyses evaluated internal consistency and construct validity of the DQOLY and its 21-item short form, the DQOLY-SF. Linear regression was used to identify predictors of HRQL and glycated hemoglobin (A1C).

RESULTS

In 85 youth (59% female; mean age, 17.5 years; mean diabetes duration, 3.7 years; mean A1C, 11.3%), DQOLY and DQOLY-SF had adequate internal consistency with Cronbach's alpha values of 0.86 and 0.84, respectively. Confirmatory factor analysis revealed adequate validity for the DQOLY-SF and DQOLY Satisfaction subscale. HRQL, as measured using the DQOLY-SF, was 62±16 (mean ± standard deviation) out of 100. Mean EQ-VAS score was 78±24 out of 100. Older age (p=0.004), female sex (p=0.02) and lower socioeconomic status (SES) (p=0.03) were risk factors for lower DQOLY score, and older age (p=0.02) and marginally female sex (p=0.06) for lower DQOLY-SF score. No predictors of EQ-VAS were identified. HRQL measures were not associated with glycemic control.

CONCLUSIONS

The DQOLY-SF and DQOLY Satisfaction subscale are valid measures of HRQL in Haitian youth with diabetes. HRQL is low and was worse in older, female and low-SES youth, but was not associated with glycemic control.

Coeliac disease is associated with depression in children and young adults with type 1 diabetes: results from a multicentre diabetes registry

AIMS

To analyse the association between coeliac disease (CD) and depression in children, adolescents, and young adults with type 1 diabetes (T1D).

METHODS

We included 79,067 T1D patients aged 6-20 years, with at least six months of diabetes duration, and treatment data between 1995 and 2019 were documented in the diabetes patient follow-up registry. We categorized patients into four groups: T1D only (n = 73,699), T1 + CD (n = 3379), T1D + depression (n = 1877), or T1D + CD + depression (n = 112).

RESULTS

CD and depression were significantly associated (adjusted OR: 1.25 [1.03-1.53]). Females were more frequent in both the depression and the CD group compared with the T1D only group. Insulin pumps were used more frequently in T1D + CD and T1D + depression compared with T1D only (both p < .001). HbA1c was higher in T1D + depression (9.0% [8.9-9.0]), T1D + CD + depression (8.9% [8.6-9.2]), both compared with T1D only (8.2% [8.2-8.2], all p < .001). We found comorbid autism, attention deficit hyperactivity disorder, anxiety, schizophrenia, and eating disorders more frequently in the T1D + CD + depression group compared with T1D only (all p < .001).

CONCLUSIONS

CD and depression are associated in young T1D patients. The double load of T1D and CD may lead to an increased risk for depression. Depression was associated with additional psychological and neurological comorbidities. Aside from imperative CD screening after T1D diagnosis and regular intervals, depression screening might be helpful in routine care, especially in patients with diagnosed CD.

Executive function mediates the link between externalizing behavior and HbA1c in children and adolescents with type 1 diabetes: A cross-national investigation

OBJECTIVE

Externalizing behavior (i.e., conduct problems, hyperactivity) and executive function (EF) problems in children and adolescents with type 1 diabetes (T1D) have been associated with worse diabetes-related and psychosocial outcomes but have not been examined in relationship to each other. We aimed to examine whether externalizing behavior is associated with HbA1c and whether this relationship is mediated by EF problems, specifically metacognition (i.e., ability to initiate, plan, organize and monitor behavior) and behavioral regulation (i.e., impulse control, regulation of emotion and behavior).

RESEARCH DESIGN AND METHODS

Cohorts of Belgian and Dutch parents of children and adolescents (6-18 years) with T1D filled out questionnaires on externalizing behavior (Strengths and Difficulties Questionnaire; SDQ) and EF (Behavior Rating Inventory of Executive Function; BRIEF) composite scales. Treating physicians collected HbA1c values. Mediation analyses were performed separately for the BRIEF composite Metacognition and Behavior Regulation scales, correcting for age, sex and diabetes duration.

RESULTS

The 335 parents of children and adolescents with T1D (mean age 12.3 ± 2.8 SD; mean HbA1c 7.6% ± 1.1 SD [60 mmol/mol ± 12.0 SD]; mean diabetes duration 5.3 ± 3.6 SD; 49.6% female) participated. Analyses showed that the association between externalizing behavior and HbA1c is mediated by metacognition (ab path Point estimate = 0.05 BCa CI 95% 0.02-0.08), and not behavioral regulation.

CONCLUSIONS

Results uncovered the influence externalizing behavior may have on EF problems in the metacognition domain, which in turn seem to influence HbA1c. Clinicians should be mindful of these EF problems when working with children and adolescents displaying externalizing behavior, and not only target behavioral but also cognitive processes.

Worse glycemic control, higher rates of diabetic ketoacidosis, and more hospitalizations in children, adolescents, and young adults with type 1 diabetes and anxiety disorders

The aim of the study was to explore the metabolic characteristics and outcome parameters in youth with type 1 diabetes and anxiety disorders. HbA1c levels, rates of severe hypoglycemia, diabetic ketoacidosis (DKA), and hospital admission in children, adolescents, and young adults with type 1 diabetes and an anxiety disorder from 431 diabetes-care-centers participating in the nationwide German/Austrian/Swiss/Luxembourgian diabetes survey DPV were analyzed and compared with youth without anxiety disorders. Children, adolescents, and young adults with type 1 diabetes and anxiety disorders (n = 1325) had significantly higher HbA1c (8.5% vs. 8.2%), higher rates of DKA (4.2 vs. 2.5 per 100 patient-years), and higher hospital admission rates (63.6 vs. 40.0 per 100 patient-years) than youth without anxiety disorders (all p < 0.001). Rates of severe hypoglycemia did not differ. Individuals with anxiety disorders other than needle phobia (n = 771) had higher rates of DKA compared to those without anxiety disorders (4.2 vs. 2.5 per 100 patient-years, p = 0.003) whereas the rate of DKA in individuals with needle phobia (n = 555) was not significantly different compared to those without anxiety disorders. Children, adolescents, and young adults with anxiety disorders other than needle phobia had higher hospitalization rates (73.7 vs. 51.4 per 100 patient-years) and more inpatient days (13.2 vs. 10.1 days) compared to those with needle phobia (all p < 0.001). Children, adolescents, and young adults with type 1 diabetes and anxiety disorders had worse glycemic control, higher rates of DKA, and more hospitalizations compared to those without anxiety disorders. Because of the considerable consequences, clinicians should screen for comorbid anxiety disorders in youth with type 1 diabetes.

Finnish diabetes-related quality of life questionnaire for children and adolescents: Reliability and validity

AIM

To study the psychometric properties, reliability and validity of the FinDiab quality-of-life questionnaire (FDQL), a strength-oriented quality-of-life (QOL) questionnaire for children and adolescents with type 1 diabetes (T1D).

METHODS

Participants were 215 youths with T1D (aged 10-17 years). They completed FDQL and comparison questionnaires (KINDL-R and SDQ). Demographic and disease measures were collected from the participants' medical records. The questionnaire's psychometric properties were investigated. Construct validity was studied through principal component analysis using Promax rotation, reliability with alphas, and criterion and convergent validity with correlations between sum scale, subscales, demographic and disease factors, and comparison measures.

RESULTS

FDQL demonstrated an adequate range of measurement and feasibility. The four-factor solution was found to be optimal, resulting in the subscales of flexibility with diabetes, well-being, social relations and health behaviour. The sum scale correlated significantly with glycaemic control and the psychosocial and QOL comparison measures. Construct, criterion and convergent validity of the subscales was also good. Children under 14 years of age reported better QOL than older adolescents.

CONCLUSION

FDQL is a practical QOL assessment method focusing on strengths. The questionnaire has good validity and reliability and is easy to use as a clinical tool.

Effects of the Information-Motivation-Behavioral Skills Model on Metabolic Control of Adolescents with Type 1 Diabetes in Turkey: Randomized Controlled Study

PURPOSE

To evaluate the effects of information-motivation-behavioral skills model interventions given by nurses during home visits on the knowledge levels, personal and social motivation levels, behavioral skills, and HbA1C levels of adolescents with poor glycemic control.

DESIGN AND METHODS

The present study was designed as randomized controlled trial. 50 adolescents with type 1 diabetes were equally divided into study and control groups. Socio-Demographic Form, Diabetes Information Evaluation Form, The Child Attitude Toward Illness Scale, The Multidimensional Scale of Perceived Social Support, and Diabetes Management Self-Efficacy Scale were utilized in data collection. The scales were administered at the beginning of the study and six months later. HbA1c levels of adolescents were evaluated in the third and sixth months. Multiple home visits and phone calls were made to each participant in the intervention group. Interventions to improve the information-motivation-behavioral skills model-based knowledge, personal and social motivation, and behavioral skills were applied during the home visits.

RESULTS

As a result of information-motivation-behavioral skills model-based interventions, knowledge levels (p<0.001), personal motivation levels (p = 0.001), social motivation levels (p = 0.004), and behavioral skills (p<0.001) of the study group improved. Additionally, HbA1c levels decreased significantly in the third (p<0.001) and sixth months (p<0.001).

CONCLUSION

Information-Motivation-Behavioral Skills Model-based intervention effectively improved glycemic control among adolescents with type 1 diabetes.

PRACTICE IMPLICATIONS

Nurses should develop strategies to increase personal motivation, social motivation, and behavioral skills to training programs planned for adolescents with type 1 diabetes.

Mentalizing in mothers and children with type 1 diabetes

Studies suggest that the relationship between psychosocial well-being and type 1 diabetes (T1D) is bidirectional, with T1D typically having a negative influence on psychological functioning, which in turn negatively affects the course of T1D. Here, we investigate the potential role of the capacity for mentalizing, or reflective functioning, in children and their mothers in diabetes control. We tested differences in mentalizing as assessed by the Reflective Functioning Scale in two groups of mother-son dyads with good (GDC) versus poor (PDC) diabetes control. Fifty-five boys (8-12 years old) and their mothers were recruited from the Juvenile Diabetes Foundation in Santiago, Chile. The mothers were interviewed with the Parental Development Interview and the children with the Child Attachment Interview, and both were scored for reflective functioning by using the Reflective Functioning Scale. Self-report measures of stress and diabetes outcomes were completed by the mothers and children, and levels of glycated hemoglobin (HbA1c) were assessed as an index of diabetes control. The results showed that both maternal and child reflective functioning were higher in the GDC than the PDC group and were negatively correlated with HbA1c in the total sample. Our findings suggest an important role for mentalizing in diabetes outcomes, but further prospective research is needed.

Diabetes distress in Indian children with type 1 diabetes mellitus and their mothers

BACKGROUND

Children and their mothers, who are usually the primary caregivers, are likely to be distressed due to type 1 diabetes (T1DM).

OBJECTIVES

(1) To assess diabetes-specific distress (DD) perceived by children and adolescents with T1DM and their mothers and association of distress between children and mothers. (2) To study the association of diabetes distress with glycemic control and disease duration.

SUBJECTS

Children and adolescents with T1DM over eight years and their mothers.

METHODS

Clinical data were recorded. DD was assessed by Problem Associated in Diabetes-Pediatric (PAID-Peds) (range 0-80) and Problem Associated in Diabetes-Parents Revised (PAID-PR) (range 0-72) questionnaires (higher scores indicate higher distress); administered to children and mothers, respectively. Sub-dimensions in questionnaires included diabetes-related emotional problems, and treatment-, food-, and social support-related problems. Correlation analysis (Spearman's) was performed, and a paired t-test was used to compare PAID-Peds and PAID-PR (SPSS 25).

RESULTS

Mean PAID-Peds and PAID-PR scores in 67 children and mothers were 24.4 ± 18.1 and 31.9 ± 21.5, respectively (p=0.009), and a significant correlation was noted between their scores (R=0.45, p=0.001). PAID-Peds score was positively associated with HbA1c (R=0.25, p=0.04). Diabetes-related emotional problems of mothers and children (R=0.38, p=0.003), treatment problems (R=0.5, p=0.001), and food problems (R=0.24, p=0.05) correlated positively. Subdimension scores were significantly different in children and mothers except in the social support domain.

CONCLUSION

DD was higher in mothers than children; higher distress in children was associated with poor metabolic control. Evaluation of DD needs to be performed in children with T1DM.

A mobile app identifies momentary psychosocial and contextual factors related to mealtime self-management in adolescents with type 1 diabetes

Effective diabetes problem solving requires identification of risk factors for inadequate mealtime self-management. Ecological momentary assessment was used to enhance identification of factors hypothesized to impact self-management. Adolescents with type 1 diabetes participated in a feasibility trial for a mobile app called MyDay. Meals, mealtime insulin, self-monitored blood glucose, and psychosocial and contextual data were obtained for 30 days. Using 1472 assessments, mixed-effects between-subjects analyses showed that social context, location, and mealtime were associated with missed self-monitored blood glucose. Stress, energy, mood, and fatigue were associated with missed insulin. Within-subjects analyses indicated that all factors were associated with both self-management tasks. Intraclass correlations showed within-subjects accounted for the majority of variance. The ecological momentary assessment method provided specific targets for improving self-management problem solving, phenotyping, or integration within just-in-time adaptive interventions.

Multisite Examination of Depression Screening Scores and Correlates Among Adolescents and Young Adults With Type 2 Diabetes

OBJECTIVES

Our aim was to evaluate self-reported depressive symptoms and clinical outcomes during routine screening for adolescents and young adults with type 2 diabetes (T2D), and examine associations among depressive symptoms and demographic and clinical characteristics.

METHODS

The Patient Health Questionnaire (PHQ) was administered to 197 adolescents and young adults with T2D using the PHQ-2 or PHQ-9 in routine pediatric diabetes care at 4 academic medical centres. Data from electronic health records were extracted from the screening date and 12 months earlier.

RESULTS

Adolescents and young adults with T2D (mean age, 16.85 years; 57% male; 77.2% non-Caucasian) completed the PHQ as part of routine diabetes care. On the PHQ, 19.3% of adolescents and young adults endorsed elevated depressive symptoms (PHQ score ≥10) and, among a subsample with item-level data (n=53), 18.9% endorsed thoughts of self-harm. Subsequently, 50.0% of those with depressive symptoms had a documented referral for mental health treatment in the electronic health record after the positive screening outcome. Older age, shorter diabetes duration, higher glycated hemoglobin level, being non-Hispanic white, more blood glucose checks per day and being prescribed oral medications were significantly associated with more depressive symptoms.

CONCLUSIONS

Screening for depressive symptoms identifies individuals in need of referral for mental health treatment. A focus on self-harm assessment, standardized methods for documentation of symptoms and mental health referrals and increased referral resources are needed.

Type 1 diabetes mellitus in children: experience in Indonesia

The prevalence of type 1 diabetes mellitus (T1DM) in children in Indonesia is increasing although the real number is unknown due to high rate of misdiagnosis. Public and healthcare awareness on T1DM in children is still low, reflected by the high number of children diagnosed with diabetic ketoacidosis (DKA). The Indonesian Pediatric Society (IPS) had published a guideline on T1DM management, which consists of insulin injection, daily monitoring of blood glucose, nutrition, physical activity, and education. Aside from low awareness, current challenges on T1DM management in Indonesia are funding by the national health insurance, fasting during Ramadan, and inequities on DM care. The involvement of society, healthcare workers, stakeholders, and the government is of importance to ensure optimal management for children with diabetes.

Youth and Parent Health-Related Quality of Life and Association With Glycemic Outcomes in Preadolescents and Adolescents With Type 1 Diabetes

INTRODUCTION

We explored differences in Health-Related Quality of Life (HRQOL) and the youth's glycosylated hemoglobin (A1c) of preadolescent and adolescent youths with type 1 diabetes (T1D) by individual (age, sex, race) and family (socioeconomic status) factors, and associations between youths' HRQOL, their parents' HRQOL, and youth's A1c.

METHOD

Correlational secondary analysis of baseline data from a randomized controlled trial testing a developmental intervention for youths with T1D and their parents from two diabetes clinics.

RESULTS

Better adolescent HRQOL was associated with better glycemic control. Better preadolescent HRQOL was associated with better parent HRQOL. Non-White adolescents had worse HRQOL than White adolescents; whereas Non-White preadolescents had worse glycemic control than White preadolescents.

DISCUSSION

Addressing HRQOL may promote better glycemic control in adolescents with T1D. For preadolescents with T1D, parent HRQOL support may impact preadolescent HRQOL and improve glycemic control moving into adolescence. Further study is warranted for non-White youths with T1D HRQOL and A1c outcomes.

Psychological Outcomes in Children and Early Adolescents With Type 1 Diabetes Following Pediatric Diabetes Summer Camp: A 3-Month Follow-Up Study

Objective: The aim of this study was to assess general psychosocial adjustment to diabetes and perceived disease management among patients with type 1 diabetes (T1D) and their parents before and after patients' participation in a diabetes summer camp. Methods: In this follow-up study, 20 children and adolescents with T1D (eight boys; mean age = 11.01 ± 0.94 years; mean diabetes duration = 3.02 ± 2.27) attending a southern Italian diabetic center, along with their parents, were assessed prior to and 3 months after the youths participated in a 1 week camp-based intervention involving didactic and interactive child-centered education and recreational activities. Patients and their parents completed measures assessing patients' quality of life and strategies employed by patients to cope with pain. Patients also completed measures evaluating their diabetes psychosocial adjustment, diabetes self-efficacy management, and illness perception; also, their parents completed measures of caregivers' perceived diabetes burden and treatment satisfaction. Youths' glycated hemoglobin (HbA1c) and standardized body mass index (z-BMI) values were also assessed. Within-subjects repeated-measures analyses of variance evaluated pre- and post-camp changes. Results: Camp attendance showed no beneficial effects on glycemic control, as indicated by HbA1c values both before (7.02%) and after (7.28%) camp being lower than 7.5%. HbA1c values were found to have increased after camp (pre-camp = 7.02%, post-camp = 7.28%; p = 0.010), but since they still fell within an acceptable range, they did not reveal clinically relevant changes in glycemic control. No substantial significant improvement in psychosocial measures was observed in children or parents (all p > 0.05). According to the parents' evaluation, social support-seeking as a patient pain-coping strategy was slightly increased (p = 0.044) after attending the camp. Conclusions: This study does not provide empirical evidence of benefits of participating in a diabetes camp for either patients or their parents. These findings suggest that healthcare providers rethink such camps as an experience for youths with T1D that actively involves parents and that includes both youth- and parent-focused psychological interventions.

Psychological Well-Being of Parents of Very Young Children With Type 1 Diabetes - Baseline Assessment

BACKGROUND

Type 1 diabetes in young children is a heavy parental burden. As part of pilot phase of the KIDSAP01 study, we conducted a baseline assessment in parents to study the association between hypoglycemia fear, parental well-being and child behavior.

METHODS

All parents were invited to fill in baseline questionnaires: hypoglycemia fear survey (HFS), WHO-5, Epworth Sleepiness Scale and Strength and Difficulties Questionnaire (SDQ).

RESULTS

24 children (median age: 5-year, range 1-7 years, 63% male, mean diabetes duration: 3 ± 1.7 years) participated. 23/24 parents filled out the questionnaires. We found a higher score for the hypoglycemia fear behavior 33.9 ± 5.6 compared to hypoglycemia worry 34.6 ± 12.2. Median WHO-5 score was 16 (8 - 22) with poor well-being in two parents. Median daytime sleepiness score was high in five parents (>10). For six children a high total behavioral difficulty score (>16) was reported. Pro social behavior score was lower than normal in six children (<6). Parental well-being was negatively associated with HFS total (r = - 0.50, p <.05) and subscale scores (r = - 0.44, p <.05 for HFS-Worry and HFS-Behavior), child behavior (r = - 0.45, p = .05) and positively with child age and diabetes duration (r = 0.58, p <.01, r = 0.6, p <.01). HFS, parental well-being nor daytime sleepiness are associated with the HbA1c.

CONCLUSION

Regular screening of parental well-being, hypoglycemia fear and child behavior should be part of routine care to target early intervention.

Disordered eating behaviors in youths with type 1 diabetes during COVID-19 lockdown: an exploratory study

BACKGROUND

Recent research indicates that patients with type 1 diabetes (T1D) are at higher risk for disordered eating behaviors (DEBs) than their peers without diabetes. The present study aimed to explore the prevalence of DEBs in a sample of Italian children and adolescents with T1D and in matched-pair healthy controls during the COVID-19 lockdown.

METHODS

In a cross-sectional study, 138 children and adolescents with T1D (aged 8.01-19.11 years, 65 boys) attending a Southern Italian diabetic service and 276 age- and gender-matched healthy peers voluntarily completed an online survey about eating behaviors (ChEAT and EAT-26), anthropometric characteristics, and clinical characteristics.

RESULTS

8.69% (N = 12) of participants with T1D and 13.4% (N = 37) of controls had ChEAT/EAT-26 scores indicating presence of DEBs, with no differences between patients-whether children (total ChEAT score F(1, 157) = .104, p = .748) or adolescents (total EAT-26 score F(1, 255) = .135, p = .731)-and healthy peers. zBMI values were lower than those measured in the latest diabetes visit (p < .0001), while HbA1c values remained unchanged (p = .110). In both groups, adolescents had lower Oral Control scores than children (T1D: F(1, 138) = 20.411, p < .0001, η2 = .132, controls: F(1, 276) = 18.271, p < .0001, η2 = .063); additionally, gender (female) and age were found to be significant predictors of several ChEAT/EAT-26 scores.

CONCLUSIONS

This exploratory study suggested that children and adolescents with T1D did not experience more DEB symptoms during the COVID-19 lockdown compared to healthy controls. Results revealed DEBs as more of a female adolescent developmental issue rather than a result of the challenges of living with a chronic illness under quarantine measures. Possible effects of parental pressure on their children's eating behaviors in the context of home confinement and of using a non-diabetes-specific measure to assess DEBs are discussed.

Weight Management in Youth with Type 1 Diabetes and Obesity: Challenges and Possible Solutions

PURPOSE OF REVIEW

This review highlights challenges associated with weight management in children and adolescents with type 1 diabetes (T1D). Our purpose is to propose potential solutions to improve weight outcomes in youth with T1D.

RECENT FINDINGS

A common barrier to weight management in T1D is reluctance to engage in exercise for fear of hypoglycemia. Healthcare practitioners generally provide limited guidance for insulin dosing and carbohydrate modifications to maintain stable glycemia during exercise. Adherence to dietary guidelines is associated with improved glycemia; however, youth struggle to meet recommendations. When psychosocial factors are addressed in combination with glucose trends, this often leads to successful T1D management. Newer medications also hold promise to potentially aid in glycemia and weight management, but further research is necessary. Properly addressing physical activity, nutrition, pharmacotherapy, and psychosocial factors while emphasizing weight management may reduce the likelihood of obesity development and its perpetuation in this population.

Assessing Health-Related Quality of Life in Children and Adolescents with Diabetes: Development and Psychometrics of the Type 1 Diabetes and Life (T1DAL) Measures

OBJECTIVE

To develop and validate new measures of diabetes-specific health-related quality of life (HRQOL) for people with type 1 diabetes (T1D) that are brief, developmentally appropriate, and usable in clinical research and care. Here we report on the phases of developing and validating the self-report Type 1 Diabetes and Life (T1DAL) measures for children (age 8-11) and adolescents (age 12-17).

METHODS

Measure development included qualitative interviews with youth and parents (n = 16 dyads) followed by piloting draft measures and conducting cognitive debriefing with youth (n = 9) to refine the measures. To evaluate the psychometric properties, children (n = 194) and adolescents (n = 257) at three T1D Exchange Clinic Network sites completed the age-appropriate T1DAL measure and previously validated questionnaires measuring related constructs. Using psychometric data, the investigators reduced the length of each T1DAL measure to 21 and 23 items, respectively, and conducted a final round of cognitive debriefing with six children and adolescents.

RESULTS

The T1DAL measures for children and adolescents demonstrated good internal consistency (α = 0.84 and 0.89, respectively) and test-retest reliability (r = 0.78 and 0.80, respectively). Significant correlations between the T1DAL scores and measures of general quality of life, generic and diabetes-specific HRQOL, diabetes burden, and diabetes strengths demonstrated construct validity. Correlations with measures of self-management (child and adolescent) and glycemic control (adolescent only) demonstrated criterion validity. Factor analyses indicated four developmentally specific subscales per measure. Participants reported satisfaction with the measures.

CONCLUSIONS

The new T1DAL measures for children and adolescents with T1D are reliable, valid, and suitable for use in care settings and clinical research.

Eating disorders in adolescents with type 1 diabetes mellitus

PURPOSE OF REVIEW

Eating disorders represent one of the most common psychiatric disorders in adolescents with type 1 diabetes mellitus (T1DM), with a prevalence twice as high as in individuals without diabetes. The increased risk for acute and long-term medical complications and a three-fold mortality rate with this dual condition makes it extremely important to screen adolescents for eating disorders as soon as possible.

RECENT FINDINGS

A number of 13 surveys in the last two years focussed on prevalence rates of disordered eating and associations with sociodemographic, eating disorder-specific and diabetes-related factors in this population. Variations in study design, sample size, age range, sex, instruments to assess eating disorders and outcome make comparisons difficult. Healthcare professionals report challenges in detecting and treating adolescents with this dual condition because of a lack of validated screening tools, guidelines, and integration across specialist care. Studies on psychological treatments for the comorbidity of eating disorders and T1DM are scarce, especially for adolescents.

SUMMARY

The development and evaluation of psychological treatments for adolescents with eating disorders and T1DM are urgently needed.

Characterization of youth goal setting in the self-management of type 1 diabetes and associations with HbA1c: The Flexible Lifestyle Empowering Change trial

INTRODUCTION

Youth with type 1 diabetes (T1D) commonly do not meet HbA1c targets. Youth-directed goal setting as a strategy to improve HbA1c has not been well characterized and associations between specific goal focus areas and glycemic control remain unexplored.

OBJECTIVE

To inform future trials, this analysis characterized intended focus areas of youth self-directed goals and examined associations with change in HbA1c over a 18 months.

METHODS

We inductively coded counseling session data from youth in the Flexible Lifestyle Empowering Change Intervention (n = 122, 13-16 years, T1D duration >1 year, HbA1c 8-13%) to categorize intended goal focus areas and examine associations between frequency of goal focus areas selected by youth and change in HbA1c between first and last study visit.

RESULTS

We identified 13 focus areas that categorized youth goal intentions. Each session where youth goal setting concurrently incorporated blood glucose monitoring (BGM), continuous glucose monitoring (CGM), and insulin dosing was associated with a 0.4% (95% CI: -0.77, -0.01; P = .03) lower HbA1c at the end of intervention participation. No association was observed between HbA1c and frequency of sessions where goal intentions focused on BG only (without addressing insulin or CGM) (β: 0.07; 95% CI: -0.07, 0.21; P = .33) nor insulin dosing only (without addressing BGM or CGM) (β: 0.00; 95% CI: -0.11, 0.10; P = .95).

CONCLUSIONS

Findings exemplify how guiding youth goal development and combining multiple behaviors proximally related to glycemic control into goal setting may benefit HbA1c among youth with T1D. More research characterizing optimal goal setting practices in youth with T1D is needed.

Association of type 1 diabetes and school wellbeing: a population-based cohort study of 436,439 Danish schoolchildren

AIMS/HYPOTHESIS

We aimed to examine the association of type 1 diabetes with school wellbeing among Danish children.

METHODS

This is a population-based cohort study involving 436,439 Danish children, of which 1499 had a confirmed diagnosis of type 1 diabetes. The children were enrolled in grade levels 4 to 9 (middle school) in Danish public schools in the years 2014-2017. Questionnaire outcomes from the yearly National Wellbeing Survey related to self-efficacy, perceived competences, peer and teacher support, bullying and somatic symptoms were analysed. Ordered logistic regression was used to compare outcomes of children with and without type 1 diabetes, and to compare subgroups of children with type 1 diabetes by different levels of HbA_1c and diabetes duration. Primary outcomes were answers to seven pre-specified questionnaire items (scale, 1 to 5).

RESULTS

A total of 817,679 questionnaires were initiated, of which n = 2681 were from children with type 1 diabetes. Compared with the background population, children with type 1 diabetes expressed more peer support; adjusted OR 1.17 (95% CI 1.08, 1.27). Children with diabetes also reported more often having a headache; adjusted OR 1.09 (95% CI 1.00, 1.19). Overall, children with poor glycaemic control (HbA_1c >70 mmol/mol) had worse outcomes on the wellbeing measures compared with the background population. Even after adjusting for socioeconomic status, they still reported significantly worse perceived competences, less teacher support and more somatic symptoms (stomach ache and headache).

CONCLUSIONS/INTERPRETATION

In Denmark, children with type 1 diabetes generally feel well supported in school but have more headaches than other children. Poor glycaemic control is associated with worse psychological school-related wellbeing. Graphical abstract.

Psychische Komorbiditäten bei Jugendlichen und jungen Erwachsenen mit Typ-1-Diabetes

Jugendliche und junge Erwachsene mit Typ-1-Diabetes sind häufig von komorbiden psychischen Störungen betroffen. Dabei zeigt die Studienlage zur Verbreitung ein heterogenes und inkonsistentes Bild. Diagnose und Behandlung der somatopsychischen Begleiterkrankungen beeinflussen den Behandlungs- und Krankheitsverlauf sowie die Lebensqualität der Betroffenen. Trotzdem wird dies in der klinischen Praxis selten frühzeitig berücksichtigt. Das multizentrische Verbundprojekt COACH verfolgt das Ziel, die Erkennung und Behandlung psychischer Komorbidität für diese Zielgruppe in der bundesweiten Routineversorgung zu optimieren.

The psychosocial experience and needs of children newly diagnosed with type 1 diabetes from their own perspective: a systematic and narrative review

AIM

To understand the psychosocial experience of children and identify their primary support needs following a type 1 diabetes diagnosis.

METHODS

A systematic review and narrative synthesis of the literature in this area was conducted.

RESULTS

A total of 32 studies were included in the review. At diagnosis, the majority of children experienced high distress, including grief, anxiety, anger, irritation and injection anxiety. The intensity of this reaction decreased rapidly over the following weeks. At diagnosis, rates of depressive symptoms, anxiety, stress disorders and suicidal ideation were elevated. The initial reaction tended to peak shortly after diagnosis and declined over the following year. Thereafter, symptoms of depression and anxiety appeared to increase once again, corresponding with the children's experience of diabetes management and implications as being more difficult and upsetting. Injection anxiety, distress and depressive symptoms persisted for a smaller group of children.

CONCLUSION

The initial high prevalence of depressive symptoms following diagnosis is transitional and should be regarded as a normal adaptive response. To facilitate this adaptive process, specific child-centred support should be prioritized as an integrated part of early diabetes care. Our findings point to five inter-related support needs following a type 1 diabetes diagnosis: (1) children need time to adjust to the diagnosis; (2) children need supportive relationships; (3) children need an opportunity for meaningful participation and appropriate protection; (4) children need to engage and explore; and (5) children need to feel supported, but not different.

Body Image Problems and Disordered Eating Behaviors in Italian Adolescents With and Without Type 1 Diabetes: An Examination With a Gender-Specific Body Image Measure

Objective

To examine body image problems and their associations with disordered eating behavior in adolescents with type 1 diabetes and well-matched healthy peers.

Methods

Using a cross-sectional design, 183 adolescents with type 1 diabetes (13.02–18.05 years) were recruited from diabetes centers in southern Italy and compared to healthy peers matched for age and gender. Participants completed self-report measures of disordered eating behaviors (DEPS-r and EDI-3RF) and a gender-specific body image problem questionnaire (SATAQ-4R). Socio-demographic and clinical data (zBMI, HbA1c, and disease duration) were also collected. Hierarchical multiple linear regression analyses were computed to determine the relative importance of diabetes variables and body image problems on participants’ disordered eating behaviors after controlling for demographic variables.

Results

Adolescents with type 1 diabetes showed diabetes-specific eating problems in 37.7% of cases and had more eating problem symptoms (assessed as drive for thinness and bulimia) than healthy peers. Male adolescents with type 1 diabetes did not display more body image problems (p > 0.05); females with type 1 diabetes compared to females in the control group were found to be more pressured by family (p = 0.025) but less by media (p = 0.022) to improve their appearance and attain a thin body. zBMI and body image problems contributed to a significant increase in disordered eating behavior risk both in male and female adolescents with diabetes and in healthy peers (zBMI 0.213 < β < 0.426, p < 0.05; body image 0.243 < β < 0.572, p < 0.05). None of the variables analyzed were found to significantly predict male bulimic symptoms (all β < 0.296, p > 0.05).

Conclusion

Since in adolescence type 1 diabetes and insulin therapy may increase the risk of weight gain and promote focus and attention on the body and thus contribute to the development of body image problems and disordered eating behaviors, continuity of medical, nutritional, and psychological care is needed.

Chronic illness and transition from paediatric to adult care: a systematic review of illness specific clinical guidelines for transition in chronic illnesses that require specialist to specialist transfer

Introduction

A quarter of a century has passed since the importance of transition from paediatric to adult care for chronically ill adolescents was highlighted by the American Society of Adolescent Health and Medicine. Despite discussions, the development of generic guidelines and some cohorting of age groups in paediatric speciality care, adolescents continue, unacceptably, to fall through the care gaps with negative clinical outcomes. Government bodies and international organisations have developed clinical practice guidelines (CPGs) for specific chronic physical illness although it remains unclear as to what extent these discuss transition from paediatric to adult care. This study systematically reviewed scientific and grey literature to determine how effectively transition has been incorporated into chronic illness specific CPGs.

Methods

Five bibliographical databases; Medline, Embase, PsycINFO, CINAHL and Web of Science plus an extensive grey literature search from the internet were used to identify published guidelines between 2008 and 2018 using key words adolescents, transition, guidelines, together with the names of over 20 chronic physical illnesses which require specialist to specialist care after transitioning from paediatric care. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. In addition a measure of trustworthiness for CPGs was included. Guidelines were benchmarked against a published set of Australian transition principles embodying the comprehensive recommendations from National Institute for health and Care Excellence (NICE) transition guidelines discussing key transition aspects on: a systematic and formal transition process; early preparation; transition coordinators, good communication and collaboration between health professionals; individualised transition plan, enhancing self-management and active follow up after transition.

Results

Initially, 1055 articles were identified from the literature searches. Eight hundred and sixty eight articles were selected for title and abstract review. One hundred and seventy eight articles were included for full text review. Ultimately, 25 trustworthy CPGs were identified and included across 14 chronic physical illnesses. Five articles exclusively discussed illness specific transition recommendations and two included all the seven key transition principles. Three provided a minimal discussion of transition to adult care due to lack of high level evidence. Follow up and evaluation was the least addressed principle with recommendations in only seven CPGs.

Conclusions

A limited number of chronic physical illnesses have illness specific CPGs that address transition from paediatric to adult care. The CPGs’ content emphasises the need for empirical data in order to develop quality transition recommendations for adolescents with chronic physical illness to ensure long term engagement and retention within health services.

Psychological care in children and adolescents with type 1 diabetes in a real-world setting and associations with metabolic control

BACKGROUND

International guidelines recommend psychosocial care for children and adolescents with type 1 diabetes.

OBJECTIVE

To assess psychological care in children and adolescents with type 1 diabetes in a real-world setting and to evaluate associations with metabolic outcome.

METHODS

Delivery of psychological care, HbA1c, and rates of severe hypoglycemia and diabetic ketoacidosis (DKA) in children and adolescents with type 1 diabetes from 199 diabetes care centers participating in the German diabetes survey (DPV) were analyzed.

RESULTS

Overall, 12 326 out of 31 861 children with type 1 diabetes were supported by short-term or continued psychological care (CPC). Children with psychological care had higher HbA1c (8.0% vs 7.7%, P<.001) and higher rates of DKA (0.032 vs 0.021 per patient-year, P<.001) compared with children without psychological care. In age-, sex-, diabetes duration-, and migratory background-matched children, HbA1c stayed stable in children supported by CPC during follow-up (HbA1c 8.5% one year before psychological care started vs 8.4% after two years, P = 1.0), whereas HbA1c was lower but increased significantly by 0.3% in children without psychological care (HbA1c 7.5% vs 7.8% after two years, P <.001). Additional HbA1c-matching showed that the change in HbA1c during follow-up was not different between the groups, but the percentage of children with severe hypoglycemia decreased from 16.3% to 10.7% in children receiving CPC compared with children without psychological care (5.5% to 5.8%, P =.009).

CONCLUSIONS

In this real-world setting, psychological care was provided to children with higher HbA1c levels. CPC was associated with stable glycemic control and less frequent severe hypoglycemia during follow-up.

Health-related quality of life and metabolic control in immigrant and Italian children and adolescents with type 1 diabetes and in their parents

OBJECTIVE

To determine if the diabetes-specific health-related quality of life (D-HRQOL) of young people with type 1 diabetes (T1D) and their parents is influenced by migrant status.

SUBJECTS AND METHODS

One hundred and twenty-five patients (12.4 ± 3.55 years, males 53.6%) with T1D and their parents (102 mothers, 37 fathers) were enrolled and categorized into: group A (both foreign parents) and group B (both native Italian parents). The Pediatric Quality of Life Inventory™ 3.0 Diabetes Module (PedsQL™ 3.0 DM) was used to evaluate the D-HRQOL. Data on diabetic ketoacidosis (DKA) at T1D onset, insulin therapy, and glycosylate hemoglobin (HbA1c) were also collected.

RESULTS

Group A (n = 40), compared to group B (n = 85), had higher frequency of DKA at T1D onset (P < .001) and a lower use of sensor augmented insulin pump (P = .015). HbA1c values were higher in group A than in group B (P < .001). Patients' "Diabetes symptoms" (P = .004), "Treatment barriers" (P = .001), and "Worry" (P = .009) scales scores were lower in group A than in group B. Mothers of group A had lower scores in "Diabetes symptoms" (P = .030), "Treatment barriers" (P < .001), "Treatment adherence" (P = .018), "Communication" (P = .009) scales, and total score (P = .011) compared to the group B ones. High PedsQL™ 3.0 DM was significantly associated with being Italian, being prepubertal, and having lower HbA1c mean levels.

CONCLUSIONS

Being a migrant confers disadvantages in terms of D-HRQOL and metabolic control in children and adolescents with T1D. Specific educational interventions should be considered in the clinical care of patients with migration background, to improve D-HRQOL and health status.

Management of children and adolescents having type 1 diabetes during COVID-19 pandemic in India: challenges and solutions

Purpose

Type 1 diabetes (T1D) requires a holistic approach and continuous care. The current COVID-19 pandemic has made the health care professionals realise its challenges even more ardently than in the normal times. In a country like India with its huge population burden and a significant number of people having T1D, the risk of COVID-19 in people having T1DM is considerably high.

Methods

In this article, we are sharing our practical experiences of problems faced by children and adolescents having T1DM during the past 2 months of lockdown.

Results

We have classified the challenges into 3 broad categories based on diabetes self-management, healthcare system and psychosocial aspects. We have tried to provide precise, comprehensive and region specific solutions to these challenges. Solutions briefly include maintaining the supply chain of essentials like insulin, syringes and glucose meter strips to psychological support, financial aid and support for hospitalization in case of COVID-19 itself or diabetes complications including diabetic ketoacidosis.

Conclusions

Children and adolescents having T1DM require special care and attention during this period of COVID-19 pandemic because of various challenges as discussed. Our proposed solutions may help them overcome these problems and help them in better diabetes management during such emergency situations.

Etiologies, trends, and predictors of 30-day pediatric readmissions after hospitalizations for diabetic ketoacidosis in the United States

OBJECTIVE

To determine the causes, predictors, and trends of 30-day readmissions following hospitalizations for pediatric diabetic ketoacidosis (DKA) in the United States (US) from 2010 to 2014.

RESEARCH DESIGN AND METHODS

We used International Classification of Diseases, ninth revision, Clinical Modification codes to identify children with DKA aged 2 to 18 years from the National Readmission Database in the US. Patients who had readmission within 30 days after an index admission for DKA were included in the study. We combined similar diagnoses into clinically important categories to determine the cause of readmission. The primary outcome was all-cause 30-day (AC30) readmissions. Categorical and continuous variables were analyzed using chi-square or student's t-test or Wilcoxon rank sum tests respectively. We performed multivariable logistic regression to identify predictors of 30-day readmission.

RESULTS

From 2010 through 2014, a weighted total of 87 815 index DKA-related pediatric hospitalizations were identified of which, 4055 patients (4.6%) had AC30 readmissions and this remained unchanged during the study period. Of all the readmissions, 69% were attributed to DKA. In multivariable regression analysis, the odds of AC30 readmission and 30-day readmission attributed to DKA alone were increased for females, adolescents, patients with depression and psychosis, and discharge against medical advice, while private insurance, the highest income quartile, and admission at teaching hospitals were associated with lower odds of AC30 readmission and 30-day readmission attributed to DKA only.

CONCLUSION

We identified several factors associated with readmission after hospitalization for DKA. Addressing these factors such as depression may help lower readmissions after an admission for DKA.

The DISABKIDS generic and diabetes-specific modules are valid but not directly comparable between Denmark, Sweden, and Norway

BACKGROUND/OBJECTIVES

Government guidance promote benchmarking comparing quality of care including both clinical values and patient reported outcome measures in young persons with type 1 diabetes. The aim was to test if the Nordic DISABKIDS health-related quality of life (HrQoL) modules were construct valid and measurement comparable within the three Nordic countries.

METHODS

Data from three DISABKIDS validation studies in Sweden, Denmark, and Norway were compared using Rasch and the graphical log-linear Rasch modeling. Monte Carlo methods were used to estimate reliability coefficient and target was defined as the point with the lowest SE of the mean. Self-report data were available from 99 Danish (8-18 years), 103 Norwegian (7-19 years), and 131 Swedish (8-18 years) young people.

RESULTS

For the DISABKIDS higher scores on most subscales were noted in the Norwegian population. The Swedish sample had a significantly higher score on the "Diabetes treatment" subscale and scores closer to optimal target than the other countries. For each country, construct validity and sensitivity were acceptable when accounting for differential item function (DIF) and local dependency (LD). Less LD and DIF were found if only Denmark and Norway were included. The combined model was reliable; however, some differences were noted in the scale translations relating to the stem and response alternatives, which could explain the discrepancies.

CONCLUSION

The Nordic versions of the DISABKIDS questionnaires measures valid and reliable HrQoL both within and between countries when adjusted for DIF and LD. Adjusting the Likert scales to the same respond categories may improve comparability.

Versorgung von Kindern und Jugendlichen mit Typ-1-Diabetes: Lösungen für technische und psychosoziale Herausforderungen

Diabetes mellitus Typ 1 ist die häufigste endokrinologische Erkrankung bei Kindern und Jugendlichen unter 15 Jahren. Eine Heilungsperspektive bezüglich der Autoimmunreaktion gegen die insulinbildenden Betazellen ist weiterhin nicht in Sicht. Dennoch konnte durch technische Innovationsschübe bei Glukosesensoren, Insulinpumpen und Steuerungsalgorithmen innerhalb der letzten Jahre die Stoffwechselkontrolle optimiert werden. Diese Entwicklungen führen zusammen mit individuellen Diabetesschulungen und psychosozialer Unterstützung zu einer deutlichen Verbesserung der Versorgung.

In diesem Übersichtsartikel wird die aktuelle Versorgungssituation von Kindern und Jugendlichen mit Typ-1-Diabetes sowie ihren Eltern dargestellt. In Deutschland ist die multidisziplinäre, spezialisierte Versorgung durch Teams aus Kinder- und Jugenddiabetolog*innen, Diabetesberater*innen, Sozialarbeiter*innen und Kinder- und Jugendpsychotherapeut*innen seit vielen Jahren etabliert und führt zu einer im internationalen Vergleich sehr guten Versorgungsqualität. Fokussiert werden die Diabetesschulung mit dem Schwerpunkt, das Selbstmanagement optimal zu unterstützen, die psychosoziale Begleitung und Intervention sowie die Inklusion in Schulen und Kindertagesstätten. Wir gehen außerdem auf neue soziale Entwicklungen der Diabetes-Online-Community ein. Ein aktuelles Beispiel ist die patientenbetriebene Bewegung „Do-It-Yourself Artificial Pancreas System“ (DIY-APS), die als Open-Source-Projekt mittlerweile Innovationsgeber auch für Medizinproduktehersteller ist. Zum Schluss beleuchten wir die damit verbundenen Chancen, aber auch die Verschiebung der klassischen Arzt-Patienten-Rollen.

Using Person-Reported Outcomes (PROs) to Motivate Young People with Diabetes

PURPOSE OF REVIEW

This manuscript describes how person-reported outcomes (PROs) can be utilized in care for young people with diabetes in the context of motivation.

RECENT FINDINGS

The use of person-reported outcome measures (PROMS) in clinical care is feasible and acceptable, and helps focus the clinical encounter on life domains important to the person with diabetes. Results with regard to impact on self-management and glycemic outcomes are limited. Motivation is an important factor for self-management. Based on self-determination theory, autonomy-supportive, person-centered, and collaborative communication by diabetes care providers is associated with better outcomes. PROMs can facilitate this conversation. Understanding of youth motivation for maintaining or improving self-management behaviors requires a person-centered approach. PROMs can be used to facilitate an autonomy-supportive and person-centered conversation in clinical care. Training diabetes care providers in autonomy-supportive, person-centered conversation skills to discuss PROs might help to tap into youth's motivation, but further research is needed.

Gestörtes Essverhalten und psychosoziale Versorgungssituation junger Menschen mit Typ 1 Diabetes

Einleitung Gestörtes Essverhalten oder klinisch relevante Essstörungen in Verbindung mit Typ 1 Diabetes haben schwerwiegende Folgen für die Qualität der Stoffwechseleinstellung und die langfristige gesundheitliche Prognose Betroffener. Eine frühzeitige Diagnose und qualifizierte therapeutische Interventionen können bereits bei gestörtem Essverhalten dazu beitragen, vorzeitige mikrovaskuläre Schädigungen zu vermeiden. In dieser Studie wurden für eine Gruppe junger Menschen mit Typ 1 Diabetes, die an einem 4-tägigen Camp teilnahmen, die Prävalenz essgestörten Verhaltens und die spezifische psychosoziale Versorgungssituation untersucht.

Material und Methoden Während eines bundesweit ausgeschriebenen Diabetescamps für junge Menschen (16–29 Jahre) beantworteten die Teilnehmenden Fragen zu ihrer aktuellen Diabetesbehandlung, zu diabetesspezifischen Belastungen (PAID-5) sowie zur psychosozialen Versorgung im Rahmen der ambulanten Langzeittherapie. Symptome gestörten Essverhaltens wurden mit einem diabetesspezifischen Screeningfragebogen, dem Diabetes Eating Problem Survey-Revised (DEPS-R), erhoben. Eine lineare multiple Regression wurde berechnet, um Prädiktoren gestörten Essverhaltens zu identifizieren.

Ergebnisse An der Umfrage beteiligten sich 308 junge Menschen mit Typ 1 Diabetes (Alter 21,4±3,4 Jahre; 73% weiblich; Diabetesdauer 10,2±5,9 Jahre; 74% in internistischer Behandlung). Bei 28,2% der Befragten ergaben sich Hinweise auf ein gestörtes Essverhalten (17% der Männer, 32% der Frauen). Teilnehmende mit einem auffälligen Summenwert im DEPS-R wurden nur zu 7% entsprechend psychologisch betreut. Das HbA1c, der BMI, die diabetesspezifischen Belastungen, das Alter, die Diabetesdauer sowie das Geschlecht erwiesen sich als signifikante Prädiktoren für das Ausmaß gestörten Essverhaltens.

Diskussion Unter den Teilnehmenden eines Diabetescamps für junge Menschen zeigten sich bei über einem Viertel Hinweise auf ein gestörtes Essverhalten. Insgesamt waren davon junge Frauen häufiger betroffen, weitere relevante Risikofaktoren waren ein erhöhter BMI, ein höheres HbA1c und stärkere diabetesspezifische Belastungen. Nur ein sehr geringer Anteil der jungen Menschen mit Typ 1 Diabetes und gestörtem Essverhalten erhielt psychologische Unterstützung.

Schlussfolgerung In der ambulanten diabetologischen Versorgung sollten diabetesspezifische Screeninginstrumente und/oder gezielte Screeningfragen insbesondere bei jungen Frauen regelmäßig eingesetzt und die Ergebnisse mit den Betroffenen im Hinblick auf eine weiterführende Behandlung besprochen werden.

The cognitive and psychological effects of living with type 1 diabetes: a narrative review

Across the lifespan, type 1 diabetes mellitus has a profound (neuro)psychological impact. In young people, type 1 diabetes can interfere with psychosocial development and hamper school performance. In adulthood, it can interfere with work life, relationships and parenting. A substantial minority of adults with type 1 diabetes experience coping difficulties and high diabetes-related distress. In youth and adulthood, type 1 diabetes is related to mild cognitive decrements as well as affective disorders, such as depression and anxiety. There is limited literature available that explores the interaction between cognitive and psychological comorbidity and underlying mechanisms. The aims of the present narrative review were to summarize the current state of the literature regarding both cognitive and psychological comorbidities in type 1 diabetes across the lifespan, and to explore potential links between the two domains of interest to make suggestions for future research and clinical practice.

Twenty-five years of diabetes distress research

The term 'diabetes distress' first entered the psychosocial research vernacular in 1995, and refers to 'the negative emotional or affective experience resulting from the challenge of living with the demands of diabetes'. At first the proponents of the concept were hesitant in advocating that diabetes distress was a major barrier to individuals' self-care and management of diabetes. Since then, a burgeoning body of evidence, now including several systematic reviews of intervention studies, suggests that diabetes distress, in both type 1 and type 2 diabetes, across ages and in all countries and cultures where it has been studied, is common and can be a barrier to optimal emotional well-being, self-care and management of diabetes. As a consequence, monitoring diabetes distress as part of routine clinical care is part of many national guidelines. The present narrative review summarizes this research and related literature, to postulate the aetiology of diabetes distress, and thus how it may be prevented. The current evidence base for the management of diabetes distress is summarized, and the next steps in the prevention and management of diabetes distress identified.

Factors associated with health psychology use in pediatric type 1 diabetes

AIMS

Identify the prevalence of health psychology use in children with type 1 diabetes (T1D) and evaluate how individual and contextual characteristics are associated with use.

METHODS

Children ages 8-16 years with T1D and their parents were recruited from two tertiary diabetes clinics. Cross-sectional data included parent and adolescent surveys and hemoglobin A1c. Parents self-reported the child's use of health psychology in the last year along with individual factors (e.g., predisposing factors including demographics, enabling factors including health insurance type, evaluated need including mental health diagnoses and perceived need including self-management barriers). Association of health psychology use with individual (e.g., demographics, enabling factors, evaluated and perceived need) and contextual (e.g., clinical site) characteristics was evaluated using logistic regression.

RESULTS

Of 363 eligible participants, 267 (74%) participated. Health psychology use was reported by only 8.2% (n = 22) of participants and was significantly associated with evaluated need factor of mental health diagnosis (OR 5.8; p < 0.001) and perceived need factor of parent-reported self-management barriers. Use was not associated with other individual or contextual factors.

CONCLUSIONS

Though infrequent, health psychology use was positively associated with mental health diagnoses and self-management barriers.

Therapeutic Inertia in Pediatric Diabetes: Challenges to and Strategies for Overcoming Acceptance of the Status Quo

Despite significant advances in therapies for pediatric type 1 diabetes, achievement of glycemic targets remains elusive, and management remains burdensome for patients and their families. This article identifies common challenges in diabetes management at the patient-provider and health care system levels and proposes practical approaches to overcoming therapeutic inertia to enhance health outcomes for youth with type 1 diabetes.

Glycemic Control Improvement in Italian Children and Adolescents With Type 1 Diabetes Followed Through Telemedicine During Lockdown Due to the COVID-19 Pandemic

BACKGROUND/OBJECTIVE

To minimize the wide spread of coronavirus disease (COVID-19) pandemic, Italy was placed in an almost complete lockdown state that forced people to "stay at home". Aim of this study was to evaluate the effects of lockdown on glycemic control in children and adolescents with type 1 diabetes (T1D) followed through telemedicine.

SUBJECTS/METHODS

This observational study involved patients with T1D using the real-time continuous glucose monitoring (CGM) Dexcom G6^®. Ambulatory glucose profile data from the 3-months before schools closure (November 26, 2019-February 23, 2020; T0) and from the 3-months of consecutive lockdown (February 24-May 18, 2020; T1) were compared.

RESULTS

Sixty-two children and adolescents (11.1 ± 4.37 years, 50% males) with T1D (median time disease 3.67 years) were enrolled in the study. Insulin total daily dose was unchanged, while time spent on physical activities was decreased (p<0.0001). Despite the lack of statistical significance, median value of the glucose management indicator decreased from 7.4% to 7.25%. Glucose standard deviation (p<0.0001) and coefficient of variation (p=0.001) improved across the study. Median time in range increased from 60.5% to 63.5% (p=0.008), time above range decreased from 37.3% to 34.1% (p=0.048), and time below range decreased from 1.85% to 1.45% (p=0.001).

CONCLUSIONS

Overall, in our children and adolescents with T1D glycemic control improved during lockdown. Despite patients were confined to their homes and limited to exercise, our data suggest that the use of real-time CGM, the continuous parental management, and the telemedicine can display beneficial effects on T1D care.

An eHealth Program for Parents of Adolescents With T1DM Improves Parenting Stress: A Randomized Control Trial

PURPOSE

The purpose of this study was to evaluate the short-term effects of the Type 1 Teamwork program for parents of adolescents with type 1 diabetes mellitus (T1DM) on the primary outcome of psychosocial stress.

METHODS

The study was a randomized wait-list control trial evaluating an eHealth program to reduce parenting stress around T1DM management during adolescence through interactive sessions on the safe transfer of responsibility, positive communication, and stress management. The primary outcome was psychosocial stress (parenting stress specific to child illness and general stress). Secondary outcomes included depressive and anxiety symptoms, parent support for adolescent autonomy, family conflict, and adolescent metabolic control (A1C). Data were collected at baseline, 3 months, and 6 months online. Mixed-model analyses were conducted, using intent-to-treat procedures.

RESULTS

Parents (n = 162) had a mean age of 45.6 (±5.3) years, were 98% female, 91% white, 91% married/partnered, 51% of high income, and geographically dispersed around the United States. Parents reported that adolescents had a mean A1C of 7.9% (±1.2%) and T1DM duration of 5.08 (±3.62) years. At 6 months, parents in the Type 1 Teamwork group demonstrated less parenting stress compared with the control group. There were no differences between groups on general stress or secondary outcomes. Attrition at 6 months was 32% in the treatment group and 11% in the control group.

CONCLUSIONS

An eHealth program for parents of adolescents with T1DM improves parenting stress in a sample of parents from across the United States.