Clinical and psychosocial factors associated with achievement of treatment goals in adolescents with diabetes mellitus

Division of Type 1 Diabetes Responsibility in Latinx and Non-Latinx White Mother-Adolescent Dyads

Incidence rates of type 1 diabetes are increasing faster in Latinx youth than other ethnic groups, yet this population remains understudied. The current study (1) tested differences in division of diabetes-related responsibility (adolescent alone, mother alone, and shared) across Latinx and non-Latinx White families (N = 118 mother-adolescent dyads, 56 = Latinx dyads, M_age=13.24 years), and (2) examined associations between diabetes responsibility and adolescent health (HbA1c, diabetes self-management behaviors, and depressive symptoms). Latina mothers reported more shared and less adolescent responsibility than non-Latinx White mothers, but there were no ethnic differences in adolescent reports of responsibility. Independent of demographic and illness-related characteristics, mother- and adolescent-reports of shared responsibility were associated with higher self-management behaviors, while individual responsibility (adolescent or mother alone) was generally associated with lower self-management behaviors. Shared responsibility associations with higher mother-reported self-management behaviors occurred among Latinx families, but not non-Latinx White families. Shared and individual responsibility were not associated with HbA1c or depressive symptoms. The findings suggest the importance of shared responsibility for diabetes management in adolescence, particularly in Latinx families.

Associations Between Depressive Symptoms, Fear of Hypoglycemia, Adherence to Management Behaviors and Metabolic Control in Children and Adolescents with Type 1 Diabetes

We examined the relationship between two malleable risk factors, depressive symptoms and fear of hypoglycemia, in children and adolescents with Type 1 diabetes and their relationship to two important outcomes, adherence behaviors and metabolic control. To assess this relationship, we used a multidimensional measure of adherence, assessing frequency of both blood glucose monitoring and healthy behaviors including diet and exercise. We predicted that higher levels of depressive symptoms and higher levels of fear of hypoglycemia would be associated with worse metabolic control as mediated by poor adherence. Eighty-three children and adolescents ages 8 to 20 (M = 13.87, SD 3.21) were recruited from March 2014 to October 2014 at an outpatient diabetes clinic in a moderately sized Southeastern city within the USA. Nested models were evaluated using structural equation modeling. Adherence significantly mediated the relationship between depressive symptoms and metabolic control with more depressive symptoms leading to worse metabolic control. Adherence marginally mediated the relationship between fear of hypoglycemia and metabolic control; however, less fear of hypoglycemia was associated with worse metabolic control. In a combined model, adherence continued to significantly mediate the relationship between depressive symptoms and metabolic control, while also independently significantly mediating the relationship between fear of hypoglycemia and metabolic control. This finding was also contrary to the predicted relationship with less fear of hypoglycemia leading to worse metabolic control. The results indicate that youth with fewer depressive symptoms and more fear of hypoglycemia had better adherence to their treatment regimen, which was associated with better metabolic control. The results of this study highlight the importance of screening for depression and fear of hypoglycemia during routine clinic visits to optimize adherence and metabolic control.

Measuring Self-Efficacy in the Context of Pediatric Diabetes Management: Psychometric Properties of the Self-Efficacy for Diabetes Scale

Objective

The Self-Efficacy for Diabetes Scale (SED) is a widely used measure of diabetes-specific self-efficacy with three subscales: diabetes-specific self-efficacy (SED-D), medical self-efficacy (SED-M), and general self-efficacy (SED-G). The present study examined the factor structure and construct validity of the SED in 116 youth, aged 10-16 years (13.60 ± 1.87), with type 1 diabetes mellitus.

Methods

Confirmatory factor analysis (CFA) was used to examine the factor structure of the SED. Correlational and regression analyses examined relations between subscales and select outcomes.

Results

CFA of the original three-factor structure provided a poor fit to the data. Factor models using rescaled items were tested. Results provided preliminary evidence for the SED-D as an independent one-factor model, and for a reduced one-factor model. Significant associations were found between the SED subscales, responsibility for diabetes management, and glycated hemoglobin.

Conclusions

Results provide limited support for the SED-D as a reliable and valid measure of diabetes-specific self-efficacy.

No Effect of an Automated Bolus Calculator in Pediatric Patients with Type 1 Diabetes on Multiple Daily Injections: The Expert Kids Study

Background: This multicenter crossover study investigated the potential beneficial effect of an automated bolus calculator (ABC) in children and adolescents with type 1 diabetes (T1D) treated with multiple daily injections (MDI). Methods: Participants were randomized to either begin or end with a 5 months intervention versus their regular treatment regimen (control), separated by a 2 months washout period. During the intervention participants were carefully instructed to use the ABC (Accu-Check Aviva Expert) versus manual insulin calculations during the control period. Participants between 8 and 18 years of age with T1D were recruited from clinics in Denmark, Belgium, and Spain. Inclusion criteria included T1D for >1 year, a minimum of 3 months MDI treatment before inclusion, and HbA1c of 7.5%-11% (57-97 mmol/mol). Improvement in HbA1c was the main outcome, and improved quality of life (QoL) and glucose variability (time spent in target glucose) were secondary outcomes. Results: A total of 65 patients with a mean age of 13.25 years and a mean HbA1c of 8.25% (66.7 mmol/mol) were included. Midway evaluation after 2 months of intervention showed no significant difference from the standard care (0.297, 95% confidence interval [CI]: -0.645 to 0.054; P = 0.10). The difference remained insignificant after the 5 months of intervention (-0.143 [95% CI: -0.558 to 0.272; P = 0.51]). Using the ABC did not change the time spent in target glucose range, nor did it change the QoL. Conclusions: Our study did not demonstrate beneficial additive effects of an ABC in children and adolescents with T1D treated with MDI neither in HbA1c, nor in any other endpoint investigated.

Evaluating fear of hypoglycemia, pediatric parenting stress, and self-efficacy among parents of children with type 1 diabetes and their correlation with glycemic control

Background: This study was designed to determine the level of fear of hypoglycemia (FoH), pediatric parenting stress and selfefficacy in parents of children with type 1 diabetes (T1D).

Methods: In this cross-sectional study, 61 families of children with T1D who had been diagnosed for at least 6 months recruited from "Gabric Diabetes Education Association" in Tehran. Sixty mothers and 41 fathers of 61 children (26 girls, age: 6.0-12.7 years) were assessed using the Hypoglycemia Fear Survey-Parent (HFS-P), Pediatric Inventory for Parents (PIP) and Self-Efficacy for Diabetes Scale-Parent (SED-P) questionnaires. Pearson correlation analysis was used to compute the correlation between HFS-P, PIP and SEDP scores separately for mother and fathers.

Results: Only 8.3% of children had controlled diabetes. Internal reliability of the Persian version of all questionnaires was good. FoH were higher for mothers. Mothers whose children had diabetes for less than two years had significantly lower mean HFS-Behavior subscale (HFS-B) scores than mothers whose children had diabetes for more than two years. There was a positive correlation between fathers’ mean HFS-B score and children’s total insulin dose per day. Parents' FoH score was positively correlated with increased pediatric parenting stress. Findings also showed considerable emotional distress in 51% of mothers and 29.7% of fathers. Frequency of selfmonitoring blood glucose tests (SMBG) correlated negatively with HbA1c.

Conclusion: We concluded that parents with high levels of FoH and stress may benefit from diabetes education. Important implications for education are considering psychological adjustment, recognizing diabetes-related fear and stress in parents, encouraging fathers to become actively involved in the child’s diabetes management and emphasizing the importance of SMBG.

Adolescent Information Management and Parental Knowledge in Non-Latino White and Latino Youth Managing Type 1 Diabetes

Objectives

The objective of this study is to examine associations between adolescents' regulation of information about their type 1 diabetes (adolescent disclosure, secrecy), parental knowledge about their adolescent's diabetes management, diabetes outcomes (adherence, HbA1c), and depressive symptoms in Non-Latino White and Latino families.

Methods

In all, 118 adolescents (56 = Latino, 62 = Non-Latino White) completed surveys of disclosure to and secrecy from parents, parental knowledge of adolescent diabetes management, adherence, and depressive symptoms, and mothers completed measures of maternal knowledge and adolescent adherence. Glycemic control was extracted from medical records. Adolescents also completed structured interviews about parental knowledge about their diabetes-related problems.

Results

Interviews revealed that adolescent disclosure is the primary method by which parents gain knowledge about adolescent diabetes management problems. Adolescent disclosure to and secrecy from parents were uniquely associated with diabetes management and depressive symptoms independent of parental knowledge across ethnic groups; maternal reports of knowledge about her adolescent's diabetes care activities were associated with diabetes management independent of adolescent disclosure and secrecy.

Conclusions

Adolescent information management strategies are a primary means by which parents gain knowledge about diabetes, which may facilitate more effective management.

Adolescent and Parent Treatment Goals in an Internet-Delivered Chronic Pain Self-Management Program: Does Agreement of Treatment Goals Matter?

Objective

To assess whether adolescent-parent agreement on treatment goals as part of an Internet-delivered cognitive-behavioral pain intervention was associated with adolescent outcomes. 122 adolescent-parent dyads selected two treatment goals. Pain intensity and pain-related disability were assessed at pre-treatment, post-treatment, and 6- and 12-month follow-ups. We compared dyads who had goal agreement versus no agreement. 74 dyads (61%) agreed on one or more treatment goals, most commonly going to school, sports, and sleep. In dyads who chose the same goal, regardless of the content, adolescents had lower pain intensity post-treatment and at follow-up. When goals were categorized by domain, in dyads who agreed on physically active goals, adolescents were more likely to report lower pain intensity compared with other groups. Agreement of goals was not associated with changes in pain-related disability. Agreement on treatment goals may be an important treatment process to maximize outcomes in self-management therapies.

Perceptions of Adolescent Patients of the "Lived Experience" of Type 1 Diabetes

The care and management of adolescents with type 1 diabetes presents numerous challenges that are inherent to the fears, attitudes, and perceptions of their illness. This qualitative study aimed to explore the "lived experience" of individuals with type 1 diabetes. In-depth interviews were conducted with 20 patients diagnosed with type 1 diabetes in their adolescent years to elicit their views, perceptions, and concerns regarding living with diabetes. All interviews were conducted and analyzed using the principles of grounded theory. Five categories defining the patients' lived experience were elicited: Barriers, Develop Skills, Manage Emotion, Social World, and Health Care Professionals. The problems experienced by adolescents with type 1 diabetes are multifactorial. Existentially, type 1 diabetes affects their daily activities and impinges on their academic achievement and personal aspirations. They have great difficulty coping with their health status and highlight a lack of empathy from health care professionals (HCPs). Their major fear is of hypoglycemia, resulting in their subsequent focus of preventing hypoglycemic episodes. Indeed, regardless of consequence, blood glucose levels are often deliberately kept above recommended levels, which serves to decrease the effectiveness of their health care management. This study shows that the quality of care provided for adolescent patients with type 1 diabetes is failing to meet their expectations and falls short of the essential standards commensurate with current health care policy. Improvements in long-term care management for these patients require changes in both patients' and professionals' understanding of the disease and of the ways it is managed.

Impact of disease-management programs on metabolic control in patients with type 1 diabetes mellitus: A cohort study in Shantou, China

The aim of this study is to evaluate the effect of diabetes disease management program (DMP) on glycemic control in type 1 diabetes mellitus (T1DM) patients in Shantou China.A sample of 240 participants recruited from 3C study Shantou subgroup was followed up in DMP for 3 years. The DMP provided self-management education, individualized therapy plan, diabetes complications screening, and laboratory examination periodical according to clinical practice guidelines. Primary outcomes were changes in hemoglobin A1C (HbA1c).Two hundred one of the participants completed the follow-up. There was a significant decrease in the HbA1c levels after DMP implemented. The mean (± SD) pre- and post-intervention HbA1c levels were 10.26% ± 3.30% and 8.57% ± 1.57% respectively with a P value <0.001. General linear mixed model analyse demonstrated that changes in glycemic control were associated with insulin treatment regimen, frequency of Self-Monitoring of Blood Glucose (SMBG), diabetes diet adherence, physical activity, and duration of diabetes.DMP helped to improve glycemic control and should be general implemented in China's T1DM. Individuals with basal-bolus regimen (multiple daily injections or pump therapy), more frequency of SMBG, following a diabetes diet, more physical activity, shorter diabetes duration may derive greater benefits from DMP.

Goal Pursuit in Youth with Chronic Pain

Children and adolescents frequently experience chronic pain that can disrupt their usual activities and lead to poor physical and emotional functioning. The fear avoidance model of pain with an emphasis on the maladaptive behaviors that lead to activity avoidance has guided research and clinical practice. However, this model does not take into consideration variability in responses to pain, in particular the active pursuit of goals despite pain. This review aims to introduce a novel conceptualization of children's activity engagement versus avoidance using the framework of goal pursuit. We propose a new model of Goal Pursuit in Pediatric Chronic Pain, which proposes that the child's experience of pain is modified by child factors (e.g., goal salience, motivation/energy, pain-related anxiety/fear, and self-efficacy) and parent factors (e.g., parent expectations for pain, protectiveness behaviors, and parent anxiety), which lead to specific goal pursuit behaviors. Goal pursuit is framed as engagement or avoidance of valued goals when in pain. Next, we recommend that research in youth with chronic pain should be reframed to account for the pursuit of valued goals within the context of pain and suggest directions for future research.

The Lived Experience of Adolescent Females With Type 1 Diabetes

PURPOSE

The purpose of this study was to gain a better understanding of what it means for adolescent females to live with type 1 diabetes.

METHODS

Van Manen's phenomenological framework was used to guide the project of inquiry. Adolescents were recruited from a diabetes camp. A purposive sample of 10 adolescent females, aged 16 and 17 years, volunteered to participate in the study. Unstructured, one-on-one interviews were conducted and participants' accounts were transcribed and analyzed for themes.

RESULTS

Five themes were identified: (1) blending in with the adolescent culture, (2) standing out and being watched, (3) weighing the options and making choices, (4) being tethered to the system and to diabetes, and (5) struggling with conflicts. These adolescent females struggled with several conflicts and choices they were forced to make on a daily basis. They felt tethered to a disease that would never go away and to the healthcare system. Yet, they adopted ways to handle their disease so that it was manageable within the context of their lives. Fitting in with their peers was often more important than diabetes management.

CONCLUSIONS

Making visible the experience of adolescent females living with type 1 diabetes has implications for practice, education, and research in diabetes education.

Psychometric Properties of the Portuguese Version of the Coping Health Inventory for Parents (CHIP) of Adolescents With Chronic Illness

Parental coping allows the family of adolescents with chronic illness to manage their daily activities, provide the care that the adolescent needs to control the disease and influence illness adaptation and family wellbeing. This study analyzed the psychometric properties of the Portuguese version of the Coping Health Inventory for Parents (CHIP).

METHODS

The sample consisted of 226 parents of adolescents (between 12 and 19years old) with type 1 diabetes, asthma or obesity, diagnosed more than a year ago, who accompanied the teenager during a routine visit. Participants answered the Coping Health Inventory for Parents (CHIP) and Illness Perception Questionnaire ((Brief-IPQ)).

RESULTS

The Portuguese version consists of one less item than the original version (44 items) organized in the same three components - Maintaining Family Integration, Maintaining Social Support and Understanding the Medical Situation - with internal consistency of .80, .82 and .76, respectively. The components of parental coping were related to illness perceptions (personal control, treatment control and concerns) in adolescents with type 1 diabetes, revealing that parental coping was associated with a more threatening perception of the illness. No significant differences were observed on parental coping based on the adolescent's gender, parent's gender, age and education level, type of chronic illness, or single versus two parent families except for adolescence stage, showing that parents of younger teenagers presented higher parental coping than parents of older teenagers.

CONCLUSION

The Portuguese version of the CHIP showed good psychometric properties to be used with parents of adolescents with chronic illness.

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

Long-term positive and negative psychosocial outcomes in young childhood cancer survivors, type 1 diabetics and their healthy peers

OBJECTIVE

This study examined posttraumatic growth (PTG) in young childhood cancer survivors (CCS) and type 1 diabetics (DM), with physically healthy peers as the control group (CG). Anxiety and depression as negative mental outcomes in the three groups, as well as fear of progression in DM and CCS were examined.

METHODS

A total of 107 participants with ages ranging from 18 to 35 years were examined: CCS (n=33), type 1 diabetics (n=39) and peers without a history of chronic disease (n=35). PTG and negative psychosocial outcomes were assessed with self-report questionnaires.

RESULTS

There was a significant difference between the groups regarding PTG. On a subscale level DM reported higher appreciation of life (p=0.024), higher personal strength (p=0.010), and more new possibilities (p=0.010) compared to CG. CCS experienced higher spiritual changes than DM (p=0.050). DM reported higher levels of anxiety compared to CCS (p=0.026) and CG (p=0.049). Depression was higher in DM compared to CG (p=0.003). Fear of progression was higher in DM compared to CCS (p<0.001).

CONCLUSION

These findings show that psychological growth was experienced by young CCS and participants with DM. Furthermore, these findings highlight that adolescents with a significant health diagnosis in childhood or youth can undergo a similar or even more positive psychosocial development as peers without a history of chronic disease. However, young type 1 diabetics seem to be a more vulnerable group in terms of anxiety, depression and fear of progression.

Diabetes Self-Care Activities and Health-Related Quality-of-Life of individuals with Type 1 Diabetes Mellitus in Shantou, China

OBJECTIVE

To assess diabetes self-care behaviours and health-related quality-of-life (HRQoL) in people with type 1 diabetes mellitus (T1DM), in China.

METHODS

Individuals with T1DM underwent face-to-face interviews over a 7-day questionnaire period. The Summary of Diabetes Self-Care Activities (SDSCA) was used to assess self-care behaviours. EQ-5D-3L was used to quantify HRQoL.

RESULTS

Of self-care activities, individuals (n = 322) were most likely to adhere to treatment and least likely to perform foot care. A total of 78.9% of participants did not examine their feet and 33.9% of participants did not monitor blood glucose during the questionnaire period. Moderate/severe anxiety or depression was reported by 28.6% of participants; 23.9% reported moderate/severe pain or discomfort. The individual's level of diabetes education, insulin injection regimen and HbA1c were independently associated with total SDSCA score. Household income and age were independently associated with EQ-5D index.

CONCLUSIONS

Enhancing diabetes education in individuals and implementing strict insulin regimens could improve self-care behaviours in people with T1DM in China.

Glycemic Control, Self-Efficacy and Fear of Hypoglycemia Among Iranian Children with Type 1 Diabetes

OBJECTIVE

This study was designed to test the reliability of a Persian version of 2 questionnaires to assess the level of fear of hypoglycemia (FoH) and self-efficacy in diabetes management and their association with glycated hemoglobin (A1C) and parents' demographic characteristics in a sample of children with type 1 diabetes.

DESIGN

We assessed 61 children with type 1 diabetes (35 boys and girls, 6.0 to 12.7 years of age) using the Hypoglycemia Fear Survey-Child version (HFS-C) and Self-Efficacy for Diabetes Scale-Child version (SED-C). Their glycemic control was evaluated by A1C levels.

RESULTS

The internal consistency of the Persian version of HFS-C and SED-C were very good. Our results showed that children older than 10 years of age report lower levels of FoH, which are related to higher levels of self-efficacy (r=-.30, p=0.025 and r=-.30, p=0.02, respectively). Of the children, 42.3% of girls and 31.4% of boys reported that low blood sugar is a big problem for them. These findings suggest that FoH is a significant concern for this target group. Only 19.7% of children had controlled diabetes based on A1C levels. There was no significant association between higher A1C levels and other variables, including HFS-C, SED-C and parents' demographic characteristics.

CONCLUSIONS

The Persian version of HFS-C and SED-C are reliable and valid measures of the fear of hypoglycemia and of self-efficacy in children with type 1 diabetes, and these questionnaires could be used in our country for identifying those children who may need diabetes education and other supports. The association between greater self-efficacy and lower fear of hypoglycemia suggests that addressing self-efficacy in diabetes education courses may be effective in helping to overcome FoH.

A revised Self- and Family Management Framework

BACKGROUND

Research on self- and family management of chronic conditions has advanced over the past 6 years, but the use of simple frameworks has hampered the understanding of the complexities involved.

PURPOSE

We sought to update our previously published model with new empirical, synthetic, and theoretical work.

METHODS

We used synthesis of previous studies to update the framework.

DISCUSSION

We propose a revised framework that clarifies facilitators and barriers, processes, proximal outcomes, and distal outcomes of self- and family management and their relationships.

CONCLUSIONS

We offer the revised framework as a model that can be used in studies aimed at advancing self- and family management science. The use of the framework to guide studies would allow for the design of studies that can address more clearly how self-management interventions work and under what conditions.

Health-related quality of life among Norwegian children and adolescents with type 1 diabetes on intensive insulin treatment: a population-based study

AIM

To examine health-related quality of life (HRQOL) in children and adolescents with type 1 diabetes on intensive insulin treatment.

METHODS

All children and adolescents with type 1 diabetes above 8 years of age scheduled for follow-up at 21 paediatric departments in Norway, and one of their parents was invited to describe HRQOL by completing DISABKIDS questionnaires. HRQOL was related to sociodemographic factors (i.e. parental economy, education, marital status and to level of physical activity and disease characteristics, obtained from the Norwegian Childhood Diabetes Registry).

RESULTS

Nine hundred and thirty seven (48%) and one of their parents responded. Mean duration of diabetes was 4.9 years (SD 3.3), 51% were girls, 56% used insulin pumps, and 44% used multiple insulin injections, predominantly of long-acting and rapid insulin analogues. Mean HbA1c was 8.5% (SD 1.3). Lower HRQOL scores were significantly associated with higher HbA1c, being a girl and experience of diabetes ketoacidosis. Mothers scored lower than fathers on total score and most subscales. No significant differences in scores were found between users of an insulin pump and multi-injection treatment.

CONCLUSIONS

Health-related quality of life was related to metabolic control and gender, but not to mode of intensified insulin treatment.

Relationship between ways of coping and quality of life in married women: toward mental health promotion

Background

Adaptive ways of coping with stress are as a major component of mental health and also this is considered as a key element in quality of life.

Objectives

The aim of this study was to investigate the relationship between quality of life and coping mechanisms in married women ages between 18-65 years in order to develop appropriate intervention programs to promote mental health.

Patients and Methods

This study was a part of interventional project to mental health promotion in married women that completed through a cross sectional studies using two standard questionnaires: Ways of Coping (WOC) and Quality of Life questionnaire (WHO, QOL-BREF).

Results

The most and the least used ways in coping with stress were Planful Problem Solving and Confronting Coping. Considering the quality of life, the most and the least scores were related to social dimension and mental health. Also women who have higher quality of life used more Positive Reappraisal way and less Escape-Avoidance way to deal with stress (P < 0.05).

Conclusions

It seems that implementation of an appropriate interventional program related to adaptive ways of coping in order to deal with stress is effective in mental health and quality of life promotion.

Longitudinal trajectories of parental involvement in Type 1 diabetes and adolescents' adherence

OBJECTIVE

The purpose of this study was to examine longitudinal trajectories of parental involvement and adolescent adherence to the Type 1 diabetes regimen, to determine whether changes in multiple facets of parental involvement over time predicted subsequent changes in adolescents' adherence, and to examine whether adolescent self-efficacy mediated the effect of parental involvement on adherence.

METHOD

Two hundred fifty-two adolescents (M age = 12.49 years, SD = 1.53; 53.6% females) diagnosed with Type 1 diabetes mellitus, their mothers, and 188 fathers were enrolled in a 2.5-year longitudinal study. Across 5 time points, up to 252 adolescents and their parents completed measures of adherence, parental involvement (diabetes monitoring, behavioral involvement in diabetes management, and acceptance), and adolescent diabetes self-efficacy.

RESULTS

Using multilevel modeling, analyses indicated significant average declines over time in adherence and most indicators of parental involvement. Lagged multilevel models indicated that declines in mothers' and fathers' acceptance and diabetes monitoring predicted subsequent declines in adolescents' adherence. Additional analyses revealed that longitudinal associations between both maternal acceptance and diabetes monitoring and subsequent adolescent adherence were mediated by adolescents' self-efficacy.

CONCLUSIONS

Results of this study, which were largely consistent across reporters, highlight the importance of maintaining parental involvement in diabetes across adolescence and suggest that parental involvement is beneficial for adolescents' adherence, in part, because it contributes to higher self-efficacy for diabetes management among adolescents.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.

Prevalence of depression among young people with Type 1 diabetes: a systematic review

AIMS

  To determine: (1) prevalence of depression among young people with Type 1 diabetes compared with control groups or population norms; (2) implications of depression for HbA(1c) level; and (3) the relationship between history of depressive symptoms and future depressive symptoms.

BACKGROUND

  Among adults with Type 1 diabetes depression is higher than the general population, and has been associated with adverse implications for self-care and HbA(1c) level. The last published review of depression among young people with Type 1 diabetes only included studies up to 1999.

METHOD

  Systematic searches were conducted for articles published from January 1999 to December 2011 including young people (up to 25 years old) with Type 1 diabetes.

RESULTS

  Twenty-three articles met the inclusion criteria. Of five studies that reported prevalence of depression compared with control groups, three found no differences. Of the three studies that investigated prevalence of depression making reference to population norms, all three showed higher rates of depressive symptoms. Fourteen of 15 studies found associations between more depressive symptoms and higher HbA(1c) level either cross-sectionally or longitudinally. Past depressive symptoms were associated with later depressive symptoms.

CONCLUSIONS

  Current evidence is inconclusive about whether there is increased prevalence of depression among young adults with Type 1 diabetes, as established among adults, but those who are more depressed have higher HbA(1c) level. This review is limited by methodological problems and no identified work in the UK met the inclusion criteria. Given the adverse clinical outcomes, we conclude there is a case for routine mental health screening for young adults with Type 1 diabetes.

A framework for the youth with type 1 diabetes during the emerging adulthood transition

Emerging adulthood, a developmental period from late adolescence to the late twenties, is a critical transition for youths with type 1 diabetes. This article proposes a framework for emerging adults with diabetes during this transitional time, integrating theoretical writings on transitions and emerging adulthood with empirical findings from younger adolescents with diabetes, about whom more is known. Key health, developmental, and behavioral outcomes are proposed, as well as key influential personal and environmental characteristics. Influential transitional events for this age group are also discussed relative to these outcomes and to personal and environmental characteristics. This framework provides a guide for longitudinal studies on the transition to young adulthood among emerging adults with type 1 diabetes. Identifying key times and influential factors will provide information for designing future effective interventions to improve glycemic control and quality of life for these youths as they transition to adulthood.

What mom and dad don't know can hurt you: adolescent disclosure to and secrecy from parents about type 1 diabetes

OBJECTIVE

To examine how adolescent disclosure to and secrecy from parents were related to parental knowledge of diabetes management behaviors, and to adolescent adherence, metabolic control, and depressive symptoms.

METHODS

A total of 183 adolescents with type 1 diabetes reported on disclosure to and secrecy from parents regarding diabetes management, adherence behaviors, depressive symptoms, and perceptions of parental knowledge. Mothers and fathers reported on their own knowledge.

RESULTS

Adolescent disclosure was associated with all reporters' perceptions of knowledge. Secrecy from both parents moderated the relationship between disclosure and adherence, and secrecy from fathers moderated the relationship between disclosure to fathers and glycosylated hemoglobin level. In all cases, disclosure was associated with better diabetes management only when secrecy was low. Finally, higher secrecy related to greater adolescent depressive symptoms.

CONCLUSIONS

Disclosure to parents appears to be an important component of how parents get their knowledge about adolescents' diabetes management, but may be most beneficial for diabetes management when it occurs together with low secrecy.

Characteristics of children with type 1 diabetes and persistent suboptimal glycemic control

OBJECTIVE

This study aims to determine the relationship between the duration of persistent poor glycemic control in type 1 diabetes mellitus (T1DM) children and the likelihood of subsequent improvement.

METHODS

A retrospective cohort study was conducted on T1DM patients aged 6-18 years, followed for at least six visits at Children's National Medical Center (Washington, DC) with at least one hemoglobin A1c (HbA1c) ≥ 10% after the first year since the initial visit (n=151). Medical records of patients with subsequently improved glycemic control were reviewed (n=39).

RESULTS

Patients aged 12-18 years, females, and Medicaid patients were twice as likely to be in persistently poor control as patients aged 6-11 years, males, and privately insured patients, respectively. Each additional visit with HbA1c ≥ 10% and one percentage point increase in the mean HbA1c reduced the likelihood of subsequent improvement by 20% and 50%, respectively. Of the 39 patients with improved control, only 5 (13%) sustained their improvement for ≥ 2 years. Multiple contributing factors for improved control were identified, but no one factor explained improved control in > 25% of patients.

CONCLUSION

This study suggests that the longer the duration of poor control, the more difficult it is to reverse the underlying factors of poor diabetes management. Strategies to improve regular clinic attendance along with reinforcement of changes which resulted in improved control are critical. Adolescents, females, and Medicaid patients in particular should be targeted for sustained intervention.

A comparison of two internet programs for adolescents with type 1 diabetes: design and methods

Implementing psycho-educational programs for youth with type 1 diabetes in clinical care and reaching diverse youth with type 1 diabetes is challenging due to youth, provider, and organizational barriers. This study was designed to compare the effectiveness of an internet coping skills training program with a control condition of internet diabetes education. Each program consists of 5 weekly interactive lessons; the coping skills training program also provides the ability for youth to interact with each other as well as a health coach. Approximately 300 youths with type 1 diabetes will be recruited to participate in this multi-site clinical trial. The primary outcomes are metabolic control, quality of life, and family conflict. Secondary outcomes include stress, coping, self-efficacy, and social competence. Usage, satisfaction, and cost will also be evaluated. In addition, mediators and moderators to intervention effects will be explored. An internet based psycho-educational program for youth with type 1 diabetes may be a promising approach that can be easily be integrated into clinical care.

Reliability and validity of the Norwegian child and parent versions of the DISABKIDS Chronic Generic Module (DCGM-37) and Diabetes-Specific Module (DSM-10)

Background

International guidelines on type 1 diabetes advocate routine screening of health-related quality of life (HRQOL). DISABKIDS questionnaires are the first instruments developed across cultures and nations to provide age-appropriate measures of HRQOL in children with chronic diseases. DISABKIDS includes a Chronic Generic Module 37 (DCGM-37) and disease-specific modules. The purpose of this study was to examine reliability and validity of the Norwegian versions of the DISABKIDS questionnaires in children and adolescents with type 1 diabetes.

Methods

The DCGM-37 and the Diabetes Specific Module-10 (DDM-10) were translated into Norwegian using standard forward-backward translation. Eight to 19 year old children and adolescents with type 1 diabetes scheduled for routine follow-up at three diabetic clinics in Norway and one of their parents were invited to complete the DCGM-37 and the DDM-10. Internal consistency was determined using Cronbach's alpha. Results were compared with those of the Child Health Questionnaire Children Form-87 (CHQ-CF87) and Child Health Questionnaire Parent Form-50 which are established generic questionnaires. DISABKIDS results were related to age, gender, duration of diabetes, mode of insulin delivery and metabolic control. Clinical data were obtained from the Norwegian Childhood Diabetes Registry.

Results

Of 198 eligible child-parent dyads, 103 (52%) completed the questionnaires. Mean age was 13.6 (2.6), range 8-19 yrs, 52% were boys. Cronbach's alpha was > 0.70 for all the DISABKIDS sub-scales except two (physical ability and social inclusion). There were moderate to high correlations (0.65-0.81) between the DISABKIDS scales and mental/emotional sub-scales of CHQ-CF87. Increasing age and higher HbA1c were significantly associated with reduced HRQOL scores. Parents tended to score their child's HRQOL lower than the children/adolescents themselves.

Conclusions

The study shows that the DISABKIDS instruments are applicable to a Norwegian childhood diabetes population. They seem to be a relevant supplement to other clinical indicators in medical practice and research.

Families with children with diabetes: implications of parent stress for parent and child health

OBJECTIVE

To examine the relation of parent stress to parent mental health and child mental and physical health.

METHODS

We interviewed children with type 1 diabetes (n = 132; mean age 12 years) annually for 5 years and had one parent complete a questionnaire at each assessment. Parents completed measures of general life stress, stress related to caring for a child with diabetes, benefit finding, and mental health. Child outcomes were depressive symptoms, self-care behavior, and glycemic control. Multilevel modeling was used to examine concurrent and longitudinal relations.

RESULTS

Greater parent general stress and greater parent diabetes-specific stress were associated with poorer parent mental health. Overall, greater parent general stress was associated with poorer child outcomes, whereas greater parent diabetes-specific stress was associated with better child outcomes.

CONCLUSIONS

Families with high levels of general life stress should be identified as they are at risk for both poor parent and child health outcomes.

Parenting goals: Predictors of parent involvement in disease management of children with type 1 diabetes

The purpose of this study was to develop a measure of diabetes-specific parenting goals for parents of children with type 1 diabetes and to examine whether parenting goals predict a change in parenting involvement in disease management. An independent sample of primary caretakers of 87 children aged 10 to 16 years with type 1 diabetes completed the measure of parenting goals (diabetes-specific and general goals); both parent and child completed measures of parent responsibility for diabetes management at baseline and 6 months. Parents ranked diabetes-specific parenting goals as more important than general parenting goals, and rankings were moderately stable over time. Parenting goals were related to parent responsibility for diabetes management. The relative ranking of diabetes-specific parenting goals predicted changes in parent involvement over 6 months, with baseline ranking of goals predicting more parental involvement at follow-up. Parenting goals may play an important role in family management of type 1 diabetes.

Assessing readiness to change the balance of responsibility for managing type 1 diabetes mellitus: adolescent, mother, and father perspectives

OBJECTIVE

This study examined the reliability and validity of items assessing adolescent and parent readiness to change the balance of responsibility for managing type 1 diabetes mellitus (T1DM).

METHODS

Sixty-nine adolescents with T1DM and their caregivers completed questionnaires assessing readiness to change the balance of responsibility, division of responsibility for diabetes management tasks, self-efficacy, and parenting stress. Stages of change classifications were determined for individual respondents and families.

RESULTS

Participant inclusion in the different readiness to change classifications was associated with the variability in scores for indices of responsibility, self-efficacy, and parenting stress. Adolescent, maternal, and paternal characteristics accounted for differing amounts of variance in predicting readiness to change the balance of responsibility scores.

CONCLUSIONS

Individual assessment of youth and caregivers' readiness to change the balance of responsibility for diabetes management tasks may be beneficial to providers during the youths' transition from adolescence to young adulthood.

A Review of Diabetes Mellitus–Specific Family Assessment Instruments

Family dynamics and attributes are increasingly recognized as affecting management of diabetes mellitus (DM); however, little research has been done on the validity and usefulness of family assessment instruments (FAIs). This article reviewed the literature that employs DM-specific FAIs and evaluates whether the instruments comprehensively captured family attributes/processes and were robust enough to be useful in understanding the relationship between family attributes/issues and DM-related health care. Studies using eight instruments were identified through a search of literature published from 1982 to 2010 and were analyzed with criteria derived from the measurement and family literatures. The findings of this study revealed that DM-specific FAIs yield useful data about family-related phenomenon; however, some domains of DM-specific care, such as family dynamics/functioning, were not overtly measured. Suggestions for improving DM-specific FAIs are provided and a rationale for why DM-specific and non-DM-specific FAIs is needed to fully measure family issues related to family dynamics/attributes on DM patient care.

Fatores associados à qualidade de vida de jovens com diabetes mellitus do tipo 1

O objetivo deste estudo foi realizar a revisão bibliográfica acerca dos fatores que podem influenciar a Qualidade de Vida Relacionada à Saúde (QV) dos adolescentes com diabetes mellitus tipo 1, por meio da estratégia de PICO. As bases de dados utilizadas foram PubMed/MEDLINE, ISI Web of Knowledge e EMBASE. O maior levantamento dos artigos foi possível com a combinação de descritores padronizados e não padronizados. Apesar da QV ser um construto específico de avaliação dos aspectos relacionados às repercussões da saúde, doença e tratamento, os fatores sócio-demográficos, psicossociais e relacionados à família parecem influenciar de forma significativa na QV.

A conceptual model of childhood adaptation to type 1 diabetes

The Childhood Adaptation Model to Chronic Illness: Diabetes Mellitus was developed to identify factors that influence childhood adaptation to type 1 diabetes (T1D). Since this model was proposed, considerable research has been completed. The purpose of this article is to update the model on childhood adaptation to T1D using research conducted since the original model was proposed. The framework suggests that, in individuals and families, characteristics such as age and socioeconomic status as well as the individuals' and families' responses (self-management, coping, self-efficacy, family functioning, social competence) influence the level of adaptation; in children with T1D, characteristics such as treatment modality (pump vs injections) and psychosocial responses (depressive symptoms and anxiety) also influence the level of adaptation. Adaptation has both physiologic (metabolic control) and psychosocial (Quality of Life [QOL]) components. This revised model provides greater specificity to the factors that influence adaptation to chronic illness in children. Research and clinical implications are discussed.

Exploring self-management characteristics in youths with type 1 diabetes mellitus: does membership in a glycemic control category matter?

BACKGROUND

Hemoglobin A1c (HbA1c) levels have been shown to worsen in adolescence and be related to long-term diabetes complications. Although categories of diabetes control (e.g., ideal, satisfactory, and poor) are routinely used in clinical practice, research has not fully explored whether these categories meaningfully distinguish between different self-management characteristics.

OBJECTIVES

This study examines potential differences in self-management characteristics for youths and their caregivers for three different categories of diabetes control (e.g., ideal, satisfactory, and poor control).

METHODS

A total of 69 adolescents (35 M/34 F) with type 1 diabetes mellitus (T1DM) (aged 12-17 yr) and their caregivers completed questionnaires of readiness to change the balance of responsibility for diabetes tasks, family responsibility in diabetes management, and self-efficacy for diabetes. A medical record review yielded demographic information, most recent HbA1c level, and health care utilization over the past year.

RESULTS

Youths in the three different categories of diabetes control demonstrated no significant differences on measures of self-management characteristics. Maternal caregivers from the satisfactory control category and youths in the poor control category demonstrated the most consistent responses across various self-management characteristics.

CONCLUSIONS

Youths classified in different categories of glycemic control may not be as different in their self-management characteristics as was presumed. Moreover, associations among self-management characteristics were not universal across responders. Therefore, individual assessments of youths' and caregivers' self-management characteristics need to occur independent of the youths' membership in a certain category of diabetes control.

Getting (the most) out of the research business: interventions for youth with T1DM

We review research on psychosocial interventions to improve outcomes for youth with type 1 diabetes mellitus. Specifically, we discuss individual- and small group-focused, family-focused, group-focused, and other interventions. After reviewing extant research in each area, we discuss how the current evidence base may be used to inform clinical practice. Finally, we conclude by discussing variations in effects of interventions on different outcomes (eg, glycemic control, family functioning) and how to consider this evidence when selecting treatments to transport into clinical settings.

Self-efficacy affects blood sugar control among adolescents with type I diabetes mellitus

BACKGROUND/PURPOSE

Self-management is crucial to diabetes control. To investigate the effectiveness of self-management in reaching target hemoglobin A1c (HbA1c) level, we conducted a study among Taiwanese adolescents with type 1 diabetes mellitus (DM).

METHODS

Patients aged 12-20 years with type 1 DM participated in an annual integrated DM care clinic at a medical center in Taiwan. All patients completed a questionnaire that included demographic data and self-efficacy measured by the Perceived Diabetes Self-Management Scale (PDSMS) in February 2008. Laboratory tests were also done at the same visit. The target HbA1c was < 7.0% in accordance with the general standard of the American Diabetes Association for patients with type 1 DM. Logistic regression analysis was used to explore the relationship between age, sex, duration of diabetes, PDSMS score, and HbA1c level.

RESULTS

Fifty-two patients were enrolled. The mean age was 16.0 +/- 2.4 years, and mean HbA1c level was 8.6 +/- 1.6%. Pearson correlation analysis showed a positive correlation between body mass index and preprandial blood sugar level (r = 0.297, p < 0.05). Negative correlations were found between PDSMS scores and duration of diabetes (r = -0.365, p < 0.01) as well as HbA1c level (r = -0.295, p < 0.05). Logistic regression analysis demonstrated that sex and PDSMS scores significantly influenced glycemic control. In multivariate logistic regression analysis, patients with higher PDSMS scores were 1.63 times (95% confidence interval = 1.03-2.59) more likely to reach target diabetes control after adjustment for other variables. Male patients also had a higher probability (odds ratio = 19.80, 95% confidence interval = 1.34-291.93) of reaching target diabetes control.

CONCLUSION

This study demonstrates that adolescents with type 1 DM and higher self-efficacy, especially males, have a higher probability of reaching target diabetes control.

Assessment of self-reported self-esteem in healthy and diabetic children and adolescents in Greece

BACKGROUND

The aim of the present study was to evaluate any possible negative effect of diabetes on the self-esteem of children and adolescents with diabetes.

METHODS

Self-esteem was evaluated using the Culture-Free Self-Esteem Inventory (CFSEI-2) in 144 patients with Type 1 diabetes mellitus (T1DM; 7-18 years of age) treated in a diabetes center and compared against that of 136 healthy children and adolescents.

RESULTS

Self-esteem was correlated with age (P = 0.017), but not with diabetes (P = 0.886). The median CFSEI-2 score for both healthy and diabetic children was 22. There was no significant correlation between self-esteem and sex, body mass index (BMI), physical exercise, HbA1c or parental educational level. According to Spearman's rank correlation coefficient (r(s)), there was a significant association between age and self-esteem (r(s) = -0.15). Conversely, although BMI (r(s) = -0.09) and treatment duration (r(s) = -0.107) had a slight negative effect on self-esteem and the duration of physical exercise (r(s) = 0.11) and parental education (r(s) = 0.07) seemed to have a positive effect, the associations did not reach statistical significance.

CONCLUSIONS

Self-esteem in diabetic children is mainly affected by their age, level of physical activity and level of family support. These findings emphasize the need to discriminate between glycemic control and diabetic adjustment.

Effects of coping skills training in school-age children with type 1 diabetes

Children with type 1 diabetes are at risk for negative psychosocial and physiological outcomes, particularly as they enter adolescence. The purpose of this randomized trial (n = 82) was to determine the effects, mediators, and moderators of a coping skills training intervention (n = 53) for school-aged children compared to general diabetes education (n = 29). Both groups improved over time, reporting lower impact of diabetes, better coping with diabetes, better diabetes self-efficacy, fewer depressive symptoms, and less parental control. Treatment modality (pump vs. injections) moderated intervention efficacy on select outcomes. Findings suggest that group-based interventions may be beneficial for this age group.

CBT in paediatric and adolescent health settings: A review of practice-based evidence

Cognitive Behavioural therapy (CBT) has strong theoretical underpinnings that facilitate the systematic evaluation of outcomes and process of change adults. CBT has been extensively adapted for use with children and young people with session content and method of delivery modified to acknowledge developmental stage and ability. Current approaches emphasise the psychological management of the impact of symptoms of particular types of physical health difficulties and prevention of the development of psychological difficulties, as well as in the alleviation of procedurally related stress. The need for collaboration with families and other parts of a child's network is particularly relevant in the paediatric setting. This review describes what we have found helpful in our work and provides a road map of where to go to find out more about how to do more. General CBT approaches are described as well as examples of how CBT has been used specifically for procedural distress, diabetes, sickle cell disease, chronic pain and chronic fatigue.