Prediction of adolescents' glycemic control 1 year after diabetes-specific family conflict: the mediating role of blood glucose monitoring adherence

Daily diabetes-specific family conflict, problems, and blood glucose during adolescence

Diabetes-related family conflict is widely regarded as a risk factor for diabetes outcomes, yet it has not been examined on a daily basis. Parental acceptance may attenuate the degree to which family conflict is associated with diabetes outcomes. The present study examined (a) within- and between-person fluctuations in diabetes problems and family conflict, (b) within- and between-person links between conflict and blood glucose (BG) mean, and (c) whether parental acceptance moderated these associations. One hundred eighty adolescents (Mage = 12.92 years) with T1D completed a 14-day diary measuring diabetes problems, conflict with mother, conflict with father, and parental acceptance at the end of each day. Daily average BG values were calculated from glucometer readings. Higher diabetes problems on average across the 14-day diary were associated with more average conflict with mothers (between-person), but daily fluctuations in the number of diabetes problems were not related to daily conflict (within-person). Adolescents with higher conflict with mothers and fathers on average across the 14 days had higher BG means (between-person); however, on days when adolescents reported higher conflict, they had greater risk for low BG (within-person). Daily parental acceptance did not moderate associations between problems and conflict nor conflict and BG mean. This study was the first to examine daily diabetes-specific conflict with mothers and fathers during adolescence. The number of diabetes problems did not predict daily conflict. Fluctuations in daily conflict were associated with greater risk for low BG, underscoring the need for future research examining in-the-moment relations among conflict and BG extremes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Naturalistically observed interpersonal problems and diabetes management in older adolescents and young adults with type 1 diabetes

OBJECTIVE

This study investigated the links between naturalistically observed and self-reported interpersonal problems, diabetes management, and glucose levels in older adolescents and young adults with type 1 diabetes.

DESIGN

Sixty-eight older adolescents and young adults (aged 17-20 years) participated in a cross-sectional study that consisted of three home visits and a daily diary segment.

MAIN OUTCOME MEASURES

Participants wore the Electronically Activated Recorder (EAR) for four days to capture interpersonal problems and wore a continuous glucose monitor for blood glucose levels. Researchers also collected HbA1c values, conducted an interview to assess diabetes management, and collected participant-reported severity of interpersonal problems.

RESULTS

High EAR-observed interpersonal problems were associated with poor diabetes management. Multiple regression analyses revealed that high EAR-observed interpersonal problems continued to explain variance in poor diabetes management after including self-reported interpersonal problems and covariates.

CONCLUSION

These findings corroborate literature suggesting that negative interactions are associated with type 1 diabetes management. This study is the first to use the EAR to capture naturalistically observed interactions in this population and identify its utility beyond self-reports. These findings highlight the importance of considering naturalistically observed interactions when developing interventions to promote better diabetes management in older adolescents and young adults.

Patient and Parent Well-Being and Satisfaction With Diabetes Care During a Comparative Trial of Mobile Self-Monitoring Blood Glucose Technology and Family-Centered Goal Setting

Patient engagement in the process of developing a diabetes treatment plan is associated with person-centered care and improved treatment outcomes. The objective of the present study was to evaluate the self-reported patient and parent-centered satisfaction and well-being outcomes associated with the three treatment strategies utilized in a comparative effectiveness trial of technology-enhanced blood glucose monitoring and family-centered goal setting. We evaluated data from 97 adolescent-parent pairs at baseline and 6-months during the randomized intervention. Measures included: Problem Areas in Diabetes (PAID) child and parent scales, pediatric diabetes-related quality of life, sleep quality, and satisfaction with diabetes management. Inclusion criteria were 1) ages 12-18 years, 2) a T1D diagnosis for at least six months and 3) parent/caregiver participation. Longitudinal changes in survey responses were measured at 6 months from baseline. Differences between and within participant groups were evaluated using ANOVA. The average age of youth participants was 14.8 ± 1.6 years with half of the participants being female (49.5%). The predominant ethnicity/race was Non-Hispanic (89.9%) and white (85.9%). We found that youth perceived 1) greater of diabetes-related communication when using a meter capable of transmitting data electronically, 2) increased engagement with diabetes self-management when using family-centered goal setting, and 3) worse sleep quality when using both strategies together (technology-enhanced meter and family-centered goal setting). Throughout the study, scores for self-reported satisfaction with diabetes management were higher in youth than parents. This suggests that patients and parents have different goals and expectations regarding their diabetes care management and care delivery. Our data suggest that youth with diabetes value communication via technology and patient-centered goal setting. Strategies to align youth and parent expectations with the goal of improving satisfaction could be utilized as a strategy to improve partnerships in diabetes care management.

Predicting optimal use of continuous glucose monitors in adolescents with type 1 diabetes: It's about benefit and burden

PURPOSE

Youth with type 1 diabetes (T1D) often use Continuous Glucose Monitoring (CGM) devices; however, many do not wear them consistently enough to obtain optimal glycemic benefit. This study aimed to identify demographic and psychosocial predictors of optimal CGM use in adolescents with T1D to inform nurse-led interventions to improve adherence.

DESIGN AND METHODS

Cross-sectional survey data from youth (12-19 years) using CGM were analyzed to determine whether perceived benefits/burdens of CGM, self-efficacy, and coping predicted being a "CGM Optimizer" (wearing CGM 6-7 days/week) or "CGM Sub-user."

RESULTS

Of 282 adolescents (54% female), 161 were CGM Optimizers and 121 were CGM Sub-Users. Optimizers were younger (15.91 ± 2.17 years vs. 16.79 ± 2.17, p = 0.001), more likely non-Hispanic White (91.9% vs 83.5%, p = 0.029), and more likely to have private insurance (82.0% vs. 69.4%, p = 0.009). Every 1-point increase on Benefits of CGM scale was associated with 2.8 times greater odds of being an Optimizer (OR = 2.82, 95% CI 1.548-5.132, p = 0.001), and every 1-point increase on the Burdens of CGM scale was associated with a 52% decrease in odds (OR = 0.48, 95% CI = 0.283-0.800, p = 0.005), with final logistic regression model (including only these two predictors) explaining 22.3% of variance.

CONCLUSION

CGM Optimizing adolescents were more likely to perceive higher benefit and lower burden of CGM.

PRACTICAL IMPLICATIONS

Nurse-led interventions to promote benefits of CGM and mitigate burden may help youth increase adherence with CGM to achieve glycemic benefit.

Longitudinal associations between family conflict, parent engagement, and metabolic control in children with recent-onset type 1 diabetes

INTRODUCTION

We prospectively investigated the associations between diabetes-related family conflict, parent engagement in child type 1 diabetes (T1D) care, and child glycated hemoglobin (HbA1c) in 127 families of school-age children who we recruited within the first year of their T1D diagnosis.

RESEARCH DESIGN AND METHODS

Parents completed the Diabetes Family Conflict Scale-Revised (DFCS-R) to assess for diabetes-related family conflict and the Diabetes Self-Management Questionnaire-Brief (DSMQ-Brief) to assess parent engagement in child T1D care at the initial study visit (T1) and at 12 (T2) and 27 (T3) months later. We also collected child HbA1c at these time points. Our analyses included Pearson correlations and repeated measures linear mixed models controlling for child age, sex, and T1D duration at T1.

RESULTS

Parents' DFCS-R scores negatively correlated with DSMQ-Brief scores (r=-0.13, p<0.05) and positively correlated with children's HbA1c (r=0.26, p<0.001). In our linear mixed models, parents' DSMQ-Brief scores were unchanged at T2 (β=-0.71, 95% CI -1.59 to 0.16) and higher at T3 (β=8.01, 95% CI 6.89 to 9.13) compared with T1, and there was an association between increasing DFCS-R and decreasing DSMQ-Brief scores (β=-0.14, 95% CI -0.21 to -0.06). Child HbA1c values were significantly higher at T2 (β=0.66, 95% CI 0.38 to 0.94) and T3 (β=0.95, 95% CI 0.63 to 1.27) compared with T1, and there was an association between increasing DFCS-R scores and increasing child HbA1c (β=0.04, 95% CI 0.02 to 0.06).

CONCLUSIONS

Increasing diabetes-specific family conflict early in T1D may associate with decreasing parent engagement in child T1D care and increasing child HbA1c, suggesting a need to assess and intervene on diabetes-specific family conflict. Trial registration number NCT03698708.

Correlates of Continuous Glucose Monitoring Use Trajectories in Children and Adolescents with Type 1 Diabetes

The goal of this study was to characterize trajectories of continuous glucose monitoring (CGM) use in youth 5-12 weeks after starting CGM and examine what factors differentiate between the trajectory groups. Parent-youth dyads completed assessments before starting CGM. Days of CGM use between weeks 5 and 12 were accessed through cloud-based data repository. Three patterns of use were observed among 96 youth (mean age 13.4 ± 2.75 years; 75% white): sustained high, declining, and sustained low. Youth in the sustained low and declining groups were more likely than those in the sustained high group to use a receiver (versus smart phone). There were no differences between the trajectory groups with respect to age, race, ethnicity, income, or insulin regimen. Future research should examine trajectory groups for a longer follow-up period and identify baseline factors that reliably predict which youth will have low or declining CGM use over time.

Psychosocial outcomes in young adolescents with type 1 diabetes participating in shared medical appointments

For youth with type 1 diabetes (T1D), the early adolescent period is associated with worsening diabetes management and high rates of negative psychosocial issues, including depressive symptoms and family conflict. Alternative clinical models may help improve both diabetes and psychosocial outcomes. Our study aims to investigate whether Team Clinic, a shared medical appointment model developed specifically for adolescents with T1D, will improve psychosocial outcomes for middle school-aged youth. Youth with T1D, 11-13 years of age, and their caregivers, participated in a randomized controlled trial comparing Team Clinic to traditional clinic visits (control group). Diabetes characteristics were obtained at every visit. Participants and caregivers completed depression screening and family conflict questionnaires at baseline and end of study. Changes in mean scores on clinical and psychosocial outcomes from baseline to end of study were compared between groups using linear mixed-effects models. Eighty-six youth (51% female; 74% White; 10% Hispanic) completed at least one visit during the 12-month study period. At the end of the study, control group participants reported increases in Emotional Problems compared to Team Clinic participants, including higher levels of Negative Mood/Physical Symptoms (p = 0.02). Team Clinic participants reported reduced family conflict surrounding diabetes at study end, compared to control group participants (p = 0.03). Caregivers did not report change in depressive symptoms or family conflict during the study. Hemoglobin A1C levels did not change over time in either group. Participation in Team Clinic was associated with improved psychosocial outcomes in middle school-aged participants with T1D.

Systematic Review: Diabetes Family Conflict in Young People With Type 1 Diabetes

OBJECTIVE

To investigate the relationships between diabetes-specific family conflict and health outcomes of young people with type 1 diabetes (T1D).

METHODS

A systematic review was performed according to the PRISMA statement (registration number: CRD42020164988). PubMed, Embase, PsycNET, reference lists of included studies, and other relevant reviews were searched (1990-2020). Two independent reviewers screened titles, abstracts, and full-texts. Studies were included if they sampled young people with T1D (mean age between 14 and 25 years) and examined the relationship between diabetes-specific family conflict and the following outcomes: glycated hemoglobin (HbA1c), treatment adherence, blood glucose monitoring, depression, anxiety, quality of life, and/or well-being.

RESULTS

A total of 20 studies met the predetermined inclusion criteria. Greater diabetes-specific family conflict was significantly related to higher HbA1c values in 17 studies. Seven studies reported a significant association between greater diabetes family conflict and suboptimal treatment adherence and/or less frequent blood glucose monitoring. However, significant relationships between conflict and HbA1c and/or treatment adherence were not found in four studies. Seven studies in total reported that greater diabetes family conflict was significantly related to poorer quality of life or well-being and greater depressive and/or anxiety symptoms in young people.

CONCLUSIONS

Diabetes-specific family conflict is associated with some adverse health outcomes for young people with T1D. However, more longitudinal studies of young people aged older than 16 years are needed. Screening for and addressing diabetes-specific family conflict is recommended, given the growing number of studies linking family conflict to various adverse health outcomes in young people with T1D.

Development and initial validation of the diabetes family conflict scale (revised)-short form in a racially and income diverse sample

OBJECTIVE

The purpose of the study was to develop a short form of the revised diabetes family conflict scale (DFCS) in a racially and income diverse sample while retaining strong psychometric properties.

METHODS

One seventy nine youth with type 1 diabetes (ages 12-18 years) and caregivers completed the DFCS-Revised as well as assessments of adherence, psychosocial functioning, and diabetes-related stress. Hemoglobin A1c was also obtained. The sample was split at random into a development sample and validation sample.

RESULTS

Confirmatory factor analyses in the validation sample supported the use of a six-item short form (DFCS-SF) either as a total score (6-items) or a direct (3-item) and indirect (3-item) score. Variations of the DFCS-SF (three items of the 6-item short form) also had acceptable model fit. The short-form questionnaires had acceptable internal consistency and convergent validity (6-item: Cronbach's a = 0.865, full scale DFCS r = 0.954; 3-item: Cronbach's a = 0.757, full scale DFCS r = 0.912). The DFCS-SF showed measurement invariance across both youth and caregiver respondents. Greater report of the DFCS-SF by both youth and caregivers was significantly associated with higher HbA1c, more diabetes-related stress, and more psychosocial concerns.

CONCLUSIONS

The DFCS-SF developed in the present study shows psychometric integrity in a diverse population of youth and can be utilized by providers to rapidly assess and potentially implement interventions to reduce diabetes family conflict, a psychosocial concern which is associated with elevated HbA1c, non-optimal adherence, diabetes-related stress, and psychological distress.

Family conflict in type 1 diabetes: Who is at risk?

BACKGROUND/OBJECTIVE

Diabetes-related conflict between caregiver and child has been associated with lower quality of life, reduced treatment adherence, and higher hemoglobin A1C. The objective of this project was to identify patient and family characteristics associated with higher levels of diabetes-specific family conflict.

METHODS

This was a cross-sectional study. Caregivers of children aged 4- to 18-years-old with type 1 diabetes were recruited from diabetes clinics across British Columbia. Data were collected through chart reviews and patient surveys, including the Diabetes Family Conflict Scale and the Adherence in Diabetes Questionnaire. All caregivers and children ≥8-years-old were invited to complete the survey. Potential predictors were explored using univariate and multivariable linear regression models.

RESULTS

In the unadjusted analysis, higher caregiver report of conflict (n = 196) was associated with: low family income, non-Caucasian ethnicity, missed school, older age at diagnosis, and insulin regimen (2-3 injections/day rather than multiple daily injections or pump). When all variables were adjusted for simultaneously, income, insulin regimen, one or more stay at home parent and recent hospitalization were significant. For the child report (n = 111), higher maternal education was associated with lower conflict in the unadjusted analysis and non-Caucasian ethnicity was associated with higher conflict in the adjusted analysis.

CONCLUSIONS

This exploratory study identified possible novel associations between patient and family characteristics and diabetes-related family conflict.

Exploring parental perspectives after commencement of flash glucose monitoring for type 1 diabetes in adolescents and young adults not meeting glycaemic targets: a qualitative study

AIMS

To explore parental perspectives after flash glucose monitoring commencement in adolescents and young adults with type 1 diabetes who were not meeting glycaemic targets.

METHODS

Twelve semi-structured interviews were conducted among parents of adolescents and young adults between the ages of 14 and 20 years (inclusive) with type 1 diabetes and not meeting glycaemic targets [HbA_1c 81-130 mmol/mol (9.6-14.0%)] participating in a randomized controlled trial. Interviews were transcribed, then thematic analysis was performed to identify themes regarding parental experiences.

RESULTS

Four key themes were found: flash glucose monitoring improved parental emotional well-being; flash glucose monitoring reduced diabetes-specific conflict within families; flash glucose monitoring facilitated the parental role in diabetes management; and sensor-related challenges, particularly sensors falling off, interfered with using flash glucose monitoring for diabetes management. The cost of self-funded sensors was the only barrier to continuing flash glucose monitoring that parents reported.

CONCLUSIONS

This study provides new insights into the potential benefits and challenges of flash glucose monitoring use, drawn from the perspective of parents of adolescents and young adults not meeting glycaemic targets. As parents are often key partners in obtaining or purchasing this technology, these findings can be used to further inform parental expectations of this technology.

Family Functioning and Medical Adherence Across Children and Adolescents With Chronic Health Conditions: A Meta-Analysis

Objectives

A meta-analysis examined family functioning and medical adherence in children and adolescents with chronic health conditions. Family functioning was evaluated at the level of the family unit, as well as parent-child interactions.

Methods

We conducted literature searches using PubMed, PsycINFO, SCOPUS, Web of Science, and Cochrane. After reviewing 764 articles, 62 studies met eligibility criteria. Pearson's r correlations were the effect size of interest. We conducted both omnibus and domain-specific (e.g., family conflict, cohesion) meta-analyses. Meta-regressions examined whether relevant covariates related to the magnitude of the effect.

Results

The omnibus meta-analysis showed that family functioning was significantly related to medical adherence across a variety of pediatric chronic health conditions. Lower family conflict, greater family cohesion, greater family flexibility, more positive communication, and better family problem-solving were each associated with better adherence. There were no significant differences in the magnitude of the omnibus effect based on child age, measurement features (subjective vs. objective or bioassay adherence; family unit vs. parent-child interactions), or study quality.

Conclusions

Consistent with social-ecological frameworks, findings supported links between family functioning and medical adherence. This study highlights several limitations of the extant research, including absence of a guiding theoretical framework and several methodological weaknesses. We offer clinical and research recommendations for enhancing scientific understanding and promotion of adherence within the family context.

Factors predicting poor glycemic control in the first two years of childhood onset type 1 diabetes in a cohort from East London, UK: Analyses using mixed effects fractional polynomial models

BACKGROUND/OBJECTIVE

Poor early glycemic control in childhood onset type 1 diabetes (T1D) is associated with future risk of acute and chronic complications. Our aim was to identify the predictors of higher glycated hemoglobin (HbA1c) within 24 months of T1D diagnosis in children and adolescents.

METHODS

Mixed effects models with fractional polynomials were used to analyze longitudinal data of patients <19 years of age, followed from T1D diagnosis for up to 2 years, at three diabetes clinics in East London, United Kingdom.

RESULTS

A total of 2209 HbA1c observations were available for 356 patients (52.5% female; 64.4% non-white), followed from within 3 months of diagnosis during years 2005 to 2015, with a mean ± SD of 6.2 ± 2.5 HbA1c observations/participant. The mean age and HbA1c at diagnosis were 8.9 ± 4.3 years and 10.7% ±4.3% (or expressed as mmol/mol HbA1c mean ± SD 92.9 ± 23.10 mmol/mol) respectively. Over the 2 years following T1D diagnosis, HbA1c levels were mostly above the National Institute for Health, Care and Excellence (NICE), UK recommendations of 7.5% (<58 mmol/mol). Significant (P < .05) predictors of poorer glycemic control were: Age at diagnosis (12-18 years), higher HbA1c at baseline (>9.5%, ie, >80 mmol/mol), clinic site, non-white ethnicity, and period (pre-year 2011) of diagnosis. Additionally in univariable analyses, frequency of clinic visits, HbA1c at diagnosis, and type of insulin treatment regimen showed association with poor glycemic control (P < .05).

CONCLUSIONS

Major risk factors of poorer glycemic control during 3-24 months following childhood onset T1D are: diagnosis prior to 2011, higher HbA1c levels at baseline, age at diagnosis, non-white ethnicity, and clinic site.

Depressive symptoms and glycaemic control in adults with type 1 diabetes: an exploratory study on the role of family functioning

AIMS

Psychological distress and family functioning have a considerable impact on diabetes self-management and glycaemic control in individuals with type 1 diabetes (T1D). However, the influence of both individual and family factors on glycaemic control has not been adequately investigated yet. This study aimed at examining the relationship between perceived family functioning and depressive symptoms with the frequency of capillary self-monitoring of blood glucose (SMBG) and glycaemic control (HbA_1c) in a large sample of adults with T1D.

METHODS

In a cross-sectional study design, we consecutively enrolled 90 adults with T1D diagnosis from at least 1 year and currently living in their family of origin or conjugal family from at least 1 year before the enrolment. Questionnaires were administered to assess family functioning and depressive symptoms. The SMBG frequency over the past 3 months and the most recent HbA_1c measurement were also collected in each individual. Correlation and mediation analyses were carried out.

RESULTS

Glycaemic control showed a positive relationship with depressive symptoms and family balanced cohesion, while SMBG frequency was correlated with family balanced flexibility and rigidity, but not with depressive symptoms. Mediation analyses showed that family rigidity mediates the effect of depressive symptoms on glycaemic control.

CONCLUSIONS

This exploratory study highlighted the significance of a cohesive family context to facilitate the achievement of individual glycaemic goals in individuals with T1D. These observations, if confirmed in larger data sets, would timely call for a comprehensive family care assessment as part of the evaluations routinely carried out in the ambulatory care of these individuals.

Special Considerations in the Systematic Psychosocial Screening of Youth with Type 1 Diabetes

Objective

The American Diabetes Association recommends psychosocial screening for individuals with type 1 diabetes (T1D). The purpose of this study is to present (a) several high priority decisions that program developers may encounter when building a new psychosocial screening program and (b) both the screening development process and results of one mental health screening program within a multidisciplinary pediatric diabetes clinic, with particular emphasis on parent-youth screening agreement and changes to elevation status over time.

Methods

Youth with T1D ages 12–17 and parents of youth with T1D ages 8–17 were administered mental health screeners as a part of outpatient diabetes visits over a 1-year period. Youth depression and anxiety were screened using self- and parent proxy-report versions of the Patient-Reported Outcomes Measurement Information System (PROMIS).

Results

Youth (n = 154) and parents (n = 211) completed mental health screening measures, such that 228 youth were screened. Intraclass correlation coefficients (ICCs) between youth- and parent proxy-report agreement were good for the measures of depression (ICC = .787) and anxiety (ICC = .781), with parent proxy-reports significantly higher than youth self-reports of anxiety (p &lt; .01). Of the 93 youth with follow-up screening data and no youth- or parent proxy-reported elevation on the initial screener, 16.1% had at least one elevated screener within 1 year.

Conclusions

Findings indicate that questions of who to screen and how often to screen may deserve increased scrutiny, as this screening program’s data suggest that there may be benefit to obtaining both youth- and parent report more often than annually.

Problems With Self-Regulation, Family Conflict, and Glycemic Control in Adolescents Experiencing Challenges With Managing Type 1 Diabetes

Objective

This study explored the associations between problems with self-regulation and glycemic control (HbA1c) in teens experiencing challenges with managing type 1 diabetes by examining greater diabetes-related family conflict and poorer adherence as serial mediators of the link between greater problems with self-regulation and higher HbA1c.

Methods

Teens experiencing challenges with managing type 1 diabetes (n = 93, HbA1c ≥8%, 96% White, 57% male) completed an HbA1c test, and their parents completed assessments including measures of adherence and family conflict related to diabetes management during an intake for a larger Web-based intervention study or fMRI study. Teen problems with self-regulation were indexed the Child Behavior Checklist using the dysregulation profile.

Results

Bivariate correlations found significant associations between greater problems with self-regulation, greater family conflict about diabetes management, poorer adherence, and higher HbA1c. However, only greater family conflict, and not adherence, significantly explained the association between greater self-regulation problems and higher HbA1c.

Conclusions

These findings suggest that among teens experiencing challenges with managing type 1 diabetes, interventions that decrease family conflict may be critical to promoting optimal glycemic control in those teens with greater problems with self-regulation.

Family Functioning, Medical Self-Management, and Health Outcomes Among School-Aged Children With Sickle Cell Disease: A Mediation Model

Background

Informed by the Pediatric Self-Management Model, the present study tested relationships between parent and family functioning, sickle cell disease (SCD) self-management, and health outcomes for children with SCD.

Method

83 children with SCD and a parent completed baseline data as part of a larger investigation of a family-based, problem-solving intervention for children with SCD (M age = 8.47). Youth and parents completed a measure of child health-related quality of life (HRQOL), and parents completed measures of family efficacy, parenting stress, and SCD self-management. SCD pain episodes and urgent health utilization information over the past year were obtained via medical chart review.

Results

SCD self-management mediated the relationship between parent-reported family efficacy and parent proxy HRQOL, as well as the relationship between parenting stress and child and parent proxy HRQOL. Mediation models were nonsignificant for outcomes beyond HRQOL, including SCD pain episodes and urgent health utilization.

Conclusion

Fostering family efficacy and reducing parenting stress may be meaningful intervention targets for improving SCD self-management and child HRQOL among school-aged children. Although findings were consistent with the Pediatric Self-Management Model in terms of HRQOL, the model was not supported for pain episodes or urgent health utilization, highlighting the need for multi-method, longitudinal research on the SCD self-management behaviors that are linked to preventable health outcomes.

Parental Self-Control as a Moderator of the Association Between Family Conflict and Type 1 Diabetes Management

OBJECTIVE

To examine whether parental self-control (i.e., parents' ability to regulate their emotions, cognitions, and behaviors) moderates the detrimental association between type 1 diabetes (T1D)-specific family conflict and adherence and HbA1c, such that conflict is most detrimental when parental self-control is low.

METHODS

One hundred and forty-nine adolescents diagnosed with T1D (Mage = 14.09; 53% female) reported on their T1D-specific conflict with their mothers and fathers and their adherence to the T1D regimen at two time points (6 months apart). Mothers and fathers reported on their self-control. Glycated hemoglobin (HbA1c) was obtained from the medical record at both time points.

RESULTS

Higher adolescent-reported conflict with father was associated concurrently with higher HbA1c and lower adherence only for fathers with low self-control (ps < .05). Higher adolescent-reported conflict with mother was also associated concurrently with lower adherence only for mothers with lower self-control (p < .05); no significant moderation was found for mothers' self-control in predicting HbA1c. Longitudinal analyses indicated family conflict with mother predicted changes in adherence and HbA1c, but there were no significant moderating effects of either mother or father self-control.

CONCLUSIONS

Lower parental self-control may prevent parents from handling diabetes-related family conflict in a productive manner. We discuss the implications of parental self-control as an intervention target for health care professionals working with adolescents with T1D and their families.

Socio-economic, demographic, and clinical correlates of poor glycaemic control within insulin regimens among children with Type 1 diabetes: the SEARCH for Diabetes in Youth Study

AIM

To examine the distribution and association of sociodemographic, adherence, and barriers-to-care factors in relation to glycaemic control within insulin regimens in US children with Type 1 diabetes in the SEARCH for Diabetes in Youth Study.

METHODS

Self- or parent-reported data from 1095 children with Type 1 diabetes aged 10-17 years were collected on insulin regimen, sociodemographics, diabetes self-management, diabetes-related family conflict and barriers to care. Multivariable logistic regression analysis identified poor glycaemic control correlates within each insulin regimen.

RESULTS

Participants included 694 children on insulin pump therapy, 188 receiving basal-bolus injections, and 213 on a mixed insulin regimen. Of these, 28.5%, 45.2% and 51.2%, respectively, had poor glycaemic control [HbA_1c ≥ 80 mmol/mol (9.5%)]. Family conflict between parent and child regarding diabetes management was the only factor significantly associated with poor glycaemic control in all insulin regimens (insulin pump, P≤ 0.0001; basal-bolus injections, P=0.0002; mixed insulin regimen, P=0.0103). For children on insulin pump, poor control was significantly associated with non-white race (P=0.0008), living in multiple households (P=0.0331), having Medicaid insurance (P=0.0090), and decreased insulin adherence (P<0.0001). For children on a mixed insulin regimen, living in multiple households (P=0.0256) and not spending enough time with healthcare provider (P=0.0058) correlated with poor control.

CONCLUSIONS

A high percentage of US children with Type 1 diabetes had poor glycaemic control, especially those not using an insulin pump. Early identification of children with risk factors associated with poor glycaemic control within insulin regimens and addressing diabetes-related family conflict may allow interventions to improve diabetes management.

Diabetes-Related Emotional Distress Over Time

BACKGROUND AND OBJECTIVES

Many adolescents with type 1 diabetes experience diabetes-related distress (DRD; the negative emotional reactions specific to managing diabetes), but most research on DRD among adolescents relies on cross-sectional data. We assess adolescents' longitudinal DRD patterns and predictors of chronic DRD.

METHODS

This secondary analysis of data from a depression prevention clinical trial included 264 adolescents with type 1 diabetes randomly assigned to a resilience or education intervention (mean age: 15.7 ± 1.1 years; 59.8% female). Youth reported their DRD at 5 assessments over 16 months. Using latent class growth analysis, we classified adolescents into trajectory groups according to baseline starting point (intercept) and rate of change (slope) of DRD. We examined bivariate associations between trajectory group membership and demographic and clinical factors. Baseline predictors of chronic DRD were assessed via multiple logistic regression.

RESULTS

Participants were classified into 4 groups: stable high DRD (7.2%; high intercept, flat slope), stable moderate DRD (28.0%; above-average intercept, flat slope), improving DRD (33.7%; average intercept, downward slope), and low DRD (31.1%; below-average intercept, downward slope). Lower hemoglobin A1c, greater adherence, fewer socioemotional difficulties, and more adaptive coping distinguished the improving and low DRD trajectories. Chronic DRD patterns were associated with female sex and higher depressive symptoms and hemoglobin A1c.

CONCLUSIONS

In this study of adolescents' DRD trajectories during and after a psychoeducational intervention, one-third of youth were classified as having chronic, elevated DRD. Links with multiple clinical factors support efforts for routine DRD screening and comprehensive interventions for distressed youth.

The Glucose Control Resistance Scale

OBJECTIVE

While past research found family conflict, disordered eating, body image concerns and anxious self-doubts may affect adolescent diabetic glucose control, available measures of adherence mainly focus on management tasks. The current study aimed to combine measures of emotional distress and beliefs with decisions concerning management in a new measure of resistance to treatment adherence: the 12-item Glucose Control Resistance Scale (GCRS).

METHODS

Participants included 135 adolescents and their parents from a pediatric diabetes clinic. Family conflict, body image concerns, anxious self-doubts and glucose control resistance were assessed.

RESULTS

Factor analysis identified 12 items, with loadings of ≥0.40, which were used to form the GCRS. The scale had adequate reliability and there was a significant correlation between child and parent GCRS scores. One factor, family conflict, was significantly related to hemoglobin A1c (HbA1c) levels, but a set of four factors explained a total of 12% of the variance in HbA1c levels. Of the demographic variables considered (gender, number of parents at home, age, body mass index z-score), only gender was significantly associated with adolescent perceptions of family conflict.

CONCLUSION

The GCRS may allow diabetic care teams to better understand the origin of family conflict perceptions and the motivational beliefs that modify behavior and contribute to independent self-management and glucose control. Each question was designed to be meaningful in interventions by addressing common items of resistance to adherence and impulsive management decisions. The GCRS may be used by providers as an initial short screening survey on an annual or semi-annual basis.

Medical and Psychological Considerations for Carbohydrate-Restricted Diets in Youth With Type 1 Diabetes

PURPOSE OF REVIEW

Given the challenges achieving recommended glycemic targets in youth with type 1 diabetes (T1D), providers may consider recommending carbohydrate-restricted diets (CRDs) to optimize glycemic control. The goal of the present review is to describe relevant literature on the potential medical and psychosocial benefits and risks of CRDs in youth with T1D.

RECENT FINDINGS

Limited data exist on the effects of CRDs in pediatric populations. Findings from studies with youth and adults are mixed; some indicate that CRDs may be associated with desirable medical outcomes, such as improved glycemic control and reduced HbA1c, which may contribute to positive psychological outcomes such as reduced diabetes distress and depressive symptoms. Others suggest that CRDs may also be associated with detrimental outcomes, including mineral deficiencies and suboptimal growth, and dietary restriction has been linked to greater diabetes distress, disordered eating, and diabetes management. More research is needed to evaluate benefits and risks of CRDs in youth. Providers should exercise caution when discussing CRDs with youth and families, particularly when considering CRDs for youth at elevated risk for eating disordered behavior.

Identifying and addressing gaps in reproductive health education for adolescent girls with type 1 diabetes

Aims

Adolescent girls with diabetes are at risk for adverse pregnancy outcomes due to age, risk-taking behavior, poor glycemic control, and lack of knowledge. Our aims were to assess attitudes and behaviors related to reproductive health education (RHE) among diabetes healthcare providers and adolescent girls with diabetes, and to pilot a brief clinic-based RHE intervention.

Methods

We surveyed 29 providers and 50 adolescent girls with type 1 diabetes about RHE experiences, attitudes, and behaviors. We piloted the RHE intervention with 9 adolescent-parent dyads.

Results

50% of providers were very uncomfortable discussing pregnancy or contraception. Most (72%) did not proactively initiate RHE; common barriers included insufficient time and subject knowledge. Fewer than 10% recommended long-acting reversible contraceptives. A minority (10%) of adolescents had discussed pregnancy or contraception with a provider. RHE sessions lasted a median of 16 (range 13–24) minutes, and there were promising trends for changes in adolescents’ self-efficacy and intentions to use contraception and seek preconception counseling and in their knowledge of reproductive health.

Conclusion

Adolescent girls with diabetes rarely receive education on pregnancy and contraception due to provider discomfort, limited knowledge, and limited time. RHE using easily-accessible materials with an educator may help address this gap in care.

Multi-informant path models of the influence of psychosocial and treatment-related variables on adherence and metabolic control in adolescents with type 1 diabetes mellitus

Background

We assessed the associations between metabolic control and adherence and a broad range of adolescent and family characteristics (e.g., gender, family structure), treatment-related variables (e.g., disease duration, treatment modality), and psychosocial factors (e.g., symptoms of depression and anxiety, parental support, self-efficacy) in a nationwide study of Danish adolescents (age 12–17 years) with type 1 diabetes mellitus (T1DM).

Methods

Sixty-four percent of invited families participated by completing a survey and providing a blood sample. Two path models of associations between generic and diabetes-related family factors, adolescent self-efficacy, emotional difficulties, and metabolic control and adherence were tested, one for adolescents and one for caregivers. Demographic variables were included as covariates.

Results

Both path models demonstrated a satisfying model fit. In both models, metabolic control was associated with adherence, age, and T1DM duration. In the adolescent model, metabolic control was also related to treatment modality, single-parent household, caregiver non-support, and anxiety, whereas in the caregiver model metabolic control was associated with family conflict and caregiver support. In both models, adherence was related to age, duration, treatment modality, family conflict, caregiver support, family functioning, and emotional difficulties of the adolescent. In the adolescent model, adherence was also related to adolescent self-efficacy, whereas in the caregiver model adherence was associated with adolescent gender and caregiver non-support and support. Adolescent self-efficacy, emotional well-being, and difficulties related to adolescent/caregiver interaction appeared to be particularly important, as indicated by their stronger association with adherence and/or metabolic control.

Conclusion

The results highlight the value of applying a multi-informant approach to address the psychosocial well-being of adolescents with diabetes in a large national sample. Self-efficacy, emotional, and family-related difficulties are important aspects to address in both clinical care and future research regarding adolescents with T1DM.

Mobile Momentary Assessment and Biobehavioral Feedback for Adolescents with Type 1 Diabetes: Feasibility and Engagement Patterns

BACKGROUND

Integration of momentary contextual and psychosocial factors within self-management feedback may provide more specific, engaging, and personalized targets for problem solving.

METHODS

Forty-four youth ages 13-19 with type 1 diabetes (T1D) were provided a Bluetooth meter and completed the 30-day protocol. Participants were randomized to "app + meter" or "meter-only" groups. App + meter participants completed mealtime and bedtime assessment each day. Assessments focused on psychosocial and contextual information relevant for self-management. Graphical feedback integrated self-monitored blood glucose (SMBG), insulin, and Bluetooth-transmitted blood glucose data with the psychosocial and contextual data. App + meter participants completed an interview to identify data patterns.

RESULTS

The median number of momentary assessments per participant was 80.0 (range 32-120) with 2.60 per day. By 2 weeks participants had an average of 40.77 (SD 12.23) assessments. Dose-response analyses indicated that the number of app assessments submitted were significantly related to higher mean daily SMBG (r = -0.44, P < 0.05) and to lower% missed mealtime SMBG (r = -0.47, P < 0.01). Number of feedback viewing sessions was also significantly related to a lower% missed mealtime SMBG (r = -0.44, P < 0.05). Controlling for baseline variables, mixed-effects analyses did not indicate group × time differences in mean daily SMBG. Engagement analyses resulted in three trajectory groups distinguished by assessment frequencies and rates of decline. Engagement group membership was significantly related to gender, mean daily SMBG, and HbA1c values.

CONCLUSIONS

Momentary assessment combined with device data provided a feasible means to provide novel personalized biobehavioral feedback for adolescents with T1D. A 2-week protocol provided sufficient data for self-management problem identification. In addition to feedback, more intensive intervention may need to be integrated for those patients with the lowest self-management at baseline.

Advancing diabetes management in adolescents: Comparative effectiveness of mobile self-monitoring blood glucose technology and family-centered goal setting

BACKGROUND

As adolescents gain autonomy, it remains important for parents to be involved with diabetes management to avoid deterioration in glycemic control. Technologies for self-monitoring of blood glucose (SMBG) allow for remote monitoring in real-time by parents. This research compared 3 strategies for improving SMBG and diabetes self-care in the short-term. These strategies were: (1) health information technology (HIT)-enhanced blood glucose meter that shared blood glucose data among patients, their parent, and care providers, and allowed for text messaging; (2) family-centered goal setting; and (3) a combination of (1) and (2).

METHODS

One hundred twenty-eight participants enrolled; 97 adolescent-parent pairs attended clinic at 3-month intervals during the 6-month intervention. Differences between treatment groups were evaluated using analysis of variance (ANOVAs) for continuous variables and χ² tests for frequencies. Within patient changes were evaluated using paired t tests.

RESULTS

Participants in the HIT-enhanced SMBG group had no change in mean glycosylated hemoglobin (HbA1c). Participants assigned to family-centered goal setting had a non-significant decrease in HbA1c of -0.3% (P = .26) from baseline to 6 months. Participants in the combined approach had a significant decrease in HbA1c of -0.6% (P = .02) from baseline to 3 months, but the decrease of -0.4% at 6 months was non-significant (P = .51). The change in HbA1c from baseline to 3 months was greater for the combined approach than for the HIT-enhanced SMBG (P = .05) or family-centered goal setting (P = .01).

CONCLUSIONS

Our data suggest that utilizing the family-centered goal setting strategy when implementing HIT-enhanced diabetes technology deserves further study.

Patterns of Family Functioning and Diabetes-Specific Conflict in Relation to Glycemic Control and Health-Related Quality of Life Among Youth With Type 1 Diabetes

Objectives

General and diabetes-specific family functioning may be associated with youth’s adaptation to type 1 diabetes (T1D); however, empirically derived patterns of family functioning and diabetes-specific conflict among youth have not been explored in relation to T1D adaptation.

Methods

Youth (N = 161, aged 12–18) with T1D and caregivers completed measures of family functioning and diabetes-specific conflict that served as indicators in latent profile analyses. Differences in glycemic control (measured by hemoglobin A1cs [HbA1c] and health-related quality of life [HRQoL]) were compared across profiles.

Results

Four profiles that varied by levels of family functioning, diabetes-specific conflict, and congruence between youth and caregiver perspectives emerged and related to T1D adaptation differently. Greater agreement between caregiver and youth and lower diabetes-specific conflict was associated with lower HbA1c and greater HRQoL.

Conclusions

Person-centered approaches are useful to quantify how many individuals fit into a particular pattern and determine how specific family dynamics may function together differently in relation to T1D adaptation for various subgroups of the population.

Codesigned Shared Decision-Making Diabetes Management Plan Tool for Adolescents With Type 1 Diabetes Mellitus and Their Parents: Prototype Development and Pilot Test

BACKGROUND

Adolescents with type 1 diabetes mellitus have difficulty achieving optimal glycemic control, partly due to competing priorities that interfere with diabetes self-care. Often, significant diabetes-related family conflict occurs, and adolescents' thoughts and feelings about diabetes management may be disregarded. Patient-centered diabetes outcomes may be better when adolescents feel engaged in the decision-making process.

OBJECTIVE

The objective of our study was to codesign a clinic intervention using shared decision making for addressing diabetes self-care with an adolescent patient and parent advisory board.

METHODS

The patient and parent advisory board consisted of 6 adolescents (teens) between the ages 12 and 18 years with type 1 diabetes mellitus and their parents recruited through our institution's Pediatric Diabetes Program. Teens and parents provided informed consent and participated in 1 or both of 2 patient and parent advisory board sessions, lasting 3 to 4 hours each. Session 1 topics were (1) patient-centered outcomes related to quality of life, parent-teen shared diabetes management, and shared family experiences; and (2) implementation and acceptability of a patient-centered diabetes care plan intervention where shared decision making was used. We analyzed audio recordings, notes, and other materials to identify and extract ideas relevant to the development of a patient-centered diabetes management plan. These data were visually coded into similar themes. We used the information to develop a prototype for a diabetes management plan tool that we pilot tested during session 2.

RESULTS

Session 1 identified 6 principal patient-centered quality-of-life measurement domains: stress, fear and worry, mealtime struggles, assumptions and judgments, feeling abnormal, and conflict. We determined 2 objectives to be principally important for a diabetes management plan intervention: (1) focusing the intervention on diabetes distress and conflict resolution strategies, and (2) working toward a verbalized common goal. In session 2, we created the diabetes management plan tool according to these findings and will use it in a clinical trial with the aim of assisting with patient-centered goal setting.

CONCLUSIONS

Patients with type 1 diabetes mellitus can be effectively engaged and involved in patient-centered research design. Teens with type 1 diabetes mellitus prioritize reducing family conflict and fitting into their social milieu over health outcomes at this time in their lives. It is important to acknowledge this when designing interventions to improve health outcomes in teens with type 1 diabetes mellitus.

Diabetes conflict outstrips the positive impact of self-efficacy on youth adherence and glycemic control in type 1 diabetes

OBJECTIVE

To examine whether self-efficacy buffers the deleterious consequences of diabetes-specific family conflict on self-monitoring blood glucose (SMBG) and glycated hemoglobin (HbA1c) in youth with type 1 diabetes mellitus (T1DM).

METHODS

A total of 129 youth with T1DM (aged 10-16 years) completed measures of diabetes-specific family conflict and self-efficacy for diabetes management, and their blood glucose meter data and HbA1c were extracted from the electronic medical record. We preformed moderation analyses to examine whether self-efficacy moderated the association that diabetes-specific family conflict had with SMBG and HbA1c. We used simple slopes analyses to probe significant interactions.

RESULTS

Our results indicated that self-efficacy moderated the association that diabetes-specific family conflict had with SMBG and HbA1c. The pattern of these findings showed that high self-efficacy buffered the negative impact of diabetes conflict on HbA1c. However, benefits of high self-efficacy for more frequent SMBG was only apparent in the context of low diabetes-specific family conflict.

CONCLUSIONS

Study findings highlight the interactive relationship between diabetes-specific family conflict and self-efficacy in relation to SMBG and glycemic control. These findings suggest that family functioning and youth's self-efficacy are promising intervention targets for families having trouble with SMBG and HbA1c.

Pediatric Type 1 Diabetes: Patients' and Caregivers' Perceptions of Glycemic Control

OBJECTIVES

(1) to describe pediatric patients with T1D and their caregivers' perceptions of measures of glycemic control (hemoglobin [A1C] and blood glucose [BG] levels) and (2) to determine the relationship between patients' and caregivers' perceptions of measures of glycemic control with actual A1C levels and adherence to diabetes self-care behaviors.

METHODS

Patients (8 to 18 years) with T1D and caregivers completed questionnaires that queried their perceptions of (1) what the A1C level assesses, (2) the ideal A1C target, and (3) the ideal BG range. Point-of-care A1C levels were measured for each patient. They also completed the Self-Care Inventory Revised (SCI-R) to assess adherence to diabetes self-care behaviors.

RESULTS

Among 253 dyads, the frequencies of patients compared to caregivers who could accurately describe what the A1C level assesses, identify the ideal A1C target, and identify the ideal BG range were 20 vs. 66, 31 vs. 56, and 72 vs. 76%, respectively. Patients' accuracy in reporting ideal targets for glycemic control was significantly associated with caregivers' accuracy. There was a trend for lower median A1C levels in patients who were part of a dyad wherein both had accurate perceptions of glycemic control.

CONCLUSIONS

Patients and caregivers had accurate knowledge of ideal BG range but were less knowledgeable about the meaning of A1C levels and ideal A1C targets. Nevertheless, whether glycemic control was perceived as an A1C measurement or a BG range, A1C levels trended lower for patients when both they and their caregivers had accurate perceptions of glycemic control.

Design and baseline data from a PCORI-funded randomized controlled trial of family-centered tailoring of diabetes self-management resources

This article describes the methodology, recruitment, participant characteristics, and sustained, intensive stakeholder engagement for Project ACE (Achieving control, Connecting resources, Empowering families). Project ACE is a randomized controlled trial of children and youth ages 8-16 with type 1 diabetes evaluating the impact of tailored self-management resources on hemoglobin A1c (A1c) and quality of life (QOL). Despite strong evidence that controlling A1c reduces long-term complications, <25% of US youth with type 1 diabetes meet A1c targets. Many interventions are efficacious in improving A1c and QOL for these youth, whose families often struggle with the substantial demands of the treatment regimen. However, most such interventions are ineffective in the real world due to lack of uptake by families and limited healthcare system resources. Project ACE is a multi-site trial designed to improve diabetes outcomes by tailoring existing, evidence-based interventions to meet families' needs and preferences. We hypothesize that this family-centered approach will result in better A1c and QOL than usual care. Project ACE has recruited and randomized 214 eligible 8-16year old youth and their parents. The 9-month intervention consisted of 4 group sessions tailored to families' self-management barriers as identified by a validated instrument. Outcomes including A1c and QOL for parents and youth will be assessed for 1year after the intervention. Stakeholder engagement was used to enhance this trial's recruitment, retention and integration into routine clinical care. Findings will inform implementation and dissemination of family-centered approaches to address self-management barriers.

TRIAL REGISTRATION NUMBER

NCT02024750 Trial Registrar: Clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT02024750.

The Impact of Frequency and Tone of Parent-Youth Communication on Type 1 Diabetes Management

BACKGROUND

The purpose of this study is to assess the impact of frequency and tone of parent-youth communication on glycemic control as measured by the Family Communication Inventory (FCI). Adolescence provides a unique set of diabetes management challenges, including suboptimal glycemic control. Continued parental involvement in diabetes management is associated with improved HbA1c outcomes; however, diabetes-related conflict within the family can have adverse effects. Although it is clear that communication plays an important role in diabetes outcomes, the specific impact of frequency and tone of such communication is largely understudied.

METHODS

A total of 110 youths with type 1 diabetes and their parents completed questionnaires assessing diabetes-related adherence, family conflict, and family communication (i.e., frequency and tone) during a routine clinic visit. Routine testing of HbA1c was performed.

RESULTS

Youth- and parent-reported frequency of communication were unrelated to HbA1c. Instead, greater discrepancies between parents and children on reported frequency of communication (most commonly parents reporting frequent and youth reporting less frequent communication) corresponded with poorer glycemic control and increased family conflict. More positive tone of communication as rated by youth was associated with lower HbA1c.

CONCLUSIONS

Diabetes-related communication is more complex than conveyed simply by how often children and their parents communicate. Tone of communication and discrepancies in a family's perception of the frequency of communication were better than frequency as predictors of glycemic control. The FCI appears to capture the frequency and tone of diabetes-related communication, though larger-scale studies are warranted to inform future use of this scale.

The Interactive Effect of Diabetes Family Conflict and Depression on Insulin Bolusing Behaviors for Youth

OBJECTIVE

Adherence to type 1 diabetes management declines as children enter adolescence. For youth, psychosocial variables including mood and interpersonal relationships play a large role in diabetes maintenance. The current study assessed the unique and interactive roles diabetes family conflict and depression have on insulin bolusing behaviors for youth ages 10-16 years.

METHODS

Ninety-one youth-parent dyads completed a survey assessing family conflict and depression. Mean daily blood glucose levels, mealtime insulin bolus scores ( BOLUS), and glycated hemoglobin (HbA1c) were collected from the medical record as outcome variables.

RESULTS

Parent-reported diabetes-related family conflict and youths' endorsed depression both significantly predicted insulin bolusing behavior, R² = .13, F(2, 88) = 6.66, P < .05. The interaction of diabetes family conflict and youth depression played a significant role in youths' bolusing behaviors, above and beyond that which was predicted by conflict and depression separately, R² = .18, F_change(1, 87) = 4.63, P < .05. BOLUS was negatively related to youths' hemoglobin A1c, r = -.556, P < .001 and mean daily blood glucose levels, r = -.428, P < .001.

CONCLUSIONS

Among depressed youth, mealtime insulin BOLUS scores declined with greater diabetes-related family conflict, while there was no change in BOLUS scores among depressed youth living in families reporting less conflict. Findings underscore the importance of screening for depression and family conflict in youth experiencing or at risk for poor adherence to mealtime insulin and higher HbA1c levels.

White Coat Adherence Occurs in Adolescents With Type 1 Diabetes Receiving Intervention to Improve Insulin Pump Adherence Behaviors

BACKGROUND

To assess the occurrence of white coat adherence, defined as an increase in adherence to treatment regimens prior to a study appointment, in adolescents with type 1 diabetes (T1D) using insulin pumps and participating in a randomized adherence intervention trial.

METHODS

Blood glucose monitoring (BGM) readings, carbohydrate inputs, and insulin boluses delivered were downloaded from the insulin pumps of adolescents, aged 10-18 years, at 3 consecutive T1D study visits. Linear mixed models were used to analyze patterns of BGM, carbohydrate inputs, and insulin boluses delivered in patients who had 40 consecutive days of data stored in their insulin pumps prior to the study visit.

RESULTS

Stratified linear mixed models revealed that adolescents randomized to the Tailored Feedback Intervention group increased their blood glucose monitoring ( P < .01), carbohydrate inputs ( P < .0001), and insulin bolusing ( P < .0001) prior to study appointments. In contrast, white coat adherence did not occur in adolescents randomized to the Treatment as Usual group ( Ps > .42).

CONCLUSIONS

White coat adherence may occur in adolescents participating in clinical trials. Meter and insulin pump data downloads representing the 1- to 2-week period prior to a study visit are likely to overestimate actual adherence during the time frame between study visits.

A multivariate model exploring the predictive value of demographic, adolescent, and family factors on glycemic control in adolescents with type 1 diabetes

OBJECTIVE

The current study examined how a comprehensive set of variables from multiple domains, including at the adolescent and family level, were predictive of glycemic control in adolescents with type 1 diabetes (T1D).

METHODS

Participants included 100 adolescents with T1D ages 10-16 yrs and their parents. Participants were enrolled in a longitudinal study about youth decision-making involvement in chronic illness management of which the baseline data were available for analysis. Bivariate associations with glycemic control (HbA1C) were tested. Hierarchical linear regression was implemented to inform the predictive model.

RESULTS

In bivariate analyses, race, family structure, household income, insulin regimen, adolescent-reported adherence to diabetes self-management, cognitive development, adolescent responsibility for T1D management, and parent behavior during the illness management discussion were associated with HbA1c. In the multivariate model, the only significant predictors of HbA1c were race and insulin regimen, accounting for 17% of the variance. Caucasians had better glycemic control than other racial groups. Participants using pre-mixed insulin therapy and basal-bolus insulin had worse glycemic control than those on insulin pumps.

CONCLUSIONS

This study shows that despite associations of adolescent and family-level variables with glycemic control at the bivariate level, only race and insulin regimen are predictive of glycemic control in hierarchical multivariate analyses. This model offers an alternative way to examine the relationship of demographic and psychosocial factors on glycemic control in adolescents with T1D.

A model of parental distress and factors that mediate its link with parental monitoring of youth diabetes care, adherence, and glycemic control

OBJECTIVE

Parental monitoring of adolescents' diabetes self-care is associated with better adherence and glycemic control (A1c). A number of parent-level factors are associated with higher levels of parental monitoring, including lower levels of parental distress (depressive symptoms, stress, anxiety), as well as higher levels of parental self-efficacy for diabetes management and authoritative parenting. Often studied in isolation, these factors may be best considered simultaneously as they are interrelated and are associated with parental monitoring and youth adherence.

METHOD

Structural equation modeling with a cross-sectional sample of 257 parent/youth (aged 11-14) dyads: (a) examined a broad model of parental factors (i.e., parental distress, parental diabetes self-efficacy, authoritative parenting), and (b) assessed their relation to parental monitoring, youth adherence, and A1c. Post hoc analyses of variance (ANOVAs) evaluated clinical implications of daily parental monitoring.

RESULTS

Parental distress was not related directly to parental monitoring. Instead less distress related indirectly to more monitoring via higher parental self-efficacy and more authoritative parenting which, in turn, related to better adherence and A1c. Higher parental self-efficacy also related directly to better youth adherence and then to better A1c. Clinically, more parental monitoring related to more daily blood glucose checks and to better A1c (8.48% vs. 9.17%).

CONCLUSIONS

A broad model of parent-level factors revealed more parental distress was linked only indirectly to less monitoring via lower parental self-efficacy and less authoritative parenting. Behaviorally, more parental monitoring related to better adherence and to clinically better A1c in adolescents. Further study of parent-level factors that relate to parental distress and monitoring of adherence appears warranted. (PsycINFO Database Record

Hemoglobin A1c (HbA1c) changes over time among adolescent and young adult participants in the T1D exchange clinic registry

OBJECTIVE

Hemoglobin A1c (HbA1c) levels among individuals with type 1 diabetes (T1D) influence the longitudinal risk for diabetes-related complications. Few studies have examined HbA1c trends across time in children, adolescents, and young adults with T1D. This study examines changes in glycemic control across the specific transition periods of pre-adolescence-to-adolescence and adolescence-to-young adulthood, and the demographic and clinical factors associated with these changes.

RESEARCH DESIGN AND METHODS

Available HbA1c lab results for up to 10 yr were collected from medical records at 67 T1D Exchange clinics. Two retrospective cohorts were evaluated: the pre-adolescent-to-adolescent cohort consisting of 85 016 HbA1c measurements from 6574 participants collected when the participants were 8-18 yr old and the adolescent-to-young adult cohort, 2200 participants who were 16-26 yr old at the time of 17 279 HbA1c measurements.

RESULTS

HbA1c in the 8-18 cohort increased over time after age 10 yr until ages 16-17; followed by a plateau. HbA1c levels in the 16-26 cohort remained steady from 16-18, and then gradually declined. For both cohorts, race/ethnicity, income, health insurance, and pump use were all significant in explaining individual variations in age-centered HbA1c (p < 0.001). For the 8-18 cohort, insulin pump use, age of onset, and health insurance were significant in predicting individual HbA1c trajectory.

CONCLUSIONS

Glycemic control among patients 8-18 yr old worsens over time, through age 16. Elevated HbA1c levels observed in 18 yr-olds begin a steady improvement into early adulthood. Focused interventions to prevent deterioration in glucose control in pre-adolescence, adolescence, and early adulthood are needed.

Psoriasis in childhood: effective strategies to improve treatment adherence

Psoriasis is a relatively common chronic inflammatory skin disease in children for which there is no cure. Most children have mild disease that can be managed with topical therapy as opposed to phototherapy or systemic therapy. Despite the mild presentation of psoriasis in most children, the disease can have a significant impact on quality of life due to the need for ongoing treatment, the frequently visible nature of the cutaneous manifestations, and the social stigma that is associated with psoriasis. Adherence to treatment, in particular topical therapy, is often poor in adults and compromises response to therapy and medical provider management strategies. Multiple factors that may contribute to nonadherence in adults with psoriasis have been identified, including lack of education on the disease and expectations for management, issues related to ease of use and acceptability of topical medications, and anxiety regarding possible medication side effects. There is currently no published data on adherence in the pediatric psoriasis population; however, poor adherence is often suspected when patients fail to respond to appropriate therapy. General strategies used to assess adherence in other pediatric disease populations can be applied to children with psoriasis, and interventions that reflect experience in other chronic dermatologic disorders such as atopic dermatitis may also be helpful for medical providers caring for children with psoriasis.

Family Density and SES Related to Diabetes Management and Glycemic Control in Adolescents With Type 1 Diabetes

OBJECTIVE

Youth with Type 1 diabetes (T1D) from single-parent families have poorer glycemic control; a finding confounded with socioeconomic status (SES). Family density (FD), or youth:adult ratio, may better characterize family risk status.

METHODS

Structural equation modeling assessed the relation of single-parent status, SES, and FD to parenting stress, diabetes-related conflict, parental monitoring, adherence, and glycemic control using cross-sectional parent and youth data (n = 257).

RESULTS

Single-parent status exhibited similar relations as SES and was removed. Lower FD was associated with better glycemic control (β = -.29, p = .014) via less conflict (β = .17, p = .038) and greater adherence (β = -.54, p < .001).

CONCLUSIONS

Beyond SES, FD plays a significant role in adherence and glycemic control via diabetes-related conflict. In contrast, the effects of single-parent status were indistinguishable from those of SES. FD provides distinct information related to adolescent glycemic control.

Adherence-related issues in adolescents and young adults with hematological disorders

Nonadherence to medical recommendations is a widespread problem well documented in a multitude of clinical settings. Nonadherence may adversely affect clinical outcomes such as survival and quality of life and increase health-care-related costs. An understanding of the factors driving nonadherence is key to developing effective adherence-enhancing interventions (AEIs). There are ongoing attempts in contemporary adherence research to better define the various components of adherence, to find optimal measures of adherence and correlations with clinical outcomes, and to create a classification system for AEIs. Nonadherence is also widely prevalent among adolescents and young adults (AYAs) with chronic hematological diseases, affecting up to 50% of patients and increasing with age. Combined use of objective (i.e. electronic monitoring, EM) and subjective (i.e. self-report) measures of adherence may be the preferred approach to assess adherence. The unique physical, social and emotional aspects of the AYA life stage are closely related to intricate causes of nonadherence in AYAs such as problems in transition to adult care. Until proven otherwise, the empirical target in AYAs with hematological disorders should be perfect adherence. Multilevel AEIs, EM feedback and behavioral interventions are among the most effective types of AEIs. Despite the magnitude of the problem, only a handful of AEIs have been evaluated among AYAs with hematological disorders. Thus, this is a field with unmet needs warranting high-quality trials using standardized and well-specified assessment methods and interventions. This review discusses the prevalence, definition, causes and clinical implications of nonadherence among AYAs with hematological disorders, along with strategies to measure and improve adherence.

Frequency of mealtime insulin bolus predicts glycated hemoglobin in youths with type 1 diabetes

BACKGROUND

Within pediatric diabetes management, two electronic measures of adherence exist: frequency of daily blood glucose monitoring (BGM) and the BOLUS score, a measure of frequency of mealtime insulin bolusing. Past research has demonstrated that the BOLUS score is superior to daily BGM in predicting youths' glycated hemoglobin (HbA1c) in a cross-sectional study. We present data comparing the two adherence measures in predicting HbA1c using a prospective, longitudinal design.

SUBJECTS AND METHODS

Blood glucose meter data and insulin pump records were collected from a clinical database of 175 youths with type 1 diabetes (mean age, 11.7 ± 3.6 years at baseline). Youths' HbA1c levels occurring at the download time and at 3, 6, 9, and 12 months post-downloads were also collected. We calculated youths' mean BGM and BOLUS score using a standardized protocol.

RESULTS

Intraclass correlations (ICCs) revealed significant absolute equivalence between youths' predicted HbA1c values using BOLUS and BGM scores and future actual HbA1c values up to 12 months post-download. However, the ICCs of BOLUS scores with future HbA1c values were consistently higher than those of the BGM scores. Also, the predictions of the BOLUS scores were significantly more accurate (P ≤ 0.002) than those of the BGM scores based on the root mean squared error of predictions.

CONCLUSIONS

In a prospective, longitudinal design, youths' BOLUS scores were superior to youths' daily BGM in predicting future values of HbA1c. Calculating a BOLUS score versus BGM can help researchers and clinicians achieve a better prediction of youths' HbA1c.

HbA1c tracking and bio-psychosocial determinants of glycaemic control in children and adolescents with type 1 diabetes: retrospective cohort study and multilevel analysis

OBJECTIVES

To explore the association between HbA1c 6 months after diagnosis (6 m-HbA1c) and long-term glycaemic control in children with type 1 diabetes, accounting for other bio-psychosocial determinants.

METHODS

This retrospective cohort study, included 155 children (≤16 yr) from the North of Scotland, diagnosed between January 1993 and August 2011, and receiving care between November 2008 and August 2012. Multilevel analysis explored the relationships between 6 m-HbA1c, other persistent or dynamic variables, and HbA1c. Patterns of glycaemic control were identified by cluster-analysis.

RESULTS

6 m-HbA1c was positively associated with diabetic ketoacidosis at diagnosis, shorter duration of partial-remission, female gender, and psychosocial adversity. In multilevel analysis the effects of 6 m-HbA1c on subsequent HbA1c trajectories remained significant after adjusting for patient- and observation-level predictors. An increase in 6 m-HbA1c of 10 mmol/mol (0.9%) was associated with an average increase in HbA1c levels of 5.3 (95% CI: 4.5-6.2) mmol/mol, or 0.48% (0.41 to 0.57%; p < 0.001) over the follow-up period. Coefficients for linear and quadratic growth identified sustained effects of 6 m-HbA1c on glycaemic control (p < 0.001). Higher average levels or accelerated increases in HbA1c were associated with age at diagnosis, falling BMI (in girls > boys), mental health diagnosis, major adverse life-events, single-parenting, child welfare concerns, neighbourhood deprivation, and clinic non-attendance. Cluster-analysis identified groups with poor or deteriorating control, characterized by older age at diagnosis, multiple psychosocial adversities, and maladaptive healthcare use.

CONCLUSION

Early HbA1c predicted future glycaemic control across childhood. Trajectories were further modified by biological factors, exposures to psychosocial adversity, and healthcare use.

Emerging Adults with Type 1 Diabetes during the First Year Post-High School: Perceptions of Parental Behaviors

Among 182 emerging adults with type 1 diabetes (93% White and 57% female), changes during the year post-high school were examined in perceptions of diabetes-specific conflict with parents, parent-youth shared responsibility, parental tangible aid, and parental autonomy support, as well as the moderating effects of living situation, gender, years with diabetes, and glycemic control. A linear mixed effects model, controlling for baseline values, tested the changes in and relationships among these variables over time. Changes over time in parent-youth conflict were moderated by living independently of parents; autonomy support and shared responsibility were moderated by years with diabetes; and tangible aid was moderated by glycemic control. Future longitudinal research needs to examine whether changes in parental behaviors lead to positive or negative diabetes outcomes among these emerging adults with diabetes.

Pediatric Diabetes Consortium Type 1 Diabetes New Onset (NeOn) Study: factors associated with HbA1c levels one year after diagnosis

OBJECTIVE

To identify determinants of hemoglobin A1c (HbA1c) levels 1 yr after the diagnosis of type 1 diabetes (T1D) in participants in the Pediatric Diabetes Consortium (PDC) T1D New Onset (NeOn) Study.

RESEARCH DESIGN AND METHODS

Diabetes-specific as well as socioeconomic factors during the first year following diagnosis were analyzed in 857 participants (mean age 9.1 yrs, 51% female, 66% non-Hispanic White) not participating in an intervention study who had an HbA1c value at 12 months.

RESULT

Mean ± SD HbA1c at 1 yr was 62 ± 16 mmol/mol (7.8% ± 1.5). In univariate and multivariate analyses, clinical center, non-Hispanic White race, private health insurance, living with both parents, higher frequency of self-monitoring of blood glucose (SMBG), and lower insulin requirements were associated with lower HbA1c concentrations at 1 yr (p < 0.01). No association was found with gender, age, Tanner stage, body mass index (BMI), diabetic ketoacidosis (DKA) at onset, number of positive autoantibodies or HbA1c at onset, or number of visits to diabetes physician during the first year.

CONCLUSIONS

White race, higher socioeconomic status, two-parent household, more frequent SMBG, and low insulin requirements are associated with lower HbA1c concentration 1 yr after the onset of T1D in children.

A contrast between children and adolescents with excellent and poor control: the T1D Exchange clinic registry experience

OBJECTIVES

Optimizing glycemic control in pediatric type 1 diabetes (T1D) is essential to minimizing long-term risk of complications. We used the T1D Exchange database from 58 US diabetes clinics to identify differences in diabetes management characteristics among children categorized as having excellent vs. poor glycemic control.

METHODS

Among registry participants 6-17 yr old with diabetes duration ≥ 2 yr, those with excellent control [(A1c <7%)(53 mmol/mol) (N = 588)] were compared with those with poor control [(A1c ≥ 9% )(75 mmol/mol) (N = 2684)] using logistic regression.

RESULTS

The excellent and poor control groups differed substantially in diabetes management (p < 0.001 for all) with more of the excellent control group using insulin pumps, performing blood glucose monitoring ≥ 5 ×/d, missing fewer boluses, bolusing before meals rather than at the time of or after a meal, using meal-specific insulin:carbohydrate ratios, checking their blood glucose prior to giving meal time insulin, giving insulin for daytime snacks, giving more bolus insulin, and using a lower mean total daily insulin dose than those in poor control. After adjusting for demographic and socioeconomic factors, diabetes management characteristics were still strongly associated with good vs. poor control. Notably, frequency of severe hypoglycemia was similar between the groups while DKA was more common in the poorly controlled group.

CONCLUSIONS

Children with excellent glycemic control tend to exhibit markedly different diabetes self-management techniques than those with poor control. This knowledge may further inform diabetes care providers and patients about specific characteristics and behaviors that can be augmented to potentially improve glycemic control.

Self-management as a mediator of family functioning and depressive symptoms with health outcomes in youth with type 1 diabetes

This study examined the relationship of family functioning and depressive symptoms with self-management, glycemic control, and quality of life in a sample of adolescents with type 1 diabetes. It also explored whether self-management mediates family functioning, depressive symptoms, and diabetes-related outcomes. Structural equation modeling was used to estimate parameters in the conceptual causal pathway and test mediation effects. Adolescents (n = 320) were primarily female (55%), younger adolescents (58%), and self-identified as White (63%). Self-management mediated the relationship between family conflict, family warmth-caring, parent guidance-control, and youth depressive symptoms with glycosylated hemoglobin (A1C). In addition, self-management mediated the relationship between family conflict and youth depressive symptoms with quality of life. Supporting optimal family functioning and treating elevated depressive symptoms in adolescents with type 1 diabetes has the potential to improve self-management, glycemic control, and quality of life.

The reliability and validity of the revised Diabetes Family Conflict Scale questionnaire, in a sample of Swedish children

AIM

The overall aim of the study was to assess the psychometric properties of the revised Diabetes Family Conflict Scale (DFCS), in a Swedish sample of children, mothers and fathers. A second aim was to analyse maternal and paternal effects separately.

METHODS

One hundred and fifty-nine families from two diabetes centres participated in the study. The revised DFCS was administered to children aged 8-18 years and their parents. Internal consistency of the scale was measured with Cronbach's alpha, and its concurrent validity was evaluated using bivariate correlations. Independent t-tests were performed to test for differences between mother- and father reports.

RESULTS

The revised DFCS total scale exceeded the criteria for satisfactory internal consistency for the child-, mother- and father reports, as did the subscale direct management, with α-values ranging from 0.72 to 0.81. Furthermore, a higher level of reported conflict on the total scale was associated with poorer metabolic control, thus confirming concurrent validity of the instrument. This was true for mother-, father- and child reports.

CONCLUSION

In summary, the study concludes that the revised DFCS can be utilized as a valuable tool both in a research setting and in clinical practice.

Impact of blood glucose monitoring affect on family conflict and glycemic control in adolescents with type 1 diabetes

BACKGROUND

This longitudinal study examined whether diabetes-specific family conflict and glycemic control were impacted/explained by negative affective responses to blood glucose checks (Negative BGM Affect).

METHOD

Adolescents (N=150, ages 13-18 years) with type 1 diabetes, and their caregivers, completed measures of Negative BGM Affect, diabetes-specific family conflict, and glycemic control (i.e., hemoglobin A1c) at baseline, 6-, and 12-months.

RESULTS

Caregiver Negative BGM Affect predicted higher A1c values at 12 months. Diabetes-specific family conflict mediated and explained 39% of the Negative BGM Affect-A1c relationship. Conflict around direct management tasks mediated the caregiver Negative BGM Affect-A1c relationship for adolescents (30.6% of variance). The impact of Negative BGM Affect on diabetes-specific family conflict is more pervasive for caregivers (direct and indirect diabetes management tasks) than adolescents (direct diabetes management tasks only).

CONCLUSIONS

Caregiver Negative BGM Affect is an important contributor to A1c via diabetes-specific family conflict. Identifying and intervening with families who endorse high levels of Negative BGM Affect may prevent diabetes-specific family conflict, thereby minimizing the impact of family conflict on glycemic control. Brief clinic-based interventions to address Negative BGM Affect can be incorporated into clinical practice to prevent long-term negative impact on glycemic control.