Psychological Support for Children with Diabetes: Are the Guidelines Being Met?

Qualitative Study Guiding the Design of a Person-Centered Shared Medical Appointment Model to Optimize Diabetes Care Delivery

PURPOSE

The purpose of the study was to explore the shared medical appointment model (SMA) with youth with type 2 diabetes (T2DM) and their caregivers to identify health education needs, access barriers, and recommendations for intervention design.

METHODS

Patient and caregiver focus group interviews were conducted in English and Spanish to address these objectives: (1) identify barriers to participation in group sessions, (2) identify barriers to diabetes self-management, and (3) prioritize preference for SMA themes. Qualitative analysis identified strategies for patient recruitment and engagement and recommendations for curriculum design of a future SMA model for youth with T2DM.

RESULTS

Both adolescents and caregivers supported the development of an SMA model. Adolescents expressed concerns of initial discomfort and nervousness, whereas young adults described stigma as the main barrier to joining a group. Patients emphasized the importance of prioritizing youth comfort and families' convenience. Early adolescents and young adults preferred autonomy in the choice to join a group, whereas mid adolescents and caregivers preferred that the caregivers make that decision. Participants recommended nine topics regarding barriers to diabetes care. The topics that received the most enthusiasm were nutrition, exercise, navigating peer interactions, and stress management.

CONCLUSIONS

Youth with T2DM and their caregivers perceived many benefits of an SMA model and provided feedback to guide the development of a health education curriculum that could be integrated into an SMA clinic.

Implementation of the Mind Youth Questionnaire (MY-Q) for routine health-related quality of life screening of adolescents with type 1 diabetes in a large tertiary care center

OBJECTIVES

Prevalence of diabetes distress and mental health comorbidities among adolescents with type 1 diabetes (T1D) is high. Despite recommendations for routine psychosocial risk assessment, there is little guidance for their implementation. This study aims to describe the implementation and baseline outcomes of the Mind Youth Questionnaire (MY-Q), a validated psychosocial screening tool for health-related quality of life (QoL) including mood, among adolescents living with T1D.

METHODS

Adolescents aged 13-18 years completed the MY-Q from October 1, 2019-April 1, 2023. Baseline characteristics, MY-Q results including categories flagged positive (noting possible areas of concern), debrief duration, and frequency of social work or mental health referral were collected and analyzed using descriptive statistics.

RESULTS

A total of 343 adolescents (mean age 15.3 years; 52 % female) completed a baseline MY-Q. Median overall MY-Q debrief time (IQR) was 10.0 min (6.0, 20.0). About 290 (84.5 %) adolescents had at least one of seven categories flagged, most commonly "Family" (61 %). About 30 % of adolescents had "Mood" flagged, and 2.9 % of adolescents were referred to mental health following debrief.

CONCLUSIONS

Without the need for additional resources, implementation of the MY-Q in a pediatric tertiary care diabetes clinic successfully identified QoL issues and mental health concerns among adolescents with T1D.

Psychosocial Staffing and Implementation of the International Society for Pediatric and Adolescent Diabetes Psychological Care Guidelines in U.S. Pediatric Diabetes Clinics

Background

Few studies have examined the implementation of the International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines for the Psychological Care of Children and Adolescents with Type 1 Diabetes.

Objective

To collect benchmark data on psychosocial staffing and implementation of the ISPAD guidelines across U.S. pediatric diabetes clinics.

Methods

Medical (n = 95; 77 endocrinologists and 18 advance practice providers) and psychosocial (n = 86; 43 social workers and 43 psychologists) providers from 98 of 115 contacted clinics completed an online survey (85% response rate). Providers reported the number of psychosocial staff and rated the adequacy of psychosocial staffing, quality of psychosocial care, and adherence to the ISPAD guidelines in their clinics. χ2 Tests and ANOVA were used to examine differences across clinic size and across medical and psychosocial providers.

Results

Clinics averaged a total of ∼4 hours per week of psychosocial provider time per 100 patients with type 1 diabetes. Only 27% of providers agreed that psychosocial staffing was adequate, and 35% described their psychosocial care as comprehensive. Implementation of the ISPAD guidelines varied across clinics, with minimal differences across clinic size. Medical providers reported that evidence-based psychological assessment and interventions were delivered consistently by <55% of clinics. Psychosocial, compared with medical, providers were more likely to report frequent implementation of psychosocial assessment and intervention guidelines.

Conclusion

Psychological care in U.S. pediatric type 1 diabetes clinics does not consistently meet the ISPAD guidelines, and many clinics lack adequate psychosocial staff. These benchmark data are a foundational step to improve psychosocial care for pediatric patients with type 1 diabetes.

Adjusted Cutoff Scores Increase Sensitivity of Depression Screening Measures in Adolescents With Type 1 Diabetes

OBJECTIVE

To measure the acceptability and diagnostic accuracy of commonly used depression screening measures to determine ideal cutoff scores that sensitively identify depressive disorders in adolescents with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

One hundred adolescents (12-17 years old) completed a reference standard, semistructured diagnostic interview and both long and short versions of five commonly used depression screening measures in the United States. To assess feasibility and acceptability, we used screener completion time and participant ratings, respectively. We used descriptive statistics, area under the receiver operating characteristic (ROC) curve analyses, and paired-sample area differences under the ROC curve to assess each measure's diagnostic validity against our reference standard and to determine ideal cutoff scores for this sample.

RESULTS

Adolescents had a mean age of 15.0 ± 1.7 years, time since T1D diagnosis of 6.0 ± 4.1 years, and glycated hemoglobin (HbA1c) of 8.9 ± 1.8%. Sixty percent of adolescents were male, 15% endorsed a current depressive disorder, and 15% endorsed lifetime suicidality. Measures demonstrated low sensitivity (0.33-0.67) to detect current depressive disorders using preexisting cutoff scores. However, adjusted cutoff scores increased sensitivity and reduced false negatives. All depression screening measures demonstrated "good" to "excellent" predictive validity, and the Children's Depression Inventory-2 Short version demonstrated significantly greater diagnostic accuracy than the Patient Health Questionnare-2 item version for adolescents.

CONCLUSIONS

Clinics should consider using screening measures with the greatest diagnostic accuracy as identified in this study and adjusting measure cutoff scores to increase sensitivity and reduce false negatives.

Psychosocial screening in a pediatric diabetes clinic: Adolescents' and mothers' perspectives

OBJECTIVE

Adolescents with type 1 diabetes (T1D) frequently experience psychosocial concerns, and mental health screening is becoming increasingly common in routine diabetes care. However, little is known about what adolescents or their caregivers think about the role of mental health screening and intervention within the context of comprehensive diabetes care, or how their diabetes care providers should be involved in navigating mental health concerns. This study used qualitative methods to obtain the perspectives of adolescents with T1D and their caregivers regarding these issues.

METHODS

Participants were 13 adolescents with T1D (ages 12-19 years; M = 15.1 years; 53.8% female; 61.5% Hispanic/Latinx White) and 13 mothers, recruited from an outpatient pediatric endocrinology clinic in South Florida, who participated in semi-structured interviews via video teleconference. Thematic content analysis was used to evaluate participants' responses.

RESULTS

Adolescents and their mothers reported positive experiences with the clinic's psychosocial screening procedures and appreciated meeting with the psychology team during visits. They wanted the clinic to offer more opportunities for peer support. Mothers highlighted barriers to seeking mental health care outside of the clinic and the importance of mental health professionals understanding diabetes. Mothers also wanted the clinic to offer more on-site therapeutic services.

DISCUSSION

Study participants valued psychosocial screening and supported addressing mental health as a routine part of diabetes comprehensive care.

Role of Psychologists in Pediatric Endocrinology

The care of youth managed within pediatric endocrine clinics is complex and requires a multi- or interdisciplinary approach. Psychosocial aspects of chronic health conditions are well-documented. Clinical practice guidelines outline the importance of routine psychosocial screening and support for youth with diabetes and obesity. This article outlines the diverse role of psychologists in pediatric endocrinology, including screening, in-clinic intervention, outpatient psychological services, and inpatient consultation. Although research exists documenting the effectiveness of behavioral interventions to improve adherence and health-related quality of life, cost analysis research is emerging.

The Diabetes-Specific Risk-Taking Inventory: Piloting a New Measure for Adolescents With Type 1 Diabetes

OBJECTIVE

We sought to develop and pilot a new measure, the Diabetes-Specific Risk-Taking Inventory (DSRI), to assess unhealthy risk-taking behaviors among adolescents with type 1 diabetes.

METHODS

Thirteen diabetes health care providers, 30 adolescents with type 1 diabetes (aged 15-19 years, 60% female, mean A1C 8.7% [72 mmol/mol], and 33% on insulin pumps), and the adolescents' caregivers rated the perceived riskiness of each item on the DSRI. Adolescents completed the DSRI, for which they reported how often they engaged in 34 behaviors that could place them at risk for acute complications of type 1 diabetes or out-of-range blood glucose levels. Adolescents also completed the risk-taking subscale from the Risk-Taking and Self-Harm Inventory for Adolescents, and parents completed the parent-proxy Diabetes Management Questionnaire. Mean A1C during the previous year was obtained via medical chart review.

RESULTS

Results indicated good content validity and feasibility for using the DSRI in a research context, as 100% of adolescents who consented to the study completed the measure. The DSRI was positively correlated with general risk-taking and negatively correlated with diabetes management, indicating preliminary evidence of convergent validity. The DSRI also correlated with A1C.

CONCLUSION

This pilot study extends our previous work in developing a conceptual model for illness-specific risk-taking. The DSRI is a promising new measure to assess illness-specific risk-taking, including unhealthy risk-taking behaviors, for adolescents with type 1 diabetes.

Comprehensive psychosocial screening in a pediatric diabetes clinic

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Discrepancies in Assessing Symptoms of Depression in Adolescents With Diabetes Using the Patient Health Questionnaire and Semi-Structured Interviews

Adolescents with diabetes have a higher prevalence of depression compared with their peers. The American Diabetes Association recommends routine mental health screening for youth with diabetes. This screening is often conducted through accessible and free depression screeners, such as the nine-item Patient Health Questionnaire (PHQ-9). Although the PHQ-9 has been validated for use in adolescents and with other medical conditions, it has yet to be validated for use in pediatric diabetes. This study evaluated adolescents' depression symptom endorsement through retrospective review of PHQ-9 screening and semi-structured interviews with a mental health provider in a multidisciplinary diabetes clinic (patients with type 1 or type 2 diabetes). Adolescent participants (n = 96) screened during one to three separate visits (n = 148) endorsed some depressive symptoms in 56% of visits (n = 84) and moderate to severe symptoms in 6% of visits on the PHQ-9. Approximately 95% of study participants did not meet the clinic cutoff for further evaluation, but greater rates of depression were endorsed in youth with type 1 diabetes. Low mood was endorsed at a higher rate during a semi-structured interview with embedded mental health providers than on the PHQ-9. Symptoms specific to low mood, including anhedonia, sleep disturbance, concentration disturbance, motor disturbance, and thoughts of death/self-harm, were more frequently endorsed on the PHQ-9 than during the interview. Although the PHQ-9 is a good screening tool, the availability of mental health providers in diabetes clinics is important to address specific endorsed symptoms and place them in perspective based on specialized training. Until more definitive research is available on the sensitivity and specificity of this measure in this population and setting, a two-part screening approach that includes both the screening questionnaire and a brief semi-structured interview is warranted.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Implementation Science in Pediatric Psychology: The Example of Type 1 Diabetes

OBJECTIVE

Evidence-based screening, assessment, and intervention practices for youth with type 1 diabetes (T1D) are underutilized. Implementation science (IS) offers theoretical models and frameworks to guide rigorous mixed methods research to advance comprehensive care for children and families.

METHODS

We conducted a targeted review of applications of IS to T1D.

RESULTS

Pediatric T1D research offers initial, but still limited studies on implementation of evidence-based psychosocial care. IS designates approaches to understanding multi-level factors that influence implementation, ways to alter these factors, and methods to evaluate strategies to improve implementation.

CONCLUSIONS

IS is promising for advancing the translation of pediatric psychology approaches into clinical care. Following the science of implementation, further documentation of the reach of evidence-based care and establishing practice guidelines are important initial steps. Examining the barriers and facilitators of evidence-based psychosocial care can guide the development of testable implementation strategies to improve integration of care. Successful strategies can be evaluated through multi-site controlled implementation trials to explore their effectiveness. These lines of inquiry can be considered within pediatric populations, but may also be used to examine similarities and differences in effectiveness of implementation strategies across populations and settings. Such research has the potential to improve the health and well-being of children and families.

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

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

Factors associated with health psychology use in pediatric type 1 diabetes

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact and Cost-Effectiveness of Integrated Psychology Services in a Pediatric Endocrinology Clinic

Including psychology services in pediatric endocrinology clinics may improve patients' adherence to diabetes management behaviors, and, subsequently, glycemic control; however, an evaluation of the impact and cost-effectiveness of this integration is needed. The change in HbA1c and cost-effectiveness of integrated psychology services, from the hospital and insurance provider perspectives, were evaluated using a linear effects model and Incremental Cost-Effectiveness Ratios (ICERs). Data from 378 patients with T1D (50% female; 65% Caucasian; M age = 12.0 years) were obtained via medical chart review (2241 appointments). Patients demonstrated significant improvements in HbA1c following clinic visits in which they met with psychology (b = - 0.16, p = 0.006). A larger proportion of the distribution of ICER values fall below the $1000/1% HbA1c threshold from both the insurance (89%) and hospital (94%) perspectives. These results indicate that providing integrated psychology services in the endocrinology clinic is highly beneficial from the patient, hospital, and insurance provider perspectives.

Strengths-Based Behavioral Intervention for Parents of Adolescents With Type 1 Diabetes Using an mHealth App (Type 1 Doing Well): Protocol for a Pilot Randomized Controlled Trial

Background

Supportive parent involvement for adolescents’ type 1 diabetes (T1D) self-management promotes optimal diabetes outcomes. However, family conflict is common and can interfere with collaborative family teamwork. Few interventions have used explicitly strengths-based approaches to help reinforce desired management behaviors and promote positive family interactions around diabetes care.

Objective

The aim of this protocol was to describe the development of a new, strengths-based behavioral intervention for parents of adolescents with T1D delivered via a mobile-friendly Web app called Type 1 Doing Well.

Methods

Ten adolescent-parent dyads and 5 diabetes care providers participated in a series of qualitative interviews to inform the design of the app. The 3- to 4-month pilot intervention will involve 82 parents receiving daily prompts to use the app, in which they will mark the diabetes-related strength behaviors (ie, positive attitudes or behaviors related to living with or managing T1D) their teen engaged in that day. Parents will also receive training on how to observe diabetes strengths and how to offer teen-friendly praise via the app. Each week, the app will generate a summary of the teen’s most frequent strengths from the previous week based on parent reports, and parents will be encouraged to praise their teen either in person or from a library of reinforcing text messages (short message service, SMS).

Results

The major outcomes of this pilot study will include intervention feasibility and satisfaction data. Clinical and behavioral outcomes will include glycemic control, regimen adherence, family relationships and conflict, diabetes burden, and health-related quality of life.

Conclusions

This strengths-based, mobile health (mHealth) intervention aims to help parents increase their awareness of and efforts to support their adolescents’ engagement in positive diabetes-related behaviors. If efficacious, this intervention has the potential to reduce the risk of family conflict, enhance collaborative family teamwork, and ultimately improve diabetes outcomes.

Trial Registration

ClinicalTrials.gov NCT02877680; https://clinicaltrials.gov/ct2/show/NCT02877680 (Archived by WebCite at http://www.webcitation.org/6xTAMN5k2)

Disturbed eating behaviors in adolescents with type 1 diabetes. How to screen for yellow flags in clinical practice?

BACKGROUND

Adolescents with type 1 diabetes are at an increased risk of disturbed eating behaviors (DEBs).

OBJECTIVE

The aims of this study are to (i) explore the prevalence of DEBs and associated 'yellow flags', and (ii) establish concordance between adolescents-parents and adolescents-clinicians with respect to DEBs.

METHODS

Adolescents (11-16 yr) and parents completed questionnaires. A stepwise approach was used to assess DEBs: only adolescents whose answers raised psychological yellow flags for DEBs completed the Diabetes Eating Problems Scale - Revised and questions from the AHEAD study. Parents and clinicians shared their observations regarding possible DEBs. Kruskal-Wallis tests, post hoc Mann-Whitney U test, and chi-squared tests were utilized to examine clinical yellow flags. Cohen's kappa was used to assess concordance.

RESULTS

Of 103 adolescents participated (51.5% girls), answers of 47 (46.5%) raised psychological yellow flags, indicating body and weight concerns. A total of 8% scored above cut-off for DEBs. Clinical yellow flags were elevated glycated hemoglobin A1c (p = 0.004), older age (p = 0.034), dieting frequency (p = 0.001), reduced quality of life (p = 0.007), less diabetes self-confidence (p = 0.015), worsened diabetes management (p < 0.001), and body dissatisfaction (p < 0.001). Body Mass Index (BMI) z-scores and gender were no yellow flags. Concordance between parents and adolescents was slight (k = 0.126 and 0.141), and clinicians and adolescents was fair (k = 0.332).

DISCUSSION

Half of the adolescents reported body and weight concerns, less than 1 in 10 reported DEBs. Screening for yellow flags for DEBs as a part of clinical routine using a stepwise approach and early assistance is recommended to prevent onset or deterioration of DEBs.

Mental health issues in children and adolescents with chronic illness

Purpose

The purpose of this paper is to consider mental health issues in children and adolescents with chronic illness or health conditions, including their treatment, and issues related to delivery of services.

Design/methodology/approach

A selective review of the literature was conducted to highlight significant mental health issues and their treatment in youth with various types of chronic illness.

Findings

A significant portion of youth experience mental health problems related to their chronic health conditions. While evidence-based treatments are available to address these problems, significant barriers exist that impede the delivery of psychological and behavioral interventions for many youth.

Research limitations/implications

More controlled studies are needed to demonstrate the effectiveness and cost offset of delivering psychological and behavioral interventions for the population of youth with various types of chronic health conditions, particularly in clinical and community settings.

Social implications

Policy reform can ensure that mental health issues are effectively addressed for children with chronic illness. Policy is needed that promotes integrated health care, whereby psychological and behavioral interventions are delivered in health care settings along with medical interventions to reduce barriers to care.

Originality/value

Significant numbers of children and adolescents have chronic health conditions and many experience mental health problems related to their conditions. While evidence-based treatments are available to address these problems, significant barriers impede the delivery of psychological and behavioral interventions for many youth. Health care policy promoting integrated health care to deliver psychological and behavioral interventions in health care settings along with medical interventions should reduce barriers to care and improve both physical and mental health outcomes for youth.

Diabetes Distress Among Persons With Type 1 Diabetes

Purpose The purpose of this study is to evaluate associations between diabetes distress and a range of psychological health behaviors and concerns among persons with type 1 diabetes for the benefit of enhancing early identification and intervention of at-risk individuals. Methods Persons with type 1 diabetes (n = 268; 57.1% female, 91.0% white, 76.8% <18 years of age, average A1C 8.4%) completed the 2-item Diabetes Distress Screening Scale (DDS2) and a battery of psychometrically sound instruments measuring satisfaction with life, self-esteem, self-efficacy, depression, perfectionism, body image satisfaction, dietary restraint and eating, and shape and weight concerns. Each subscale score was compared within age groups (<18 years vs ≥18 years) between groups (diabetes distress level [low, moderate, high]) using analysis of variance (with Bonferroni correction or the Kruskal-Wallis test if the variables were not normally distributed). Results For both age groups, high diabetes distress was independently associated with greater A1C values, higher depression scores and eating, and shape and weight concerns than those with low or moderate distress. For patients <18 years of age, those with high diabetes distress scored lower on measures of satisfaction with life, self-esteem, and self-efficacy and higher on dietary restraint and several areas of perfectionism than those with low or moderate distress. Conclusions Individuals with type 1 diabetes who have high diabetes distress also report higher A1C values and poorer psychological health concerns. A brief diabetes distress questionnaire can help to identify those who need additional screening, education and support, and treatment for overall health and well-being.

Implementation of quality of life monitoring in Dutch routine care of adolescents with type 1 diabetes: appreciated but difficult

OBJECTIVE

Monitoring quality of life (QoL) improves well-being and care satisfaction of adolescents with type 1 diabetes. We set out to evaluate the implementation of the program DAWN (Diabetes Attitudes Wishes and Needs) MIND-Youth (Monitoring Individual Needs in Young People With Diabetes) (DM-Y), in which Dutch adolescents' QoL is assessed with the MIND Youth Questionnaire (MY-Q) and its outcomes are discussed. Successful implementation of DM-Y warrants close study of experienced barriers and facilitators as experienced by diabetes care teams as well as adolescents and parents.

METHODS

The study was conducted in 11 self-selected Dutch pediatric diabetes clinics. A mixed methods approach was used. Ten diabetes teams (26 members) were interviewed; 36 team members, 29 adolescents, and 66 parents completed an online survey.

RESULTS

Two of 10 teams successfully implemented DM-Y. Whereas 92% of teams valued DM-Y as a useful addition to routine care, most clinics were not able to continue because of logistical problems (lack of time and manpower). Still, all teams had the ambition to make DM-Y integral part of routine care in the nearby future. Seventy-nine percentage of the parents and 41% of the adolescents appreciated the usage of MY-Q, same percentage of adolescents neutral.

CONCLUSIONS

DM-Y is highly appreciated by teams, as well as adolescents and parents, but for most clinics it is difficult to implement. More effort should be paid to resolve logistic problems in order to facilitate dissemination of DM-Y in care nationwide.

A review of adolescent adherence in type 1 diabetes and the untapped potential of diabetes providers to improve outcomes

Only 21 % of adolescents with type 1 diabetes (T1D) meet glycemic goals set forth by the American Diabetes Association. Adherence to therapy is a particular concern in this population, and the association between poor adherence and worsening glycemic control indicates that there is a critical need to improve adherence to therapy in adolescents with T1D. In this article, we review barriers to adherence in adolescents with T1D and discuss interventions aimed at improving adherence to therapy and glycemic control. Interventions include technology-based applications, family-based therapies, motivational interviewing, and others. Notably, less than 10 % of the interventions reviewed are provider-led, clinic-based interventions, and few have focused on regimen-related aspects of adherence. This article also outlines the importance of provider communication and the role of providers in facilitating adherence behaviors in adolescents with T1D. Finally, we suggest future directions of research to improve adherence to therapy in adolescents with T1D.