Disentangling the roles of parental monitoring and family conflict in adolescents' management of type 1 diabetes

Parent-Adolescent Communication, Self-Efficacy, and Self-Management of Type 1 Diabetes in Adolescents

PURPOSE

The purpose of this study was to investigate adolescent perspectives of parent-adolescent communication, type 1 diabetes mellitus (T1DM)-specific family conflict, self-efficacy, and their relationship to adolescent self-management of T1DM.

METHODS

A cross-sectional survey design was employed. Adolescents completed measures of parent-adolescent communication, T1DM-specific family conflict, self-efficacy, and self-management, which included activation and division of responsibility for management tasks.

RESULTS

Surveys were completed by 113 adolescents ages 11 to 17 years (mean age 13.85 years, SD 1.78) and living with T1DM for 6 months and longer. Hierarchical multiple regression sought to determine what variables make the most unique contribution to self-management of T1DM, division of family responsibility for management tasks, and activation. Self-efficacy was a significant predictor of division of family responsibility for T1DM management, patient activation, and all self-management subscales except collaboration with parents. Openness in parent-adolescent communication was a significant predictor of the diabetes communication and goals subscale of the self-management measure and activation. Problems in communication was a significant predictor of collaboration with parents and self-management goals.

CONCLUSIONS

These findings suggest that family context characteristics, particularly parent-adolescent communication, and self-efficacy are important for engagement with self-management for adolescents living with T1DM. Findings can inform future family-focused self-management interventions to improve T1DM outcomes for adolescents living with T1DM.

Towards standardization of person-reported outcomes (PROs) in pediatric diabetes research: A consensus report

BACKGROUND

Diabetes ranks among the most common chronic conditions in childhood and adolescence. It is unique among chronic conditions, in that clinical outcomes are intimately tied to how the child or adolescent living with diabetes and their parents or carers react to and implement good clinical practice guidance. It is widely recognized that the individual's perspective about the impact of trying to manage the disease together with the burden of self-management should be addressed to achieve optimal health outcomes. Standardized, rigorous assessment of behavioural and mental health outcomes is crucial to aid understanding of person-reported outcomes alongside, and in interaction with, physical health outcomes. Whilst tempting to conceptualize person-reported outcomes as a focus on perceived quality of life, the reality is that health-related quality of life is multi-dimensional and covers indicators of physical or functional health status, psychological well-being and social well- being.

METHODS

In this context, this Consensus Statement has been developed by a collection of experts in diabetes to summarize the central themes and lessons derived in the assessment and use of person-reported outcome measures in relation to children and adolescents and their parents/carers, helping to provide a platform for future standardization of these measures for research studies and routine clinical use.

RESULTS

This consensus statement provides an exploration of person-reported outcomes and how to routinely assess and incorporate into clincial research.

Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors

OBJECTIVES

Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms.

METHODS

Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression.

RESULTS

DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management.

CONCLUSIONS

Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.

Moderating Effect of Depression on Glycemic Control in an eHealth Intervention Among Black Youth With Type 1 Diabetes: Findings From a Multicenter Randomized Controlled Trial

BACKGROUND

Black adolescents with type 1 diabetes (T1D) are at increased risk for suboptimal diabetes health outcomes; however, evidence-based interventions for this population are lacking. Depression affects a high percentage of youth with T1D and increases the likelihood of health problems associated with diabetes.

OBJECTIVE

Our aim was to test whether baseline levels of depression moderate the effects of a brief eHealth parenting intervention delivered to caregivers of young Black adolescents with T1D on youths' glycemic control.

METHODS

We conducted a multicenter randomized controlled trial at 7 pediatric diabetes clinics located in 2 large US cities. Participants (N=149) were allocated to either the intervention group or a standard medical care control group. Up to 3 intervention sessions were delivered on a tablet computer during diabetes clinic visits over a 12-month period.

RESULTS

In a linear mixed effects regression model, planned contrasts did not show significant reductions in hemoglobin A1c (HbA1c) for intervention adolescents compared to controls. However, adolescents with higher baseline levels of depressive symptoms who received the intervention had significantly greater improvements in HbA1c levels at 6-month follow-up (0.94%; P=.01) and 18-month follow-up (1.42%; P=.002) than those with lower levels of depression. Within the intervention group, adolescents had a statistically significant reduction in HbA1c levels from baseline at 6-month and 18-month follow-up.

CONCLUSIONS

A brief, culturally tailored eHealth parenting intervention improved health outcomes among Black adolescents with T1D and depressive symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03168867; https://clinicaltrials.gov/study/NCT03168867.

Self-Reported Food Security in Adolescents with Type 1 Diabetes: Association with Hemoglobin A1c and Mental Health Symptoms Independent of Household Food Security

BACKGROUND

Typically, child exposure to food insecurity is assessed by caregiver reports of household food security. Child report has the potential for greater accuracy because it pertains only to the child whose experiences may differ from caregiver reports.

OBJECTIVE

We assessed if adolescent-reported food insecurity was associated with levels of hemoglobin A1c (HbA1c), acute diabetes-related complications, depressive symptoms, and disordered eating behaviors in adolescents with type 1 diabetes, independently from household food security.

METHODS

In a cross-sectional analysis of the multicenter SEARCH for Diabetes in Youth Cohort Study (phase 4, 2016-2019) including 601 adolescents aged 10-17 y with type 1 diabetes and their caregivers, household food security, and adolescent-reported food security were assessed using the 18-item Household Food Security Survey Module and the 6-item Child Food Security Assessment questionnaire. Age-stratified (10-13 and 14-17) regression models were performed to estimate independent associations, adjusting for sociodemographics, clinical factors, and household food security.

RESULTS

Food insecurity was reported by 13.1% (n = 79) of adolescents and 15.6% (n = 94) of caregivers. Among adolescent-caregiver dyads, 82.5% (n = 496) of reports were concordant and 17.5% (n = 105) discordant, Cohen's κ= 0.3. Adolescent-reported food insecurity was not independently associated with HbA1c, diabetic ketoacidosis, and severe hypoglycemia, including in age-stratified analyses. Adolescent-reported food insecurity was independently associated with elevated odds of depressive symptoms [odds ratio (OR): 3.6; 95% confidence interval (CI): 1.3, 10.3] and disordered eating behaviors (OR: 2.5, 95% CI: 1.4, 4.6) compared with adolescents reporting food security; these associations remained in both age groups for disordered eating behaviors and in the older group for depressive symptoms.

CONCLUSIONS

Adolescents with type 1 diabetes may experience food insecurity differently than caregivers. Adolescent-reported food insecurity was independently associated with depressive symptoms and disordered eating behaviors and thus may be an important attribute to assess in addition to household food security in adolescents with type 1 diabetes.

Diabetes Care and Mental Health During the COVID-19 Pandemic: Perspectives of Adolescents with Diabetes, Parents, and Providers

This study explored ways in which the COVID-19 pandemic impacted adolescents' diabetes management and psychosocial functioning, and how adolescents, parents, and providers viewed telemedicine. We present data from three studies: (1) a comparison of psychosocial functioning and glycemic levels before and after pandemic onset (n = 120 adolescents; 89% with type 1 diabetes), (2) an online survey of parents about pandemic-related stressors (n = 141), and (3) qualitative interviews with adolescents, parents, and medical providers about the pandemic's impacts on adolescents' diabetes care and mental health (n = 13 parent-adolescent dyads; 7 medical providers). Results suggested some adverse effects, including disrupting routines related to health behaviors and psychosocial functioning and impairing adolescents' quality of life. Despite these challenges, most participants did not endorse significant impacts. Some even noted benefits, such as increased parental supervision of diabetes management that can be leveraged beyond the pandemic. Furthermore, telemedicine offers benefits to continuity of diabetes care but presents challenges to care quality. These findings underscore the varied and unique impacts of the COVID-19 pandemic on adolescents with diabetes.

Health-Related Quality of Life of Adolescents and Children With Type 1 Diabetes in the Jazan Region of Saudi Arabia

BACKGROUND

Type 1 diabetes mellitus (T1DM) is increasingly prevalent among Saudi Arabian youth, particularly in the Jazan region. This chronic condition necessitates lifelong insulin therapy and poses significant daily management challenges for affected adolescents. Despite the high incidence rates, there is a notable lack of research into how T1DM impacts the health-related quality of life (HRQoL) of these individuals.

OBJECTIVE

This study aimed to assess HRQoL and its demographic correlates in T1DM patients in the Jazan region of Saudi Arabia.

METHODS

In this cross-sectional study, 236 T1DM patients completed the Pediatric Quality of Life Inventory Diabetes Module 3.0 (PedsQL DM). The HRQoL across domains of diabetes symptoms, treatment barriers, adherence, worry, and communication was compared by gender, nationality, age, education, residence, and healthcare follow-up using t-tests and ANOVA. Multivariate regression identified predictors of overall HRQoL.

RESULTS

Most respondents were female (51.3%), 42.8% were between the ages of seven and 12 years, and 94.5% were Saudi nationals. Males reported better HRQoL than females, with fewer symptoms, treatment barriers, and better communication (all p<0.05). Non-Saudis had better treatment adherence, communication, and overall HRQoL than Saudis (all p<0.05). Older children (13-18 years) reported lower treatment barriers than younger children (three to six years) (p<0.05). Those with intermediate education had lower treatment barriers than those with preliminary education (p = 0.038). Only the female gender (-0.171, p = 0.009) independently predicted poorer overall HRQoL.

CONCLUSION

This study revealed disparities in HRQoL among T1DM children and adolescents. Males, non-Saudis, older children, and those with more education had better HRQoL. Females were at particular risk for poorer outcomes. Targeted interventions are needed to address this region's demographic disparities in diabetes-related HRQoL.

Exploring the Mediating Role of Parental Anxiety in the Link between Children's Mental Health and Glycemic Control in Type 1 Diabetes

Pediatric diabetes type 1 diabetes mellitus (T1D), as a chronic, incurable disease, is associated with psychoemotional and socioeconomic burden for the whole family. Disease outcomes are determined by the metabolic compensation of diabetes, characterized by the level of glycated hemoglobin (HbA1c). The caregivers play a critical role in the metabolic control of children with T1D. The aim of this study was to investigate which environmental factors may explain the relationship between diabetes compensation and anxiety and depression of a child. The cross-sectional interdisciplinary study recruited dyads from adolescents and their parents (N = 251). Adolescent and parent groups were screened for anxiety and depression. General linear model (GLM) mediation analysis was performed to determine the potential mediating effect of surrounding factors on the relationship between dependent variables (glycated hemoglobin) and independent variables (the child's anxiety and depression symptoms). The study revealed that the relationship between HbA1c and the child's anxiety and depression is fully mediated (B = 0.366, z = 4.31, p < 0.001) by parental anxiety. Diabetes metabolic control in adolescents with T1D is related to adolescents' mental health via parents' anxiety. This means that parents' anxiety plays a more significant role in the level of HbA1c than the anxiety and depression of the adolescent.

Adolescent perspectives on negotiating self-management responsibilities for type 1 diabetes with their parents

OBJECTIVE

The overall purpose of this study was to explore adolescent perspectives on communicating about self-management of type 1 diabetes (T1D) and negotiating responsibilities for self-management with parents.

METHODS

Semi-structured interviews were conducted with 28 adolescents aged 11-17 years living with T1D. Interviews were audio-recorded, transcribed verbatim and thematically analysed.

RESULTS

Two themes and five subthemes were identified. The first theme, 'changing levels of involvement in self-management' describes the division of responsibility for self-management within the family and adolescents collaborating and sharing responsibilities with parents for self-management. The second theme, 'talking about self-management with parents' describes changes in patterns of parent-adolescent communication about T1D over time, adolescents' seeking parental feedback and advice and the factors that contribute to the promotion of self-management communication between adolescents and parents.

CONCLUSION

This study identified that how adolescents perceive communication with their parents contributes to negotiation of responsibilities for self-management during adolescence. The findings provide a nuanced understanding of adolescent perspectives on communication with parents about T1D self-management and how parent-adolescent communication can be framed in ways that promote positive adolescent engagement with T1D self-management.

PRACTICE IMPLICATIONS

Targeting parent-adolescent communication strategies may result in more optimal sharing of responsibilities and improved self-management.

Self-Regulation as a Protective Factor for Diabetes Distress and Adherence in Youth with Type 1 Diabetes During the COVID-19 Pandemic

OBJECTIVE

The COVID-19 pandemic increased economic, social, and health stressors for families, yet its impacts on families of youth with chronic conditions, such as type 1 diabetes (T1D), are not well understood. Self-regulation (SR)-or the capacities to control emotions, cognition, and behavior in response to challenge-is known to support T1D management and coping in the face of stress. Strong SR may have protected youth with T1D from the impacts of pandemic-related stressors. This study compared youth and parent emotional functioning and T1D management before and after the pandemic's onset in relation to family pandemic-related stress and youth SR.

METHODS

Parents of youth with T1D (N = 88) and a subset of these youth (N = 43; Mean age 15.3 years [SD 2.2]) completed surveys regarding SR, stress, emotional functioning, and T1D-related functioning prior to and after March 2020. Outcomes were compared using mixed effects models adjusting for covariates. Family pandemic-related stress experiences and youth SR were tested as moderators of change.

RESULTS

Parents' responsibility for T1D management increased across pandemic onset and their diabetes-related distress decreased. Family pandemic-related stress was associated with decreased emotional functioning over time. Youth SR, particularly emotional and behavioral aspects, predicted better emotional and T1D-related functioning.

DISCUSSION

While youth with T1D whose families experienced higher pandemic-related stress had poorer adjustment, strong emotional and behavioral SR appeared to protect against worsening youth mood and adherence across pandemic onset. Both social-contextual and individual factors are important to consider when working with families managing T1D.

Parent-Child Conflict Moderates the Relationship Between Executive Functioning and Child Disruptive Behaviors in Youth with T1D

Executive function (EF) skills, parent-child conflict, and high blood glucose (BG) may impact child externalizing behaviors. We examined these child and parent factors in families of 5-9 year olds with recent-onset type 1 diabetes (T1D). Parents (N = 125) reported child EF, child externalizing behaviors, and conflict regarding T1D-specific tasks. We used self-monitoring BG uploads to calculate the percentage of time children had high BG (> 180 mg/dl). We entered data into a moderated path analysis using MPlus8. The path analysis revealed a positive direct effect for parent-reported child EF and child externalizing behavior (p < .01). Further, T1D-specific conflict moderated the positive association between parent-reported child EF and child externalizing behaviors (p < .05). Early screening of child EF, externalizing behavior, and family conflict may be particularly important in the recent-onset period of T1D. The introduction of T1D-related conflict after diagnosis may impact child externalizing behavior and limited child EF skills that pre-date diagnosis.

A Descriptive Study of the Quality of Life and Burden of Mothers of Children and Adolescents with Type 1 Diabetes

The purpose of this cross-sectional survey was to examine the quality of life and level of burden experienced by mothers of children and adolescents with type 1 diabetes (n = 199). Data was collected using a sociodemographic questionnaire, the Zarit Burden Interview Scale (ZBIS), and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) instruments. A simple descriptive analysis was conducted, and the Pearson's correlation coefficient was utilized to determine the correlation among variables. Most respondents (68.9%) reported moderate to severe burden on the ZBIS. Across age groups, statistically significant, negative correlations were found between burden and physical health (r = -0.371, p < 0.001), social relationships (r = -0.389, p < 0.001), psychological health (r = -0.445, p < 0.001) and environment (r = -0.438, p < 0.001). Mothers of children and adolescents with type 1 diabetes reported an inverse relationship between burden and quality of life influenced by the occupation of caregiving. Occupational therapy practitioners can address strategies to reduce caregiver burden and improve mothers' quality of life.

Diabetes-Related Stigma among Adolescents: Emotional Self-Efficacy, Aggressiveness, Self-Care, and Barriers to Treatment Compliance

Recent studies indicate that over 60% of adolescents with type 1 diabetes (T1D) experience diabetes-related stigma (DRS). DRS may affect their emotional self-efficacy (ESE), behavior, and self-care while increasing barriers to comply with physical and mental health treatment. We examined differences in ESE, aggressiveness, self-care, and barriers to comply with treatment among 51 T1D youths (aged 12-17 years) with (G1; n = 35) and without (G2; n = 16) any history of DRS enrolled in a depression treatment study. Using a MANOVA followed by individual univariate analyses, we compared groups in continuous variables, and to conduct comparisons in categorical variables, we used Chi-square tests. MANOVA results were significant, F(5, 45) = 3.20, p = .015. G1 reported lower scores than G2 on ESE, perception of the potential therapeutic impact of group sessions, and family support to comply with insulin treatment. G1 caregivers perceived their offspring as more aggressive and affected by barriers to treatment adherence than their counterparts. G1 members showed a higher proportion of cases with body mass index problems, non-compliance with their meal plan, and multiple episodes of hypoglycemia. Compared to G2, a lower percentage of adolescents in G1 met the recommended glycemic control levels. Our findings support the relationship of DRS with a lower ESE, more behavioral problems, difficulties in food-related self-care, and more barriers to comply with the treatment of diabetes and emotional problems in adolescents. They suggest the need for large-scale education to prevent DRS and psychosocial interventions to combat its impact in adolescents.

Do baseline resilience profiles moderate the effects of a resilience-enhancing intervention for adolescents with type I diabetes?

OBJECTIVE

Resilience processes include modifiable individual and family-based skills and behaviors and are associated with better health and emotional outcomes for youth with Type I diabetes (T1D). There is likely heterogeneity among adolescents with T1D based on differing profiles of resilience processes. At-risk adolescents with lower levels of modifiable skills and assets may benefit more from psychosocial skill-building interventions, compared to adolescents who already have strong resilience processes. This article identified whether there are subgroups of adolescents with T1D based on resilience process profiles and assessed differences in glycemic control, diabetes management behaviors, and distress at baseline. It also evaluated subgroups as moderators of the efficacy of a psychosocial skill-building program.

METHOD

Two hundred sixty-four adolescents with T1D (14 to 18 years) were randomly assigned to a resilience-promoting program (N = 133) or diabetes education control (N = 131). Data were collected at seven time points over 3 years and analyzed with latent profile analysis and latent growth curve modeling.

RESULTS

There were two subgroups with high- versus low-resilience processes. The low-resilience subgroup exhibited more distress, higher HbA1c, less glucose monitoring, and fewer diabetes management behaviors at baseline. Differences persisted over 3 years. Subgroup membership did not moderate the efficacy of a resilience-promoting program compared to control. The resilience program resulted in lower distress regardless of subgroup.

CONCLUSIONS

There is heterogeneity in resilience process profiles, which are associated with clinically meaningful differences in distress, diabetes management, and glycemic control. Findings can be used to identify at-risk teenagers and inform a targeted approach to care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Health-Related Quality of Life, Family Conflicts and Fear of Injecting: Perception Differences between Preadolescents and Adolescents with Type 1 Diabetes and Their Mothers

Good management of diabetes requires at the same time self-regulation behaviour and a balanced involvement of family components. This cross-sectional study’s aims were: understanding fear of injections and perceptions of family conflicts in preadolescents and adolescents with type 1 diabetes mellitus and their mothers, comparing their perceptions, and identifying the risk factors impacting patients’ quality of life. Eligibility criteria were: treatment for diabetes mellitus type I, currently aged 10–18 years, attending the hospital for annual hospital follow-ups. Exclusion criteria were: intellectual disabilities, inability to complete questionnaires alone and neuropsychiatric illness with active pharmacotherapy. The study design was cross-sectional. Participants were one hundred and two patients (Mean age = 14.6, SD = 2.4; age range = 10–19 years; Females = 52 and Males = 50) and their mothers (Mean age = 46.9, SD = 6.2, age range = 27–63 years), who filled in self and proxy-report questionnaires (N total= 204). The results showed that 20% of patients and 14.7% of their mothers reported clinical scores for fear of self-injection and blood testing. The mothers reported lower fear of injecting and higher family conflicts compared with the patients. Age, fear of injecting and family conflicts were significantly associated with patients’ quality of life perceptions. Clinical considerations and recommendations are given based on the empirical results.

"I Live in Constant Fear of Highs," the Daily Impact of Type 1 Diabetes

Limited research exists regarding the burdens associated with type 1 diabetes (T1D). The study’s objective was to understand the impact of T1D from people with T1D and caregivers of minors with T1D. Six focus groups were conducted, with a total of 31 participants. Participants included people with T1D, ages 23 to 72 (n = 17) and caregivers ages 34 to 55 (n = 14). Participants were recruited from T1D Exchange Glu. People with T1D reported time spent managing diabetes had greatest impact, while caregivers reported financial and employment sacrifices as most impactful. Our findings provide insight into the real-world daily impact of diabetes.

Type 1 Doing Well: Pilot Feasibility and Acceptability Study of a Strengths-Based mHealth App for Parents of Adolescents with Type 1 Diabetes

Background: We evaluated the feasibility and acceptability of a pilot behavioral intervention delivered to parents of adolescents with type 1 diabetes (T1D) via mobile-friendly web app. The Type 1 Doing Well app aimed to promote supportive family diabetes management by helping parents recognize and reinforce teens' positive diabetes-related behaviors ("strengths"). Methods: Parents (n = 80, 74% recruitment) of adolescents (age range = 12-17 years, M = 15.3 ± 1.5 years, 59% female, 56% insulin pump, M hemoglobin A1c (HbA1c) = 9.0% ± 2.1%) were randomized 2:1 to intervention or control (i.e., usual medical care with or without app) for 3-4 months between diabetes appointments. The app prompted parents daily to track adolescents' strengths and generated weekly summaries of their teen's top strengths. Parents could access a library of text messages to praise their teens. Exploratory pre/post data included questionnaires (98% completed) and HbA1c. Results: Parents used the app for M = 106.1 ± 37.1 days, logging in ≥once/day on 80% of days. Ninety-one percent of parents used the app ≥2 days/week on average. Parents viewed M = 5.6 ± 4.7 weekly summaries and "favorited" 15 praise texts in the library. App acceptability ratings (7-point scale) were high: Satisfaction 5.0 ± 1.5, Usefulness 4.8 ± 1.5, Ease of Use 6.2 ± 0.8, and Ease of Learning 6.5 ± 0.8. Parents (n = 48) and adolescents (n = 47) gave positive feedback and suggestions via qualitative interviews. There were no significant between-group differences for change in exploratory outcomes (HbA1c, questionnaires). Conclusions: Type 1 Doing Well was feasible to deliver and highly acceptable and engaging for parents of adolescents with T1D. It may have a larger impact on behavioral or clinical outcomes as part of a multicomponent intervention protocol. Trial Registration: ClinicalTrials.gov NCT02877680.

The Role of Parent Self-Regulation in Youth Type 1 Diabetes Management

PURPOSE OF REVIEW

Youth with strong self-regulation (SR), or the ability to manage thoughts, emotions, and behaviors, engage in more effective type 1 diabetes (T1D) management. However, while parent support and engagement are critical to ensuring positive youth T1D outcomes, it is rarely considered that parents' SR may also influence youth T1D management. If this is the case, novel interventions to improve parents' SR or ensure adequate support for parents with SR challenges offer great potential to improve family functioning and youth T1D management.

RECENT FINDINGS

Theoretical and preliminary empirical evidence suggests that parental SR impacts family processes that support youth T1D treatment regimen adherence. Furthermore, parent and youth SR likely interact, with high parent SR enhancing the positive effects of high youth SR or compensating for low youth SR. Continued research is needed to better understand the ways in which parent SR matters to youth T1D management and identify how to support improvements in T1D management among families of parents with low SR.

Understanding adolescent and parent acceptability and feasibility experience in a large Type 1 diabetes mellitus behavioural trial

AIMS

Using an 18-month, multisite randomized control trial as an exemplar, the aim of this study was to identify themes related to adolescent and parental feasibility and acceptability for participation in large behavioural trials designed to improve adolescents' Type 1 diabetes self-management.

METHODS

Thematic analysis methodology was used to develop themes describing factors related to acceptability and feasibility.

RESULTS

Based on a sample of interviews (N = 72), factors contributing to intervention acceptability and feasibility were identified. Aspects of acceptability included: a framework for goal-setting, the coach as a non-judgemental listener, perception of an ongoing benefit to participation and the delivery mode. Aspects of feasibility included: participants' altruism to help adolescents with Type 1 diabetes; pre-enrolment preparation for intervention content and duration; and the option of remote intervention delivery via telephone or video, which minimized travel time and costs. In addition, participants described positive outcomes including improvements in behaviour, Type 1 diabetes self-management behaviours and parent-adolescent communication, and emotion-attitude changes. Participants also described potential revisions that may inform future trials.

CONCLUSIONS

Acceptability and feasibility of behavioural interventions with adolescents with chronic illness have multifactorial dimensions. While empowering adolescent self-management, parental support is also an under-appreciated aspect to consider. Potential revisions were identified for subsequent behavioural trials.

Monetary reinforcement for self-monitoring of blood glucose among young people with type 1 diabetes: evaluating effects on psychosocial functioning

AIMS

To explore the auxiliary psychosocial effects of a monetary reinforcement intervention targeting self-monitoring of blood glucose among young people with Type 1 diabetes.

METHODS

Sixty young people with Type 1 diabetes, HbA_1c concentrations between 58 and 119 mmol/mol (7.5-13.0%), and average self-monitoring of blood glucose <4 times per day were randomized to either enhanced usual care or a 24-week intervention of monetary rewards for self-monitoring of blood glucose and associated behaviours (e.g. uploading glucose meters). Data were collected from the young people and their parents at baseline, during the intervention (6, 12 and 24 weeks) and after the intervention (36 weeks).

RESULTS

Linear mixed models were used to evaluate the intervention effects on psychosocial outcomes, adjusting for corresponding baseline levels and potential moderation by baseline level. The intervention reduced diabetes distress at week 6 among young people who had average and high baseline distress. It also reduced diabetes distress at weeks 12 and 24 among those with low baseline distress. The intervention also reduced young person-reported diabetes-related family conflict and diabetes-related interference among those with high baseline scores in these areas; however, the intervention worsened young person-reported diabetes interference among those with low baseline interference. Effects were medium-sized and time-limited.

CONCLUSIONS

Findings indicate predominantly positive impacts of monetary reinforcement interventions on psychosocial outcomes, although effects varied by outcome and time point. Whereas early improvements in diabetes distress were observed for all who received the intervention, improvements in other areas varied according to the level of psychosocial challenge at baseline. Incorporating psychosocial interventions may bolster and maintain effects over time.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diabetes-specific family conflict and responsibility among emerging adults with type 1 diabetes

Emerging adulthood is a transitional period for type 1 diabetes management, and aspects of family functioning such as family conflict and responsibility for diabetes management likely change following high school graduation. This study examined changes in diabetes-specific family conflict, family responsibility for diabetes management tasks, and associations with glycemic control up to 1 year after high school. Seventy-nine emerging adults with type 1 diabetes (M age = 18.09 ± .43 years; 51% female; 71% Caucasian) and their parents (73% female) completed self-report measures on diabetes-specific family conflict and family responsibility at 3 consecutive clinic visits, beginning in the spring of their senior year of high school. Hemoglobin A1c (HbA1c) was obtained from medical records. Diabetes-specific family conflict was relatively low; scores did not significantly change from baseline to Time 3. Parent responsibility for diabetes care decreased from baseline to Time 3. Higher parent- and emerging adult-reported family conflict and higher parent responsibility for diabetes care were associated with worse glycemic control (ps < .05). Parent-reported family conflict and the interaction between parent-reported family conflict and responsibility predicted HbA1c 1 year after high school. Conversely, HbA1c did not predict diabetes-specific family conflict or responsibility 1 year after high school. Findings indicate that diabetes-specific family conflict is associated with glycemic control after high school, even when emerging adults assume greater responsibility for diabetes self-care. Diabetes-specific family conflict levels were generally low and did not change over time despite this transitional period. If diabetes-specific conflict is present, it should be an important avenue for potential intervention for emerging adults with type 1 diabetes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The effects of family functioning and resilience on self-management and glycaemic control among youth with type 1 diabetes

AIMS AND OBJECTIVES

To examine the effects of family functioning and resilience on self-management and glycaemic control among youth with type 1 diabetes and to determine whether resilience mediates the effects of family functioning on self-management and glycaemic control.

BACKGROUND

Poor self-management and glycaemic control are common in youth with type 1 diabetes. Family functioning and resilience are known to be important psychosocial factors that contribute to individual health and development. However, no studies have explored the effects of family functioning and resilience on self-management and glycaemic control among youths with type 1 diabetes in mainland China.

DESIGN

This study was conducted using a survey with a convenience sample following the STROBE guidelines.

METHODS

A total of 204 Chinese youth who had been diagnosed with type 1 diabetes for at least 6 months were recruited. Family functioning, resilience, self-management and diabetes distress were measured using self-reports and standard measurement tools. Glycaemic control was assessed by glycated haemoglobin (HbA_1C ) levels. A structural equation model was used to test the hypothesised model.

RESULTS

The final model accounted for 52.1% and 19.5% of the total variance of self-management and HbA_1C level, respectively. Resilience had a direct effect on self-management and an indirect effect on control of HbA_1C . Family functioning had an indirect effect on both self-management and control of HbA_1C through resilience. The model remained invariant across the mild-distress and severe-distress groups.

CONCLUSION

In Chinese youth with type 1 diabetes, resilience positively affected self-management and ultimately optimised glycaemic control, even in the presence of diabetes distress. Family functioning positively affected self-management and glycaemic control by promoting resilience.

RELEVANCE TO CLINICAL PRACTICE

This study found that family functioning and resilience had positive effects on self-management and glycaemic control in youth. This study confirms the importance of incorporating resilience assessments and family-based resilience interventions into clinical nursing practice with youth with type 1 diabetes.

Using Relational Agents to Promote Family Communication Around Type 1 Diabetes Self-Management in the Diabetes Family Teamwork Online Intervention: Longitudinal Pilot Study

Background

Family conflict can reduce adolescent adherence to type 1 diabetes management tasks. The Family Teamwork in-person intervention was shown to be efficacious in reducing conflict and low adherence to diabetes-related tasks. Its reach and potential impact, however, were limited by the need to deliver the intervention sessions in person. Relational agents (ie, computerized versions of humans) have been shown to appeal to diverse audiences and may be an acceptable replacement for a human in technology-based behavior change interventions.

Objective

The purpose of this paper is to present the results of a pilot study assessing feasibility and acceptability of Diabetes Family Teamwork Online, an adapted version of the Family Teamwork intervention, delivered over the internet and guided by a relational agent.

Methods

Parent-adolescent dyads were recruited through a diabetes care clinic at a large tertiary care hospital in the southwestern United States. A one-group design, with assessments at baseline, immediate postintervention, and 3 months later, was used to assess feasibility. A priori feasibility criteria included an assessment of recruitment, completion, attrition, program satisfaction, therapeutic alliance, attitudes toward the relational agent, and data collection. The institutional review board at Baylor College of Medicine approved the protocol (H-37245).

Results

Twenty-seven adolescents aged 10 to 15 years with type 1 diabetes and their parents were enrolled. Criteria used to assess feasibility were (1) recruitment goals were met (n=20), (2) families completed ≥75% of the modules, (3) attrition rate was ≤10%, (4) program satisfaction was high (≥80% of families), (5) therapeutic alliance was high (average score of ≥60/84), (6) families expressed positive attitudes toward the relational agent (average item score of ≥5 on ≥4 items), (7) ≥80% of data were collected at post 1 and post 2, and (8) few technical issues (≤10%) occurred during intervention delivery. All feasibility criteria were met. Qualitative data confirmed that adolescents and parents had positive reactions to both the content and approach.

Conclusions

The Diabetes Family Teamwork Online intervention proved to be a feasible and acceptable method for enhancing communication around diabetes management tasks in families with an adolescent who has type 1 diabetes.

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.5817

Outcomes, care utilization, and expenditures in adolescent pregnancy complicated by diabetes

BACKGROUND AND OBJECTIVE

Adolescence and pregestational diabetes separately increase risks of adverse pregnancy outcomes, but little is known about their combined effect. To analyze pregnancy outcomes, healthcare utilization, and expenditures in adolescent pregnancies with and without pregestational diabetes using a national claims database.

METHODS

Retrospective study using Truven Health MarketScan Commercial Claims and Encounters Database, 2011 to 2015. Females 12 to 19 years old, continuously enrolled for at least 12 months before a livebirth until 2 months after, were included. Pregestational diabetes, diabetes complications (ketoacidosis, retinopathy, neuropathy, nephropathy), comorbidities, and pregnancy outcomes (preeclampsia, preterm delivery, high birthweight, cesarean delivery) were identified using claims data algorithms. Healthcare utilization and payer expenditure were tabulated per enrollee. Multivariate logistic regressions assessed pregnancy outcomes; multivariate OLS regression assessed payer expenditures.

RESULTS

About 33 502 adolescents were included. Adolescents without diabetes had pregnancy outcomes consistent with national estimates. Adolescents with uncomplicated diabetes had increased odds of preeclampsia adjusted odds ratios 2.41 (95% confidence interval 1.93-3.02), preterm delivery 1.50 (1.21-1.87), high birthweight 1.84 (1.50-2.27), and cesarean delivery 1.81 (1.52-2.15). Diabetes with ketoacidosis and/or end-organ damage had higher odds of preeclampsia 5.62 (2.77-11.41), preterm delivery 5.81 (3.00-11.25), high birthweight 2.38 (1.08-5.24), and cesarean delivery 3.43 (1.78-6.64). Adolescents with diabetes utilized significantly more outpatient and inpatient care during pregnancy. Payer expenditures increased by 45.3% (34.8-55.9%) among adolescents with diabetes and by 82.6% (49.1-116.0%) among adolescents with diabetes complicated by ketoacidosis and/or end-organ damage.

CONCLUSION

Compared with normal adolescent pregnancies, pregestational diabetes significantly increases risks of adverse pregnancy outcomes and significantly escalates healthcare utilization and cost.

Predictor factors of glycemic control in children and adolescents with type 1 diabetes mellitus treated at a referral service in Rio de Janeiro, Brazil

AIM

To evaluate the predictive factors of glycemic control in children and adolescents with type 1 diabetes mellitus (T1DM).

METHODS

Cross-sectional study at a referral service in Rio de Janeiro, Brazil. Sociodemographic, anthropometric, clinical, and dietary factors were evaluated. Food consumption was evaluated by 24 h dietary recall and the NOVA system was adopted for classifying the foods according to the extent and purpose of industrial processing. The predictive factors were evaluated by multivariate linear regression, adopting p < 0.05.

RESULTS

One hundred and twenty children and adolescents participated, with a mean age of 11.74 years (±2.88) and HbA1c of 8.13% (±1.26). The mean diabetes duration was 6.68 years (±3.33) and the insulin used was 1.05 units per kilogram of ideal weight (IU/kg of ideal weight; ±0.46) About 80% (n = 96) used carbohydrate counting and it was verified that 24.27% (±17.89) of the participants' total calories came from ultraprocessed foods. For each year of diagnosis with T1DM and for each IU/kg of weight used, HbA1c increased by 0.087% (β = 0.087, p = 0.007) and 0.651%, respectively (β = 0.651; p = <0.001). Use of carbohydrate counting was associated with a 1.058% reduction in HbA1c (β = -1.058; p = 0.001).

CONCLUSION

Disease duration and insulin dose were directly reflected in HbA1c concentrations, while carbohydrate counting showed an inverse association.

Family Environment Scale Parental Ratings of Conflict among Latino Families of Depressed Adolescents with Type 1 Diabetes

OBJECTIVE

Family conflict is related to depression, difficulties with treatment adherence and glycemic control, in adolescents with type 1 diabetes (T1D). We examined the psychometric properties of a parent-rated family conflict measure and the most frequent behaviors endorsed by caregivers of these youths.

METHODS

Participants were 51 caregivers (86.27% women) of adolescents (aged 12-17) with T1D, recruited during a psychotherapy study for youth depression. Both (caregivers and youths) completed questionnaires during the eligibility evaluation. Caregivers completed the Conflict subscale of the Family Environment Scale, considering to what extent its items described their whole family or its majority.

RESULTS

The most frequent indicators of conflict where becoming upset, displaying anger openly, believing that something can be achieved by speaking loudly, and criticizing and fighting, although not physically. Internal consistency for the subscale when rating conflict indicators in a dichotomous format was .69 and .76 when rated in an ordinal format. Conflict scores correlated moderately and significantly (p less than or equal .05) with other measures completed by youths and caregivers. Caregivers of youths with the worst glycemic control reported the highest levels of conflict. The subscale also showed a satisfactory sensitivity to change by reflecting a significant reduction in caregivers' reports of family conflict after adolescent group treatment.

CONCLUSION

Our results confirm the frequent occurrence of conflict (especially verbal conflict) in these families and document the psychometric properties of a measure for its assessment, which may be useful in studies that examine the impact of family conflict in both youth depression and diabetes.

A systematic review of non-genetic predictors and genetic factors of glycated haemoglobin in type 1 diabetes one year after diagnosis

Type 1 diabetes (T1D) results from autoimmune destruction of the pancreatic βcells. Although all T1D patients require daily administration of exogenous insulin, their insulin requirement to achieve good glycaemic control may vary significantly. Glycated haemoglobin (HbA1c) level represents a stable indicator of glycaemic control and is a reliable predictor of long-term complications of T1D. The purpose of this article is to systematically review the role of non-genetic predictors and genetic factors of HbA1c level in T1D patients after the first year of T1D, to exclude the honeymoon period. A total of 1974 articles published since January 2011 were identified and 78 were finally included in the analysis of non-genetic predictors. For genetic factors, a total of 277 articles were identified and 14 were included. The most significantly associated factors with HbA1c level are demographic (age, ethnicity, and socioeconomic status), personal (family characteristics, parental care, psychological traits...) and features related to T1D (duration of T1D, adherence to treatment …). Only a few studies have searched for genetic factors influencing HbA1c level, most of which focused on candidate genes using classical genetic statistical methods, with generally limited power and incomplete adjustment for confounding factors and multiple testing. Our review shows the complexity of explaining HbA1c level variations, which involves numerous correlated predictors. Overall, our review underlines the lack of studies investigating jointly genetic and non-genetic factors and their interactions to better understand factors influencing glycaemic control for T1D patients.

Positive Well-Being in Youth With Type 1 Diabetes During Early Adolescence

Developmental shifts during early adolescence relate to type 1 diabetes (T1D) self-management, increased risk of emotional distress, and worsening health status. Less is known about positive experiences related to T1D. This study evaluated associations of positive well-being (PWB) with diabetes burden, self-management, and glycemic control. Youth (N = 55, age = 12-13 years; X̄ age = 12.75 + 0.56 years, 50.9% male, 38.2% non-Caucasian) reported PWB, depressive symptoms, and diabetes burden. Parents reported on overall T1D adherence. Adherence behaviors and glycemic control were assessed objectively. Higher PWB correlated with lower depressive symptoms (r s = -.45), less diabetes burden (r s = -.48), and better glycemic control (r s = -.43), all p < .01. When controlling for diabetes duration, higher PWB correlated with lower depressive symptoms and better glycemic control. PWB was not related to demographics or adherence. Initial exploration suggests PWB is related to key diabetes constructs, and maybe valuable to consider along with efforts to support youth with T1D during a vulnerable developmental period.

Improving medication adherence in the pediatric population using integrated care of companion animals

Medication non-adherence occurs in more than half of children with chronic conditions. Unfortunately, most strategies for improving adherence have had limited success in the pediatric population highlighting the need for novel interventions that establish healthy self-management habits for children and adolescents. In this paper we discuss innovative strategies to improve adherence by embedding a medical regimen within a pet care routine, thereby capitalizing on the benefits of a structured habit while providing opportunities for development of autonomy in children and fostering collaborative parent interactions.

The Diabetes Strengths and Resilience Measure for Adolescents With Type 1 Diabetes (DSTAR-Teen): Validation of a New, Brief Self-Report Measure

Objective

Despite the challenges of managing type 1 diabetes, many adolescents achieve optimal outcomes. A validated measure of diabetes-specific strengths is needed to measure adaptive behaviors and attitudes associated with overcoming challenges and achieving "resilient" outcomes.

Methods

Baseline data from 260 adolescents (age 14-18 years, M = 15.7 ± 1.1, 60% female, 33% Non-Caucasian, M A1c = 9.1 ± 1.9%) and caregivers in a behavioral intervention trial were analyzed to evaluate psychometric properties of the 12-item self-report Diabetes Strengths and Resilience measure for adolescents (DSTAR-Teen). Reliability and validity were examined in relation to measures of related constructs, regimen adherence, and glycemic outcomes, and confirmatory factor analysis was conducted.

Results

Reliability was good (internal consistency: α = .89; item-total correlations: r range = .55-.78). Significant correlations demonstrated construct and criterion validity. A two-factor structure reflecting intrapersonal and interpersonal processes fit the data better than a one-factor solution.

Conclusions

The DSTAR-Teen has strong psychometric properties, captures adaptive aspects of adolescents' diabetes management (i.e., "strengths"), and is related to clinical outcomes.

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.

Screening and support for emotional burdens of youth with type 1 diabetes: Strategies for diabetes care providers

Multiple sources of burden for youth with type 1 diabetes (T1D) impact key outcomes including quality of life, self-management, and glycemic control. Professional diabetes organizations recommend diabetes care providers screen for psychosocial and behavioral challenges and implement strategies to support youth with T1D. The purpose of this article is to review the literature and recommend practical strategies medical providers can use for screening and behavioral support for youth with diabetes and their families. As part of their routine medical care, diabetes care providers are well-positioned to identify and intervene to address emotional distress related to the burdens of living with diabetes. In collaboration with multidisciplinary team members, including psychologists and mental health professionals, medical providers may be able to successfully implement brief behavioral strategies for screening and providing emotional support.

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)

Family-Based Interventions Targeting Improvements in Health and Family Outcomes of Children and Adolescents with Type 1 Diabetes: a Systematic Review

PURPOSE OF REVIEW

A systematic review was conducted of family-based interventions to improve glycemic control, adherence, and psychosocial outcomes in children and adolescents with type 1 diabetes (T1D). Electronic databases were searched for randomized controlled trials (RCTs) published since the seminal Diabetes Control and Compliance Trial (DCCT). Interventions are summarized and findings reviewed to help guide clinical practice and future research.

RECENT FINDINGS

Twenty-five RCTs are reviewed. The majority of studies (n = 15) focused on interventions targeting both children and adolescents and their caregivers and were delivered in diabetes clinics, outpatient settings, mental health clinics, or participants' homes. Family-based interventions for youth with T1D appear effective at improving diabetes and family-centered outcomes. Additional research is needed to examine the pathways to improvement in glycemic control, as outcomes were mixed. Future research should also involve measures beyond HbA1c given new markers for sustained health improvement and outcomes are being explored.

Diabetes-specific family conflict: Informant discrepancies and the impact of parental factors

Family conflict in adolescents with type 1 diabetes (T1D) has been linked to worse disease management (i.e., glycemic control, adherence to treatment regimen) and reduced quality of life. We sought to examine parental risk factors associated with increased levels of diabetes-specific family conflict and to investigate the discrepancies between parent and adolescent reports of conflict. Adolescents with T1D and their parents (N = 120 dyads) completed measures of diabetes-specific family conflict. Adolescents also reported on health-related quality of life, and parents reported on demographic information. Clinical data were obtained from adolescents' medical records. Adolescents reported significantly greater levels of conflict than their parents around direct diabetes management tasks (e.g., checking blood sugars) and indirect management tasks (e.g., carrying supplies for high or low blood sugars). Several demographic factors were associated with family conflict, including parental education, marital status, and household income. Discrepancies between parent and adolescent reports of family conflict were significantly associated with diabetes-related outcomes. Specifically, higher quality of life was related to discrepancies between parent and adolescent reports of conflict around indirect management tasks. In addition, poorer glycemic control was related to discrepancies between parent and adolescent reports of family conflict around direct diabetes management tasks. These results support obtaining both the adolescent and parent report of conflict for unique information regarding family functioning. (PsycINFO Database Record

Impact of quality of life (QoL) on glycemic control (HbA1c) among adolescents and emerging adults with long-duration type 1 diabetes: A prospective cohort-study

OBJECTIVE

To evaluate the impact of self-reported chronic-generic and condition-specific quality of life (QoL) on glycemic control among adolescents and emerging adults with long-duration type 1 diabetes (T1D) in a longitudinal design.

METHODS

The database used was a nationwide cohort study of patients with ≥10 years T1D duration at baseline in Germany. The baseline questionnaire survey was conducted in 2009-2010, the follow-up survey in 2012-2013; additional clinical data of routine care procedures were linked. QoL was assessed by the DISABKIDS chronic generic module (DCGM-12) and diabetes module (DM) with treatment and impact scales. Regression analyses were conducted for the outcome hemoglobin A1c (HbA1c) at follow up with baseline DISABKIDS scores as predictors and sociodemographic and health-related covariates.

RESULTS

At baseline, the included 560 patients had a mean age of 15.9 (SD 2.3) years, a diabetes duration of 13.0 (2.0) years, and an HbA1c of 67 (14.2) mmol/mol. Mean follow-up time was 3.0 (0.6) years. Univariate analyses indicated associations between baseline QoL scores and HbA1c at follow-up (β[DCGM-12] = -0.174 (SE 0.038), β[DM treatment] = -0.100 (0.022), β[DM impact] = -0.177 (0.030), p < .001). The associations remained significant after adjustment for sociodemographic and illness-related factors, but dissolved (p > .60) when additionally adjusting for baseline HbA1c. In patients with poor baseline HbA1c (>75 mmol/mol), significant associations were observed between DCGM-12 and DM impact scores and follow-up HbA1c (β[DCGM-12] = -0.144 (0.062), p = .021; β[DM impact] = -0.139 (0.048), p = .004).

CONCLUSIONS

QoL was inversely associated with HbA1c after 3 years in the course of T1D only in patients poorly controlled at baseline.

Delay discounting and parental monitoring in adolescents with poorly controlled type 1 diabetes

In a sample of adolescents with poorly controlled type 1 diabetes, this study examined if delay discounting, the extent to which individuals prefer immediate over delayed rewards, was associated with severity of non-adherence and poor glycemic control, and if parental monitoring of diabetes management moderated those associations. Sixty-one adolescents (M _age = 15.08 years, SD 1.43) with poorly controlled type 1 diabetes completed a delayed discounting task and an HbA1c blood test. Adherence was assessed via self-monitoring of blood glucose (SMBG) data from adolescents' glucometers. Parents completed a parental monitoring questionnaire. Greater delay discounting was associated with higher HbA1c, but not SMBG. Direct parent observation of diabetes tasks, but not indirect parental monitoring, moderated the link between greater delay discounting and higher HbA1c, with higher direct parent observation buffering the link between greater discounting and poorer glycemic control. Delay discounting may be a target for future interventions to improve HbA1c in youth with type 1 diabetes.

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.

Brief Computer-Delivered Intervention to Increase Parental Monitoring in Families of African American Adolescents with Type 1 Diabetes: A Randomized Controlled Trial

BACKGROUND

African American adolescents with type 1 diabetes (T1D) are at elevated risk for poor diabetes management and metabolic control. Parental supervision and monitoring of adolescent diabetes management have been shown to promote better diabetes management among adolescents, but parents typically decrease their oversight during the transition to independent diabetes care.

INTRODUCTION

The purpose of the study was to conduct a randomized clinical trial to test the feasibility and efficacy of a three-session, computer-delivered motivational intervention (The 3Ms) to promote increased parental monitoring among primary caregivers of young African American adolescents with T1D. The intervention was brief and optimized for delivery during routine diabetes clinic visits.

MATERIALS AND METHODS

Sixty-seven adolescents with T1D aged 11-14 and their primary caregiver were randomly assigned to one of three arms: adolescent and parent motivational intervention (Arm 1), adolescent control and parent motivational intervention (Arm 2), or adolescent and parent control (Arm 3). Intervention effects were assessed 1 month after intervention completion.

RESULTS

Parents in Arm 1 and Arm 2 had significant increases in knowledge of the importance of monitoring adolescents' diabetes care. Parents in Arm 2 also had trend to significant increases in direct observation and monitoring of adolescent diabetes care, and adolescents in Arm 2 had significant improvements in glycemic control.

DISCUSSION AND CONCLUSIONS

Findings from the present study provide preliminary support for the efficacy of a brief, computer-delivered parenting intervention for improving family management practices and adolescent health outcomes among African American adolescents with T1D and their caregivers.

The social context of managing diabetes across the life span

Diabetes self-management is crucial to maintaining quality of life and preventing long-term complications, and it occurs daily in the context of close interpersonal relationships. This article examines how social relationships are central to meeting the complex demands of managing Type I and Type 2 diabetes across the life span. The social context of diabetes management includes multiple resources, including family (parents, spouses), peers, romantic partners, and health care providers. We discuss how these social resources change across the life span, focusing on childhood and adolescence, emerging adulthood, and adulthood and aging. We review how diabetes both affects and is affected by key social relationships at each developmental period. Despite high variability in how the social context is conceptualized and measured across studies, findings converge on the characteristics of social relationships that facilitate or undermine diabetes management across the life span. These characteristics are consistent with both Interpersonal Theory and Self-Determination Theory, 2 organizing frameworks that we utilize to explore social behaviors that are related to diabetes management. Involvement and support from one's social partners, particularly family members, is consistently associated with good diabetes outcomes when characterized by warmth, collaboration, and acceptance. Underinvolvement and interactions characterized by conflict and criticism are consistently associated with poor diabetes outcomes. Intrusive involvement that contains elements of social control may undermine diabetes management, particularly when it impinges on self-efficacy. Implications for future research directions and for interventions that promote the effective use of the social context to improve diabetes self-management are discussed. (PsycINFO Database Record

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

Stress and A1c Among People with Diabetes Across the Lifespan

Stress is known to negatively affect health and is a potentially serious barrier to diabetes-related health outcomes. This paper synthesizes what is known about stress and glycemic control among people with type 1 and type 2 diabetes across the lifespan. Chronic stress-especially in relation to living with diabetes-was most strongly associated with A1c, particularly among subgroups that face disproportionate stress, such as minority groups or adolescents/young adults. Mechanisms of the stress-A1c association include physiological, psychological, behavioral, and environmental links. Understanding the dimensions of stress as they relate to health in diabetes can be of significant clinical importance, and interventions targeting mechanisms that either exacerbate or buffer stress have reported modest improvements in A1c.

Adherence in adolescents with Type 1 diabetes: strategies and considerations for assessment in research and practice

Suboptimal adherence remains a significant concern for adolescents with Type 1 diabetes, the treatment regimen for which is complex and includes numerous behaviors. Accurate assessment of adherence is critical for effective healthcare and to measure trial outcomes. Without a valid biomarker of adherence, assessment strategies must rely on measuring management behaviors. This paper provides an overview of approaches to measure adherence, with an emphasis on contemporary, validated measures that are appropriate for current diabetes care. Objective measures include electronic data from diabetes management devices. Subjective measures include self/parent-report questionnaires, structured interviews and diaries/logbooks. Practical strategies for selecting measurement approaches for clinical and research purposes are reviewed, and implications of adherence assessment for clinical care delivery and adherence-promotion are discussed.