Family conflict, adherence, and glycaemic control in youth with short duration Type 1 diabetes

Short-term effects of coping skills training in school-age children with type 1 diabetes

OBJECTIVE

Little is known about the use of psychosocial interventions in children younger than adolescence with type 1 diabetes (T1D) and their parents. We report preliminary short-term outcomes of a randomized controlled trial of coping skills training (CST) compared with group education (GE) in school-aged children with T1D and their parents.

METHODS

One hundred and eleven children (range = 8-12 yr) with T1D for at least 6 months (3.71 +/- 2.91 yr) were randomized to CST (55.6% female (F); 81.5% white (W)) or GE (69.7% F; 90.9% W). Children and parents (n = 87) who completed the intervention, baseline, 1- and 3-month data are included. Children completed measures of self-efficacy, coping, and quality of life; parents completed measures of family functioning (adaptability and cohesion), diabetes-related conflict, parent depression, and parent coping. Metabolic control was assessed with glycosylated hemoglobin A1c. Mixed-model repeated measures anova was used to analyze the data.

RESULTS

CST and GE group composition was generally comparable. Children had good psychosocial adaptation and metabolic status. CST parents reported significantly more improvement in family adaptability compared with GE parents, and a trend was seen indicating that CST children showed greater improvement in life satisfaction than GE children. Effect sizes for this short-term follow-up period were small, but group participants were receptive to the intervention and reported positive gains.

CONCLUSIONS

In these preliminary results, CST and GE were more similar than different across multiple measure of psychosocial adaptation, although CST showed promising statistical trends for more adaptive family functioning and greater life satisfaction. Longer term follow-up is underway.

Mediators of depressive symptoms in children with type 1 diabetes and their mothers

OBJECTIVE

To examine the relationships among maternal and child depressive symptoms and child and family psychosocial factors.

METHOD

Secondary analysis of baseline data for a coping skills intervention for school-age children (ages 8-12) with type 1 diabetes (T1D) and their mothers. Children and mothers completed measures of depressive symptoms, coping, quality of life, and family functioning.

RESULTS

There was a strong relationship between maternal and child depressive symptoms (r = .44, p < .001). Maternal depressive symptoms were negatively related to child quality of life, perceptions of coping, and family functioning. Impact of diabetes on quality of life, finding coping with diabetes upsetting, and family warmth mediated the relationship between maternal and child depressive symptoms.

CONCLUSIONS

Maternal depression may negatively affect child adjustment through its influence on quality of life, coping, and family functioning. Implications for interventions to improve psychosocial adjustment in children with T1D are discussed.

The Use of Continuous Subcutaneous Insulin Infusion (CSII): Parental and Professional Perceptions of Self-care Mastery and Autonomy in Children and Adolescents

OBJECTIVE

To describe parent-perceived mastery of Continuous Subcutaneous Insulin Infusion (CSII) specific skills and level of autonomy for these tasks among youth with type 1 diabetes.

METHODS

One hundred and sixty-three parents of youth using CSII and 142 diabetes clinicians participated. Parents reported their child's mastery and autonomy of CSII-specific skills. Clinicians indicated the age at which 50% of their patients mastered these skills.

RESULTS

Parents report CSII skill mastery between 10.9 and 12.8 years. Very few achieved skill mastery on all CSII-related tasks. Parent- and clinician-expectations for age of skill acquisition were consistent with one another. Parents shared CSII task responsibility with their children even after their children have attained skill mastery.

CONCLUSION

The recent emphasis on maintaining parental involvement in diabetes care seems to have been translated into clinical practice. Parents remain involved in their child's CSII care even after they believe their child has mastered these skills.

Assessment of an empowerment education programme. A randomized study in teenagers with diabetes

AIMS

To determine the effects of an empowerment programme on glycaemic control and empowerment, and to study the role of parental involvement.

METHODS

The wait-list design is a randomized controlled trial lasting for 6 months, after which the control group participate in the same education programme as the intervention group. After 6 months, data from the two groups are analysed together (pre/post). Thirty-two teenagers with Type 1 diabetes (12-17 years) completed an empowerment group education programme, meeting weekly for 6 weeks. They were also offered an extra meeting together with their parents, which resulted in three groups: together with parents, only parents and no parent involvement at all. HbA(1c) was measured before intervention and after 6, 12, 18 and 24 months, and empowerment before, and 6 and 12 months after.

RESULTS

HbA(1c) and empowerment were similar in the intervention group and the control group 6 months after intervention. In pre/post analysis, HbA(1c) was significantly higher 6 and 12 months after intervention in teenagers > 14 years (from 8.4% to 9.3%; P < 0.05 to 9.6%; P < 0.01), but returned to baseline 18 months after the programme. In teenagers < or = 14 years of age, HbA(1c) did not change during the study. The teenagers felt more ready for changes after the programme than before (3.9 sd = 0.5 to 4.1 sd = 0.5; P < 0.05). In the teenagers in the group that involved their parents, there was a significant decrease in HbA(1c) 12 and 24 months after intervention, from 8.9% (sd = 1.1) to 7.6% (sd = 1.3; P < 0.05, confidence interval 0.37, 2.26).

CONCLUSION

This empowerment programme for teenagers with diabetes showed no positive glycaemic or empowerment effects. Empowerment programmes for diabetic teenagers in early and middle adolescence should include parental involvement.

Evaluation of treatment adherence in type 1 diabetes: a novel approach

BACKGROUND

Intensified insulin therapy requires outstanding compliance but no measure of therapy adherence has been agreed upon. The aim of the current study was to test the hypothesis that treatment adherence, as described by a novel multiple regression model, relates to glycosylated haemoglobin and hypoglycaemia frequency in type 1 diabetes. Furthermore, we sought to analyse the complex diurnal patterns of therapy adherence.

MATERIALS AND METHODS

Thirty type 1 diabetes patients (20 females and 10 males), treated with intensified insulin therapy, were studied in a retrospective manner. Patients were trained to follow treatment algorithms for adjusting regular insulin dosage which took into account the actual blood glucose, food intake and the time of the day. By means of multiple linear regression analysis, with regular insulin dosage as the dependent variable, blood glucose and food intake as the independent variables, the insulin treatment algorithms actually used by the individual patient were retrieved. The correlation between prescribed and implemented insulin therapy served as a measure of adherence. Metabolic control was assessed by glycosylated haemoglobin and hypoglycaemia frequency.

RESULTS

Median glycosylated haemoglobin was 7.7% (range: 6.3-10.8); median monthly hypoglycaemia frequency was 3.8 (range: 0-9.8). Patients with good metabolic control (glycosylated haemoglobin < 7.7 and/or hypoglycaemia frequency < 3.8 per month) adhered to prescribed insulin dosing algorithms more frequently than those with poor metabolic control.

CONCLUSIONS

In patients with type 1 diabetes on intensified therapy a positive relationship between adherence to the therapy prescribed and metabolic control exists.

Type 1 Diabetes

Type 1 diabetes is a tremendously challenging and complex disease for children and families to manage. Advances in research are constantly bringing about changes in therapies and treatments with the hope of improving the quality of life for youth with type 1 diabetes and their families. Accurate diagnosis, education, treatment, and referral to a certified diabetes educator, endocrinologist, dietitian, social worker, and psychologist are needed to provide the child with the skills necessary to manage diabetes over a lifetime. Nurses and nurse practitioners must be informed of the most current treatments and research available for their patients so that they can encourage their patients to live full and healthy lives.

Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis

BACKGROUND

Atopic dermatitis is a common problem for which topical agents are the primary treatment. When topical medications fail, further therapy may include systemic agents with the potential for greater toxicity. Adherence to topical treatment of atopic dermatitis has not been well characterized. Poor adherence to topical medication could account for failure of topical therapy.

PURPOSE

To determine adherence to topical treatment in patients with atopic dermatitis.

METHODS

Thirty-seven children were given 0.1% triamcinolone ointment and were counseled to use it twice daily. They were told to return in 4 weeks, at which time they were told to continue treatment for another 4 weeks. Electronic monitors were used to measure adherence over the entire 8 week study. Patients were not informed of the compliance monitoring until the end of the study.

RESULTS

Twenty-six patients completed 8 weeks of treatment. Mean adherence from the baseline to the end of the study was 32%. Adherence was higher on or near office visit days and subsequently decreased rapidly.

LIMITATIONS

This study was limited by the large number of subjects who failed to return for follow-up appointments or withdrew from the study.

CONCLUSIONS

Adherence to topical medications is very poor in a clinic population of children with atopic dermatitis. Office visits are one means to increase adherence. If adherence to topical treatment can be improved, exposure to more costly and potentially toxic systemic agents may be avoidable.

Teenagers with type 1 diabetes--a phenomenological study of the transition towards autonomy in self-management

BACKGROUND

Becoming autonomous is an important aspect of teenagers' psychosocial development, and this is especially true of teenagers with type 1 diabetes. Previous studies exploring the everyday problems of teenagers with diabetes have focused on adherence to self-care management, how self-determination affects metabolic control, and the perception of social support.

OBJECTIVE

The aim of the study was to elucidate lived experiences, focusing on the transition towards autonomy in diabetes self-management among teenagers with type 1 diabetes.

DESIGN AND METHOD

Data were collected using interviews, and a qualitative phenomenological approach was chosen for the analysis.

PARTICIPANTS

Thirty-two teenagers (18 females and 14 males) were interviewed about their individual experiences of self-management of diabetes.

FINDINGS

The lived experiences of the transition towards autonomy in self-management were characterized by the over-riding theme "hovering between individual actions and support of others". The findings indicate that individual self-reliance and confirmation of others are helpful in the transition process. Growth through individual self-reliance was viewed as a developmental process of making one's own decisions; psychological maturity enabled increased responsibility and freedom; motivation was related to wellbeing and how well the diabetes could be managed. The theme "confirmation of others" showed that parental encouragement increased the certainty of teenagers' standpoints; peers' acceptance of diabetes facilitated incorporation of daily self-management activities; support from the diabetes team strengthened teenagers' self-esteem.

CONCLUSION

In striving for autonomy, teenagers needed distance from others, but still to retain the support of others. A stable foundation for self-management includes having the knowledge required to practice diabetes management and handle different situations.

Self-care of young adolescents with type 1 diabetes

The purpose of this study was to describe the universal and health deviation self-care of adolescents with Type 1 diabetes and the associations of basic conditioning factors with universal and health deviation self-care. Subjects for this study were 152 adolescents aged between 11 and 15 years with a diagnosis of Type 1 diabetes. Data were collected in the home setting of each adolescent and his or her family. The mean universal self-care scores ranged from 66.62% to 90%. The overall mean for this sample was 75.37, indicating that these adolescents took care of their self-care needs 75% of the time. Health deviation self-care was a mean of 27.26, indicating more positive self-care behaviors and treatment adherence. Health deviation and universal self-care were significantly and positively related (r = .36, p < .001). Ethnicity and adolescent sex were statistically significant in predicting universal self-care. Adolescent age was statistically significant in predicting health deviation self-care. Health deviation self-care decreases with age, suggesting that early adolescence or late school age is an appropriate time for interventions to strengthen self-care behaviors. Furthermore, the interrelationship of the two types of self-care supports the potential for a synergistic effect of intervention.

Factors associated with glycaemic outcome of childhood diabetes care in Denmark

AIMS

To study how structure and process of care is associated with outcome assessed by HbA(1c).

METHODS

Data for this cross-sectional study originated from the nationwide Danish Registry for Childhood Diabetes and two questionnaires. One questionnaire was sent to all children under 16 years of age with Type 1 diabetes in the year 2000 (N = 1087, response rate 80%). Another questionnaire was sent to the 19 centres in Denmark treating these children (response rate 100%). Simultaneously the children were asked to take a blood sample for central HbA(1c) analysis. Linear mixed models were used for analysis of associations between structure and process indicators and HbA(1c). Age, diabetes duration, sex, ethnicity, family structure and parents' occupational status were included as patient factors possibly affecting HbA(1c).

RESULTS

More visits to the outpatient clinic and higher insulin dosage were significantly associated with higher HbA(1c) (P = 0.002 and P = 0.0001, respectively). Increased frequency of blood glucose monitoring (BGM/week) and completed nephropathy screening were significantly associated with lower HbA(1c) value (estimates -0.008 and -0.49, P = 0.02, respectively). The structure indicators were not associated with HbA(1c), but telephone hot-line was positively associated with the process indicator BGM (estimate 4.02, P = 0.04). Children without Danish parents performed BGM significantly less frequently (-7.11, P = 0.0005) and had higher HbA(1c) (0.41, P = 0.06).

CONCLUSIONS

Most process indicators were significantly associated with HbA(1c), indicating relevant action of staff on glucose regulation. The structure indicators were not associated with outcome, necessitating more detailed studies on the influence of staffing resources, treatment strategies and targets in childhood diabetes management.

Parents' perceptions of factors that affect successful diabetes management for their children

OBJECTIVE

To learn which factors parents perceive to be most influential in determining successful type 1 diabetes management.

METHODS

A 4-stage mixed qualitative-quantitative method that consists of a series of focus groups, a survey, and in-depth interviews was used to ensure that parents generated, prioritized, and explained their own ideas. In each stage, parents offered a new level of insight into their perception of how children achieve good metabolic control while living as normal a life as possible. The survey responses were divided into statistically different ranks, and the Kruskal-Wallis test was used to compare the results between subgroups.

RESULTS

A total of 149 parents participated in the formative qualitative phases, 799 families (66%) responded to the parent-generated survey, and 67 explanatory interviews were conducted. The families who responded to the survey had children of varied ages (mean: 11.9 years; SD: 4.44) and diabetes control (mean hemoglobin A1c: 8.22%; SD: 1.65); 84.1% of respondents were white, 12.3% were black, and 89% were privately insured. The 30 survey items were statistically discriminated into 8 ranks. The items cover a wide range of categories, including concrete ways of achieving better control, families' or children's traits that affect coping ability, actions of the health care team that support versus undermine families' efforts, and the availability of community supports. No clear pattern emerged regarding 1 category that parents perceived to matter most.

CONCLUSIONS

Clinicians can affect many of the factors that parents perceive to make a difference in whether they can successfully raise a resilient child in good diabetes control. Future research needs to determine whether health care teams that address the concerns that parents raised in this study are more effective in guiding children to cope well with diabetes, to incorporate healthier lifestyles, and ultimately to achieve better metabolic control.

Evaluation of a programme of group visits and computer-assisted consultations in the treatment of adolescents with Type 1 diabetes

AIM

To examine the effects of group visits and computer-assisted consultations on quality of life and glycaemic control in adolescents with Type 1 diabetes.

METHODS

A total of 116 adolescents, aged 11-17 years, and their parents were randomly assigned to an intervention (n = 62) or a control group (n = 54). The intervention group was invited to a 15-month programme comprising group visits and computer-assisted consultations. The control group was offered traditional out-patient consultations. Outcomes included changes in HbA(1c) and the adolescents' assessment of generic and disease-specific health-related quality of life measured by the Child Health Questionnaire (CHQ-CF87) and the Diabetes Quality of Life Questionnaire (DQOL), respectively.

RESULTS

One hundred and one adolescents (55/46) agreed to participate, mean age 14.2 years (sd 1.5), mean diabetes duration 6.5 years (sd 3.6, range 1-16 years), mean HbA(1c) 9.3% (sd 1.4, range 6.1-12.8%). Eighty-three (72%) completed the questionnaires at follow-up (intervention/control 45/38). There were significant age by randomization group interactions for diabetes-related impact (P = 0.018), diabetes-related worries (P = 0.004), mental health (P = 0.046) and general behaviour (P = 0.029), implying that the intervention was effective in older adolescents (above 13-14 years). No significant effects on mean HbA(1c) were identified.

CONCLUSIONS

Group visits and computer-assisted consultations had beneficial effects on health-related quality of life in older adolescents, the role of this intervention being questionable in younger adolescents.

The impact of psychiatric comorbidities on readmissions for diabetes in youth

OBJECTIVE

Comorbid psychiatric disorders have been associated with poorer disease outcomes in diabetic youth. Less is known, however, about the relationship between psychiatric disorders and repeat hospitalizations for youth with diabetes.

RESEARCH DESIGN AND METHODS

We performed a retrospective cohort study using data from the Pediatric Health Information System, which included detailed discharge data from 37 non-competing children's hospitals in the U.S. Using logistic regression, we examined whether the presence of coded diagnoses for internalizing or externalizing disorders at an index hospitalization for diabetes was associated with increased risk for rehospitalization during follow-up (duration of follow-up ranged from 3 to 24 months). The analysis was stratified by age-groups, and we controlled for potential confounders including sex, age, race/ethnicity, type 1 versus type 2 diabetes, Medicaid status, intensive care unit utilization, length of stay during index admission, and duration of follow-up.

RESULTS

Among adolescents aged 13-18, internalizing disorders were associated with significantly increased odds of rehospitalization (odds ratio 1.79 [95% CI 1.27-2.52]); the point estimate for externalizing disorders was similar, but the finding was not statistically significant at the alpha = 0.05 level (1.74 [0.96-3.15]). No significant association between psychiatric diagnoses and odds of repeat hospitalization was observed in diabetic children aged 5-12 years.

CONCLUSIONS

Internalizing disorders are associated with increases in repeat hospitalizations for diabetes among adolescents. Future research is needed to explore the reasons for this finding, such as degree to which treatment nonadherence mediates this relationship and whether appropriate treatment of internalizing disorders results in improved diabetes outcomes and decreased readmissions.

Patient-reported assessments in diabetes care: clinical and research applications

Patient-reported assessments play an increasing role in diabetes care and research today. These assessments are used to evaluate new treatment regimens, explore attitudes, beliefs, and needs of diabetes populations, support inclusion of psychosocial aspects in daily care, and establish new patient-centered standards for quality-of-care improvement initiatives. Much work remains to be done to ensure that these activities will result in improved access to patient-centered diabetes care.

Is the relationship between adherence behaviours and glycaemic control bi-directional at adolescence? A longitudinal cohort study

AIM

To analyse the change in adherence to diabetes treatment and its association with metabolic control from childhood to adolescence. The Tanner pubertal staging model was selected as a marker of developmental maturity.

METHODS

In a multicentre, longitudinal cohort study, 142 children with Type 1 diabetes completed a scale that assessed adherence to treatment and a test of diabetes knowledge at the beginning of the study (T0) and four years later (T4). HbA1c and clinical data were collected at T0 and at T4.

RESULTS

From T0 to T4, the mean HbA1c increased from 8.2 +/- 1.6 to 9.1 +/- 1.4% (P < 0.001). Among patients at pubertal stages 1-4, adherence did not decline from T0 to T4, whereas the HbA1c level increased and a positive correlation between adherence and the knowledge score was noted (r = 0.32; P < 0.02). Among adolescents at pubertal stage 5, the level of adherence decreased (P < 0.01) from T0 to T4 and the HbA1c level increased despite an increase in the knowledge score (P < 0.001), a negative correlation between HbA1c and adherence was found (r = -0.37; P = 0.001) and adherence at T4 significantly added to the prediction of HbA1c at T4.

CONCLUSIONS

In this longitudinal study, an initial worsening of glycaemic control as a result of puberty preceded worsening of adherence behaviours. Low levels of adherence become predictive of HbA1c degradation among pubertal stage 5 adolescents. These results suggest a potential bi-directional relationship between glycaemic control and adherence.

Past 10-year status of insulin therapy for preschool-age Japanese children with type 1 diabetes

The aim of this study was to evaluate the past 10-year status of insulin therapy for preschool-age children with type 1 diabetes in Japan. One-hundred and forty-two patients who had been diagnosed at less than 5 years of age within the past 10 years (1993-2002) at 36 hospitals were registered in this study on April 2003. The methods of daily insulin therapy and episodes of severe hypoglycemia during the preschool period were investigated. Eighty-six (60.6%) children were treated with a pen-type device and 56 (39.4%) were treated with a syringe-type device. The once-a-day insulin regimen was used for 2, a twice-a-day regimen for 104, a three-times-a-day for 28 and a four-times-a-day for 8. Episodes of severe hypoglycemia were recorded in nearly half of the subjects, and one-fourth of the subjects had repeated episodes. One hundred and eleven of their parents were questioned regarding the degree of psychosocial stress experienced during the care of their children. Most parents worried about the glycosylated hemoglobin value at each hospital visit. They were next very afraid of nocturnal severe hypoglycemia, independent of any actual experience. These results suggest that although insulin therapy can involve various methods, the important point is to simultaneously provide good glycemic control and prevent severe hypoglycemia, especially during this age.

A randomized trial of regular standardized telephone contact by a diabetes nurse educator in adolescents with poor diabetes control

OBJECTIVE

The aim of this study was to determine the effect of regular standardized telephone contact by a diabetes nurse educator (DNE) on metabolic control, treatment compliance, and quality of life in adolescents with poorly controlled type 1 diabetes.

METHODS

A single-blinded 6-month randomized controlled trial was used. Participants included 46 of 49 eligible adolescents (13-17 yr) with type 1 diabetes >1-yr duration and hemoglobin A1c (HbA1c) >8.5% for the previous 6 months. Subjects were randomly assigned to 6 months of standard diabetes management or standard care plus weekly telephone contact by a DNE. Telephone conversations included review of events in the adolescents' lives and diabetes education, but the primary focus was on blood glucose results and insulin-dose adjustments. HbA1c, compliance with glucose monitoring, quality of life [Diabetes Quality of Life Scale for Youth (DQOLY)], and family functioning [Family Environment Scale (FES)] were assessed at baseline, and at 3 and 6 months. Posthoc, HbA1c levels were assessed 6 months following study completion.

RESULTS

Six months of regular telephone contact by a DNE had no immediate effect on any of the outcome measures. However, posthoc 6 months, HbA1c levels decreased (1% change compared to baseline) in 6/21 of the study group and 0/18 of the control group, while HbA1c increased in 4/21 of study subjects compared to 8/18 of control subjects (p = 0.015).

CONCLUSIONS

In contrast to adult studies, regular telephone contact did not lead to immediate improvements in metabolic control in adolescents with poorly controlled type 1 diabetes. However, knowledge and skills gained during the intervention may have had a delayed beneficial effect in these high-risk adolescents.

The Blood Glucose Monitoring Communication questionnaire: an instrument to measure affect specific to blood glucose monitoring

OBJECTIVE

The aim of this study was to present the psychometric properties of a new tool for evaluating affective response to blood glucose monitoring (BGM) in youths with type 1 diabetes and their parents.

RESEARCH DESIGN AND METHODS

Study participants included 153 youths with type 1 diabetes and their parents. Each youth and parent completed the Blood Glucose Monitoring Communication (BGMC) questionnaire, Diabetes Family Conflict Scale, and Pediatric Quality of Life Inventory. Statistical analyses evaluated the psychometric properties of the BGMC questionnaires and their association with glycemic outcomes.

RESULTS

Youth and parent BGMC questionnaires had acceptable internal consistency (youth, alpha = 0.77; parent, alpha = 0.82) and 1-year test-retest reliability (youth, r = 0.60; parent, r = 0.80). Higher BGMC questionnaire scores (indicating more negative affect) showed a strong association with higher levels of diabetes-specific family conflict (youth, r = 0.33; parent, r = 0.44) and poorer health-related psychosocial quality of life (youth, r = -0.50; parent, r = -0.42). Higher BGMC questionnaire scores were also associated with poorer glycemic control (youth, r = 0.28; parent, r = 0.20), even when the effects of diabetes-specific family conflict and psychosocial quality of life were controlled. Youths with BGMC questionnaire scores in the upper quartile had A1c values 1 percentage point higher (9.1%) than youths with scores in the lowest quartile (8.0%).

CONCLUSIONS

The BGMC questionnaires have strong psychometric properties and are convenient measures of affect specific to BGM. Further, BGM affect is associated with glycemic outcomes and may provide a unique contribution to factors associated with glycemic control in youths.

Diabetes self-care: lessons from research on the family and broader contexts

The foundation of diabetes management is the self-care behavior of the patient. All of the systems within which the person with diabetes interacts, as well as the media and broader social and cultural values, affect this self-care behavior. In this article I focus on recent research that has examined the link between relationships in the patient's intimate network (i.e., family and close friends) and in the patient's exchange network (i.e., patient-provider relationship, Internet support). The goal of this review is to identify relational targets associated with self-care behaviors that are potentially modifiable within the diabetes medical care setting. Evidence-based suggestions are made for points of intervention entry, and areas for future research are explored.