Predictors of Youth Diabetes Care Behaviors and Metabolic Control: A Structural Equation Modeling Approach

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.

High prevalence of depressive symptoms among people with pediatric-onset and adolescent-onset type 1 diabetes: A cross-sectional analysis of the Diabetes Study from the Center of Tokyo Women's Medical University

AIMS

To investigate the prevalence of depressive symptoms by the age of onset of type 1 diabetes and its association with the condition of individuals with pediatric- and adolescent-onset type 1 diabetes.

MATERIALS AND METHODS

This single-center cross-sectional study enrolled Japanese participants with type 1 diabetes. All participants completed a questionnaire about their diabetes-related condition and the Patient Health Questionnaire-9, which was used to evaluate depression. Individuals with a Patient Health Questionnaire-9 score of ≥10 points were defined as having moderate depressive symptoms.

RESULTS

A total of 1,267 participants (mean age, 40 years; mean duration of type 1 diabetes, 21 years; 68% female; mean glycated hemoglobin, 7.8%) were included and classified according to the age of onset of type 1 diabetes to identify the proportion of moderate depressive symptoms in each group: 21% (0-12 years), 18% (13-19 years), and 13% (20-40 years). The prevalence of moderate depressive symptoms was significantly higher among participants with pediatric-onset type 1 diabetes (p<0.05). Moderate depressive symptoms were associated with increased glycated hemoglobin, neuropathy, and hypoglycemia unawareness.

CONCLUSIONS

Regular screening for depressive symptoms and hypoglycemia awareness is important. Healthcare professionals should provide appropriate psychosocial care for people with pediatric-onset and adolescent-onset type 1 diabetes from childhood through to adulthood.

Responsibility sharing for adolescents with type 1 diabetes: A scoping review

BACKGROUND

The term 'Responsibility Sharing', albeit poorly defined, has emerged from the diabetes literature, to describe a distinct mechanism for comprehensively managing the characteristic shift in responsibility that underpins the transition to self-management for adolescents.

METHODS

A scoping review, following the PRISMA-ScR guidelines, distilled the literature from seven databases to answer the questions: What is responsibility sharing? Who are the key stakeholders? What factors affect responsibility transaction? What are its recognized outcomes? How is responsibility shared?

RESULTS

Responsibility sharing is a transactional arrangement between youth and their caregiver/s that functions to repeatedly and flexibly apply ownership to the management of diabetes care tasks, across the course of adolescence. In the main, responsibility sharing was associated with better metabolic and/or psychosocial outcomes. Effective responsibility sharing was seen as being responsive to adolescent capacity and driven by autonomy supportive, sustained communication patterns that enable mutually agreeable responsibility assumption by all stakeholders.

CONCLUSION

Different perspectives on responsibility sharing for adolescents with Type 1 diabetes, and the lack of a universal definition, have led to discordance within the literature about its operationalization and measurement. This paper proposes a definition of responsibility sharing for future researchers to apply.

Factors Associated With Achieving Target A1C in Children and Adolescents With Type 1 Diabetes: Findings From the T1D Exchange Quality Improvement Collaborative

The optimal care of type 1 diabetes involves consistent glycemic management to avoid short- and long-term complications. However, despite advancements in diabetes technology and standards, achieving adequate glycemic levels in children and adolescents remains a challenge. This study aimed to identify factors associated with achieving the recommended A1C target of <7% from the United States-based multicenter T1D Exchange Quality Improvement Collaborative cohort, including 25,383 children and adolescents living with type 1 diabetes.

Risky sexual behaviors in adolescents and young adult women with type 1 diabetes: An overlooked problem

The presence of unprotected sex activity in women living with type 1 diabetes (T1D) who have insufficient glycemic control should be considered as a specific risky behavior. To evaluate risky behaviors, including unprotected sexual activity, sources of information and knowledge related to reproductive health in adolescents and young adult women with T1D (PwT1D) compared to a group of adolescents and young adult women without diabetes (Comparison group). PwT1D and the Comparison group completed a questionnaire with validated measures that assessed reproductive health. PwT1D (n = 115, age = 17.7 ± 3.2 years) and Comparison group (n = 386, age = 18.3 ± 2.9) were recruited. The proportion of women reporting having sex without any contraceptive was similar in both groups (57.1% and 50%, in PwT1D and Comparison group, respectively). The use of non-effective contraceptive was reported in 63.2% and 63.6% of the PwT1D and Comparison group, respectively. Among PwT1D, parents, formal sex education, and friends were the primary source of information on reproductive health. Low levels of knowledge about diabetes and pregnancy were observed in PwT1D. HbA1c level was associated with having at least one sexual activity without any contraception (OR = 1.63, p = 0.039). PwT1D have similar rates of risky behaviors compared to a Comparison group. Sexual risky behaviors should be especially considered in PwT1D with glycemic control above the optimal level. Parents are an important source of reproductive health information for PwT1D. Use of effective contraception should be reinforced in sexually active PwT1D.

Cross-Lag Model of Medical Responsibility and Skills in Youth With Spina Bifida

OBJECTIVE

This study examined bidirectional associations between mother- and father-reported medical responsibility and medical skill mastery in youth with spina bifida (SB).

METHODS

Participants were 140 youth with SB and their parents who participated in three waves of a longitudinal study across four years (ages 8-15 years at Time 1). Mother- and father-report of both medical responsibility and medical skill mastery were used, and age and estimated intelligence quotient were included as covariates, in cross-lagged models.

RESULTS

The cross-lagged model provided evidence for significant bidirectional associations between mother-reported medical responsibility and skill mastery across time (root mean square error of approximation=0.09, comparative fix index=0.97). These paths showed that higher levels of child responsibility predicted an increase in skill mastery and that higher levels of mastery predicted an increase in child responsibility across time. Moreover, based on mother-report, sharing of responsibility had stronger effects on increases in skill mastery (Time 1 to Time 2 β=.25, Time 2 to Time 3 β=.27) than skill mastery had on increases in child responsibility (Time 1 to Time 2 β=.08, Time 2 to Time 3 β=.07). The only significant cross-lagged path for father-report was from Time 1 skill mastery to Time 2 responsibility (β=.34).

CONCLUSIONS

Mothers perceive a bidirectional relationship between responsibility and skill mastery across time, whereas fathers appear to mainly consider how skills might affect a subsequent increase in responsibility sharing. Thus, it is important to consider both parents' perspectives when working to increase medical autonomy in youth with SB.

Initial Validation of IBD KNOW-IT: Measuring Patient and Caregiver Knowledge of a Child's Disease and Treatment Regimen

The present study describes the development and initial validation of a newly developed measure of child and caregiver knowledge of the child's own IBD and treatment, called IBD KNOW-IT. One hundred and fifty-five children and their caregivers completed the IBD KNOW-IT as well as a scale designed to compare each dyad's perceived knowledge to their actual knowledge. Initial psychometric evaluation of IBD KNOW-IT was completed by conducting factor analysis and determining internal consistency, convergent validity, and associations with demographic and medical characteristics. Results supported the validity of a 12-item measure with 4 subscales including Symptoms, Medication Regimen, Disease Monitoring, and Medical Team. Support for the internal consistency of IBD KNOW-IT was obtained. Evidence of validity was demonstrated by significant correlations between child and caregiver scales, and high congruence between perceived and actual knowledge across all subscales. The reliability of the measure was demonstrated by good internal consistency and test-retest reliability. Preliminary psychometric evaluation suggests that IBD KNOW-IT is reliable and valid.

Disordered Eating Behaviors Among Italian Adolescents with Type 1 Diabetes: Exploring Relationships with Parents' Eating Disorder Symptoms, Externalizing and Internalizing Behaviors, and Body Image Problems

The purpose of this study is to examine associations of disordered eating behaviors (DEBs) with body image problems, parents' eating disorder symptoms, and emotional and behavioral problems among adolescents with type 1 diabetes (T1D). 200 adolescents (M age = 15.24 ± 1.45 years) with T1D completed a self-report measure of DEBs and body ideal internalization, and their parents completed self-report measures of parents' eating problems and child's psychological symptoms. Seventy-three (36.5%) adolescents were DEPS-r-positive (scores ≥ 20), with higher rates among girls (χ² = 9.034, p = .003). Adolescents with T1D and DEBs reported lower SES, worse metabolic control, higher zBMI (p < .001), more eating disorder symptoms, more body image problems, and more emotional and behavioral problems than adolescents with T1D but no DEBs (all p < .05). Parents of adolescents with DEBs showed higher levels of bulimia (p = .028) than parents of adolescents without DEBs. In both genders, pressure to conform to societal norms about body image (p < .01) and externalization symptoms (p < .05) emerged as significant predictors of DEBs. Findings suggest that adolescents with T1D and DEBs showed an alarming psychological condition, with higher level of body image and more emotional and behavioral problems.

Finnish diabetes-related quality of life questionnaire for children and adolescents: Reliability and validity

AIM

To study the psychometric properties, reliability and validity of the FinDiab quality-of-life questionnaire (FDQL), a strength-oriented quality-of-life (QOL) questionnaire for children and adolescents with type 1 diabetes (T1D).

METHODS

Participants were 215 youths with T1D (aged 10-17 years). They completed FDQL and comparison questionnaires (KINDL-R and SDQ). Demographic and disease measures were collected from the participants' medical records. The questionnaire's psychometric properties were investigated. Construct validity was studied through principal component analysis using Promax rotation, reliability with alphas, and criterion and convergent validity with correlations between sum scale, subscales, demographic and disease factors, and comparison measures.

RESULTS

FDQL demonstrated an adequate range of measurement and feasibility. The four-factor solution was found to be optimal, resulting in the subscales of flexibility with diabetes, well-being, social relations and health behaviour. The sum scale correlated significantly with glycaemic control and the psychosocial and QOL comparison measures. Construct, criterion and convergent validity of the subscales was also good. Children under 14 years of age reported better QOL than older adolescents.

CONCLUSION

FDQL is a practical QOL assessment method focusing on strengths. The questionnaire has good validity and reliability and is easy to use as a clinical tool.

The division and transfer of care responsibilities in paediatric type 1 diabetes: A qualitative study on parental perspectives

Aim

To determine which factors other than child age play a role in the division and transfer of diabetes care responsibilities between parents and children with type 1 diabetes.

Design

Qualitative focus group study.

Methods

Across four sites in the Netherlands, 18 parents (13 mothers) of children (9–14 years) with type 1 diabetes participated in four focus groups in 2015–2016, as part of the research project 'Whose diabetes is it anyway?'. Qualitative content analysis and the constant comparison method were used to analyse the data.

Results

According to parents, the transfer process included both direct and indirect tasks, had different levels (remembering, deciding, performing), was at times a difficult and stressful process, and showed large variation between families. A large number of child, parent and context factors were identified that affected the division and transfer of diabetes care responsibilities according to parents. Both positive and negative consequences of the transfer process were described for parental and child health, behaviour and well‐being. Parental final evaluations of the division and transfer of diabetes care responsibilities appeared to be dependent on parenting values.

Conclusion

How families divide and transfer diabetes care tasks appeared to be affected by a complex interplay of child, parent and context characteristics, which had an impact on several parent and child domains.

Impact

Parents struggle with the right timing of transfer, which calls for more support from diabetes nurses. The identified factors can be used as input for integrating a more family‐based approach into current age‐based guidelines, to improve regular care.

Interstitial glucose and subsequent affective and physical feeling states: A pilot study combining continuous glucose monitoring and ecological momentary assessment in adolescents

OBJECTIVE

Circulating glucose may relate to affective and physical feeling states reflective of emotional disorder symptoms. No prior studies have investigated within-day associations between glucose and subsequent affective and physical feeling states (positive affect, negative affect, and fatigue) as they occur naturally among healthy adolescents; this pilot study assessed these associations by combining data collected from ecological momentary assessment (EMA) and continuous glucose monitors (CGM).

METHODS

Participants (N = 15, mean age = 13.1[±1.0] years, 66.7% female, 40.0% Hispanic, 66.7% healthy weight) wore a CGM for 7-14 days. Simultaneously, participants reported on their current positive affect, negative affect, and fatigue randomly during specified windows up to 7 times daily via EMA. CGM-measured mean interstitial glucose was calculated during the time windows (mean minutes = 122.5[±47.3]) leading up to each EMA prompt. Multilevel models assessed within-subject (WS) associations between mean interstitial glucose since the previous EMA prompt and EMA-reported affective and physical feeling states at the current prompt.

RESULTS

Participants provided 532 interstitial glucose-matched EMA reports of affective and physical feeling states. During intervals when interstitial glucose was higher than one's usual, higher positive affect (WS β = 0.01, p < .0001, f² = 0.02) and lower fatigue (WS β = -0.01, p < .0001, f² = 0.09) were subsequently reported. Interstitial glucose was unrelated to negative affect (WS β = -0.002, p = .10, f² = 0.01). Associations were weakened, but remained significant following further adjustment for time of day.

CONCLUSIONS

Though effect sizes were small, within-person variations in interstitial glucose may relate to subsequent affective and physical feeling states among healthy youth. Investigations using similar methodologies in larger, more diverse samples are warranted.

Parenting, self-regulation, and treatment adherence in pediatric chronic headache: A self-determination theory perspective

This study examined parenting factors associated with children's self-regulation and physician-rated treatment adherence using a self-determination theory framework in pediatric chronic headache. Participants were 58 children and adolescents (aged 10-17 years), who underwent initial and follow-up multidisciplinary evaluation at a headache clinic, and their mothers. Regression analyses showed that higher maternal autonomy support and structure were significantly related to children's lower treatment-related reactance and higher adherence. Maternal controllingness had associations in the opposite directions. Children's fear of pain was related to maternal controllingness. Results suggest the importance of parents' provision of clear expectations and engaging children in treatment problem-solving and decision-making.

Adherence to diabetes care: Knowledge of biochemical processes has a high impact on glycaemic control among adolescents with type 1 diabetes

AIM

To evaluate the impact of patients' understanding of biochemical processes involved in glucose regulation (causal-biochemical knowledge) and of diabetes self-management knowledge on adherence to treatment recommendations among adolescents with type 1 diabetes mellitus.

DESIGN

A cross-sectional study.

METHODS

Adolescents with type 1 diabetes mellitus, aged 12-18 years and able to read and write in Hebrew or in Arabic were eligible. Participants were recruited between August 2016 - January 2018 during routine visits to the Paediatric Diabetes Clinic; informed consent was obtained as customary. Patients completed sociodemographic, clinical and type 1 diabetes mellitus self-management and biochemical knowledge questionnaires. Adherence to treatment was assessed by patients' serum HbA1c levels, collected from medical records.

RESULTS

Ninety-seven patients participated in the study. Mean HbA1c levels were 9.2% (1.9%) and only 24 (24.7%) patients met the recommended HbA1c ≤ 7.5%. Lower HbA1c levels were strongly associated with higher family income, older age at diagnosis and with better type 1 diabetes mellitus self-management and causal-biochemical knowledge. A regression model showed that causal-biochemical knowledge contributed to the variance in HbA1c levels. Furthermore, causal-biochemical knowledge, but not self-management knowledge, was found to mediate the negative relationship between low family income and high HbA1c levels.

CONCLUSIONS

Causal-biochemical knowledge is a valuable component for the adherence to diabetes care and glycaemic control.

IMPACT

Our study suggests that causal knowledge is a valuable component that should be included in nursing and healthcare educational programmes for adolescents with type 1 diabetes mellitus.

Characterization of Adults With Type 1 Diabetes Not Attending Self-Management Education Courses: The Barriers to Uptake of Type 1 Diabetes Education (BUD1E) Study

People with type 1 diabetes mellitus (T1DM) are offered attendance at diabetes self-management education courses to provide them with skills for self-management of flexible insulin dose adjustment. Attendance is poor, even when courses are evidence-based and nationally available. To understand barriers to attendance, we sought common characteristics of nonattenders from adults with T1DM living in south London. Twenty-five in person semistructured interviews were carried out until thematic saturation occurred. Thematic framework analysis identified six themes: psychological capability, numerical capability, internal/external judgment, confidence in self, thirst for knowledge, and barriers to attendance. Characterization of response profiles according to the themes identified four different typologies. These identified typologies and themes for barriers to attending diabetes self-management courses suggest strategies to improve attendance and extend the benefit of such courses more widely.

Youth With Type 1 Diabetes Taking Responsibility for Self-Management: The Importance of Executive Functioning in Achieving Glycemic Control: Results From the Longitudinal DINO Study

OBJECTIVE

Successful self-management of type 1 diabetes requires cognitive skills such as executive functioning (EF). In the transition to adolescence, youth take over responsibility for diabetes management. We set out to test: 1) the association between EF and glycemic control over time and 2) whether this association was moderated by: a) youth, shared, or parent responsibility for diabetes management and b) youth's age.

RESEARCH DESIGN AND METHODS

Within the Diabetes IN DevelOpment study (DINO), parents of youth with type 1 diabetes (8-15 years at baseline; N = 174) completed a yearly assessment over 4 years. Glycemic control (HbA_1c) was derived from hospital charts. Youth's EF was measured using the Behavior Rating Inventory of Executive Functioning (BRIEF)-parent report. The Diabetes Family Responsibility Questionnaire (DFRQ)-parent report was used to assess diabetes responsibility (youth, shared, and parent). Linear generalized estimating equations were used to analyze data including youth's sex, age, and age of diabetes onset as covariates.

RESULTS

Relatively more EF problems are significantly associated with higher HbA_1c over time (β = 0.190; P = 0.002). More EF problems in combination with less youth responsibility (β = 0.501; P = 0.048) or more parental responsibility (β = -0.767; P = 0.006) are significantly associated with better glycemic control over time. Only age significantly moderates the relationship among EF problems, shared responsibility, and glycemic control (β = -0.024; P = 0.019).

CONCLUSIONS

Poorer EF is associated with worse glycemic control over time, and this association is moderated by responsibility for diabetes management tasks. This points to the importance of EF when youth take over responsibility for diabetes management in order to achieve glycemic control.

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Preliminary Feasibility and Acceptability of the Remote Food Photography Method for Assessing Nutrition in Young Children with Type 1 Diabetes

Background

Nutrition is a critical component of diabetes and other chronic diseases for young children. However, nutritional intake is burdensome to measure accurately and easily, making it difficult to evaluate in research or clinical contexts.

Objective

This pilot study examined the feasibility and acceptability of having parents of young children with T1D use the Remote Food Photography Method (RFPM) to measure breakfast nutrition.

Methods

Participants were 9 mothers of children ages 2-5 years (M_age=4.2), with a T1D duration of at least 1 year (M_age=2.4 years at diagnosis), representing diverse backgrounds (55.6% Caucasian; 44.4% African American; 55.6% married). During baseline and follow-up of a healthy eating and physical activity intervention for children with T1D, parents used the RFPM to capture before and after images of their children's breakfast. Feasibility and acceptability were assessed by adherence to taking photos, percent of usable photos, and participant satisfaction.

Results

The RFPM was feasible across participants with high adherence rates (100% at baseline and 87% at follow-up) for sending usable photographs. Most participants reported satisfaction with the method.

Conclusions

Using the RFPM to assess nutrition in a small sample of young children with T1D was feasible and acceptable. Given the importance of assessing nutrition in young children with T1D as well as other chronic illnesses (e.g., cystic fibrosis, obesity), the RFPM may be a useful tool for both research and clinical data collection in lieu of other methods. More research is needed to evaluate reliability and validity of RFPM in pediatric populations.

The Role of Authoritative Parenting in Adolescent Type 1 Diabetes Management

Objective

Adolescents with Type 1 diabetes are at risk for poorer adherence, lower quality of life (QOL), and poorer glycemic control (HbA1c). Authoritative parenting (AP) along with youth adherence and QOL was hypothesized to relate to better HbA1c.

Methods

Parent-youth dyads (N = 257) completed baseline measures of adherence and QOL. Youth completed an AP questionnaire, and HbA1c samples were evaluated. Structural equation modeling determined relations among AP, adherence, QOL, and glycemic control.

Results

AP indirectly linked to better HbA1c (β = -.15, p = .021) through both better adherence and higher QOL. AP also was associated directly with better adherence (β = .26, p = .001), which in turn was linked to better HbA1c (β = -.35, p = .021). In addition, adherence was associated directly with QOL (β = -.56, p = .001).

Conclusions

Together, better youth adherence and higher QOL are two mechanisms by which more AP indirectly relates to better glycemic control during the early adolescent years.

Considering Culture: A Review of Pediatric Behavioral Intervention Research in Type 1 Diabetes

PURPOSE OF REVIEW

Type 1 diabetes (T1D) incidence in youth is growing across all racial/ethnic backgrounds, with the most marked increase in African-American youth under 5. Underrepresented racial/ethnic minorities are at an increased risk for health complications. This review focuses on the reported disparities, demographics of samples in behavioral interventions, and study design considerations.

RECENT FINDINGS

Recruitment data from two ongoing behavioral intervention trials for young children with T1D are presented to compare enrolled/non-enrolled individuals and to discuss culturally appropriate study design considerations. Data were compared to the demographics of children (ages 1-6) with T1D in the clinic populations from the recruitment sites. Enrolling a representative sample and designing culturally appropriate behavioral interventions are important for generalizability, yet there is a gap between the individuals participating in T1D research and those who are most negatively affected by T1D. Suggestions are offered for ways to expand inclusion of diverse samples in behavioral intervention research in T1D.

Teens with Type 1 Diabetes: How Does Their Nutrition Measure Up?

OBJECTIVE

To characterize the intake of macronutrient and fiber in adolescents with type 1 diabetes (T1D) and examine their association with health indicators.

METHODS

Baseline data from an RCT were examined. Adolescent-parent dyads (n = 257, mean age 12 ± 1.2 years, 49.4% girls) reported dietary intake via two separate 24-hour recall interviews during a two-week period. Demographic and medical variables were abstracted from questionnaires and medical charts.

RESULTS

Controlling for demographic and diet variables, a higher percentage of daily energy intake from fats was associated with poorer HbA1c. In contrast, an association between higher percent of energy intake from proteins and carbohydrates was found with higher systolic and diastolic BP, respectively.

CONCLUSIONS

Many early adolescents with T1D did not meet diabetes nutritional guidelines. Lower adherence to nutritional guidelines, specifically more than recommended energy intake from fats, was associated with poorer HbA1c. Addressing nutritional guidelines and increasing adherence as part of treatment may improve health outcomes for youth with T1D.

Expectancy and Achievement Gaps in Educational Attainment and Subsequent Adverse Health Effects Among Adolescents With and Without Chronic Medical Conditions

PURPOSE

While education-based disparities in health are common, the extent to which chronic conditions contribute to education gaps and to consequent health disparities is not fully understood. As such, we sought to investigate educational aspirations, expectations, and attainment among youth with and without chronic conditions and to determine if these relationships mediated subsequent disparities in health and well-being.

METHODS

Longitudinal data on 3,518 youths are from the 1997-2013 Panel Study of Income Dynamics, a population-based survey. Multivariate regression was used to assess disparities in educational aspirations, expectations, and attainment by chronic conditions and the subsequent effects on health and well-being, adjusting for important potential confounders.

RESULTS

Youth with chronic medical conditions (YCMCs) did not report significantly lower educational aspirations than their healthy peers; however, YCMC reported lower expectations for their educational attainment and fewer YCMC had earned their desired degree by the end of follow-up (e.g., ≥bachelor's degree: 19.9% for YCMC vs. 26.0% for peers, p < .05). YCMC reported significantly worse general health, lower life satisfaction, and lower psychological well-being in young adulthood than did their healthy peers. These disparities persisted after adjustment for confounders; the association between chronic disease and health was partially, but significantly, mediated by actual educational attainment.

CONCLUSIONS

Findings suggest an important risk mechanism through which YCMC may acquire socioeconomic disadvantage as they develop and progress through educational settings. Disproportionate lags in education, from expectation to attainment, may in turn increase YCMC's susceptibility to poor health and well-being in the future.

Formative evaluation on cultural tailoring breathing awareness meditation smartphone apps to reduce stress and blood pressure

BACKGROUND

Chronic stress is an independent risk factor for essential hypertension (EH), cardiovascular disease (CVD), and is sometimes confronted by mal-adaptive coping behaviors (e.g., stress eating, excessive alcohol consumption, etc.). Pre-essential hypertension (preEH) is the leading predictor of future EH status. Breathing awareness meditation (BAM) can result in clinically beneficial blood pressure (BP) reductions, though face-to-face sessions presents barriers to reach those in need. The purpose of this study was to identify if a culturally tailored approach is needed in the design and preferences between groups of preEH African American and White adults toward using a smartphone BAM app, the Tension Tamer (TT) app.

METHODS

TT includes audio delivered BAM instructions, real-time heart rate, feedback graphs and motivational reinforcement text messaging. Questionnaires and two focus groups each of African American and White adults, [n=34, mean age =43.1 years, (SD 13.8 years), 44.1% African American] were conducted to understand stress, EH knowledge, app usage along with feedback from a hands-on demonstration of TT. Grounded theory using NVivo 10 was used to develop themes and combined with the questionnaires in the analysis.

RESULTS

No racial differences were found in the analysis including app use scenarios, preferences, knowledge, technology use or the attitudes and acceptance toward mobile health (mHealth) programs. Reported stress was high for African Americans [PSS-4: mean 6.87 (SD 3.3) versus mean 4.56 (SD 2.6); P=0.03]. Four main themes were found: (I) stress was pervasive; (II) coping strategies were both positive and negative; (III) BAM training was easy to incorporated; and (IV) tracking stress responses was useful. Responses suggest that additional personalization of app interfaces may drive ownership and adherence to protocols. Measures and reports of heart rate monitoring while in session were favorably viewed with low issues with confidentiality or trust issues on collected session data.

CONCLUSIONS

Results suggest that a culturally tailored approach may be unnecessary in the design of BAM apps. Further investigation is warranted for other racial groups, age ranges, and disease conditions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Substance Use Patterns Through Early Adulthood: Results for Youth With and Without Chronic Conditions

INTRODUCTION

Adolescence and emergent adulthood are periods of peak prevalence for substance use that pose risks for short- and long-term health harm, particularly for youth with chronic medical conditions (YCMC) who are transitioning from adolescence to adulthood. As there have been no nationally representative studies of substance use during this period for these medically vulnerable youth, the authors sought to examine onset and intensification of these behaviors for a national sample of youth with and without chronic conditions.

METHODS

Longitudinal data are from 2,719 youth between the ages of 12 and 26 years interviewed from 2002 to 2011 for the Panel Study of Income Dynamics, Child Development and Transition to Adulthood Supplements, a nationally representative, population-based survey. Multivariate generalized linear mixed models were used to estimate patterns of alcohol, tobacco, and marijuana use during adolescence and emergent adulthood for youth with and without chronic conditions, adjusting for potential confounders.

RESULTS

Overall, 68.8%, 44.3%, and 47.8% of youth reported ever trying alcohol, tobacco, and marijuana, respectively. Among users, 42.2%, 73.4%, and 50.3% of youth reported binge drinking, regular cigarette use, and recent marijuana use, respectively. YCMC were more likely to engage in any and heavier substance use; transition years and early adulthood were periods of peak risk for YCMC compared with their healthy peers.

CONCLUSIONS

Substance use among YCMC during adolescence and emergent adulthood is a substantial concern. Increased prevention and case detection are in order to address these behaviors and promote optimal health outcomes for medically vulnerable youth.

Contribution of income to self-management and health outcomes in pediatric type 1 diabetes

Low income has been established as a risk factor for poorer outcomes in youth with type 1 diabetes; however, the effect of moderate income has not been studied. The purpose of this secondary analysis of baseline data from a multi-site study was to compare glycemic control, self-management, and psychosocial outcomes [depression, stress, and quality of life (QOL)] at different income levels in adolescents with type 1 diabetes. Youth (n = 320, mean age = 12.3 + 1.1, 55% female, 64% white, mean A1C = 8.3 ± 1.4) completed established self-management and psychosocial measures. A1C levels were collected from medical records. Caregivers reported annual family income, categorized as high (>$80K), moderate ($40-80K), or low (<$40K). Youth from high-income families had significantly lower A1C (mean = 7.9 ± 1.2) than those from the moderate-income group (8.6 ± 1.7, p < 0.001) or the low-income group (mean A1C = 8.6 ± 1.5, p = 0.003). Youth from the high-income group reported significantly better diabetes problem solving and more self-management goals than those from the moderate- or low-income groups (both p < 0.01). Youth from the high-income group also reported significantly fewer symptoms of depression, lower levels of perceived stress, and better QOL than those in the moderate or low-income groups (all p < 0.05). Multivariate linear regression models were used to test psychological and behavioral predictors of A1C and QOL. Parents' education status (p < 0.05) and self-management activities (p < 0.01) were significant predictors of hemoglobin A1c, while income (p < 0.01) and self-management activities (p < 0.05) were significant predictors of QOL.

Structural equation model for estimating risk factors in type 2 diabetes mellitus in a Middle Eastern setting: evidence from the STEPS Qatar

AIMS

Understanding type 2 diabetes mellitus is critical for designing effective diabetes prevention policies in Qatar and the Middle East.

METHODS

Using the Qatar 2012 WHO STEPwise approach to surveillance survey, a subsample of 1224 Qatari participants aged 18-64 years was selected. Subjects had their fasting blood glucose levels tested, had not been diagnosed with or treated for diabetes, had a fasting time >12 hours and were not pregnant. We applied a hypothesized structural equation model (SEM) to assess sociodemographic, behavioral, anthropometric and metabolic variables affecting persons with type 2 diabetes mellitus.

RESULTS

There is a direct effect of triglyceride levels (0.336) and body mass index (BMI) (0.164) on diabetes status. We also found that physical activity levels negatively affect BMI (-0.148) and positively affect high-density lipoprotein (HDL) (0.106); sociodemographic background negatively affects diet (-0.522) and BMI (-0.352); HDL positively affects total cholesterol (0.230) and has a negative effect on BMI (-0.108), triglycerides (-0.128) and waist circumference (-0.104). Diet has a positive effect on triglycerides (0.281) while family history of diabetes negatively affects total cholesterol (-0.104). BMI has a positive effect on waist circumference (0.788) and mediates the effects of physical activity over diabetes status (-0.028). BMI also mediates the effects that sociodemographic factors (-0.058) and physical activity (-0.024) have on diabetes status. BMI and HDL (-0.002) together mediate the effect of physical activity on diabetes status and similarly HDL and tryglycerides (-0.005) also mediate the effect of physical activity on diabetes status. Finally diet and tryglycerides mediate the effects that sociodemographic factors have on diabetes status (-0.049).

CONCLUSIONS

This study's main finding is that triglyceride levels and BMI are the main variables directly affecting diabetes status in the Qatari population.

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.

Psychological distress of children with early-onset type 1 diabetes and their mothers' well-being

AIM

Few studies have focused on the psychological adjustment of pre-adolescent children with type 1 diabetes. This study examined psychosocial functioning in nine- and 10-year-old children with early-onset type 1 diabetes, and their mothers, and associations between psychosocial functioning and diabetes management.

METHODS

The mothers of 63 children with early-onset diabetes and 86 healthy children evaluated their own psychosocial functioning, and their child's, with standardised rating scales. We used general linear models to analyse the children's behaviour problems and the mothers' well-being. Associations between the children's behaviour problems, diabetes-related measures and the mothers' well-being were studied with partial correlations.

RESULTS

Children with diabetes had more internalising problems than the controls (p = 0.001), and these were associated with poor glycaemic control at the early stage of the illness (p = 0.033) and the use of insulin pumps in girls (p = 0.004). Mothers in the diabetes group had more child-related stress than the controls (p < 0.001), and poorer well-being was associated with the children's behavioural problems (p < 0.024).

CONCLUSION

Children with early-onset diabetes faced an increased risk of internalising problems in middle childhood. The mothers' psychological distress was associated with children's behaviour problems rather than their diabetes.

Correlates of Problem Resolution during Parent-Child Discussions about Chronic Illness Management

Families impacted by pediatric chronic illness must navigate treatment regimens that can present multiple problems and decisions to be addressed on a daily basis. The extent to which parents and children are able to solve such problems is likely to have implications for health behaviors and outcomes. The aims of this study were to examine correlates of problem resolution in families of children with a chronic illness. Participants were 167 children (ages 8-16) with type 1 diabetes or cystic fibrosis and a parent. Parent-child dyads recounted a recent discussion they had related to illness management and completed questionnaires. The research team coded the discussions for topic and outcome (i.e., did the dyad come up with a plan to address the problem). The results indicated that the majority of dyads in both illness groups came up with a plan during their discussions. Lack of problem resolution during the discussion was associated with higher parent coercion, more child resistance to the regimen, and worse adherence. Parent coercion and child resistance could be the targets of interventions to enhance problem solving and improve adherence.

Predicting Health Resilience in Pediatric Type 1 Diabetes: A Test of the Resilience Model Framework

OBJECTIVES

This research examined whether individual and family-level factors during the transition from late childhood to early adolescence protected individuals from an increased risk of poor glycemic control across time, which is a predictor of future diabetes-related complications (i.e., health resilience).

METHODS

This longitudinal, multisite study included 239 patients with type 1 diabetes and their caregivers. Glycemic control was based on hemoglobin A1c. Individual and family-level factors included: demographic variables, youth behavioral regulation, adherence (frequency of blood glucose monitoring), diabetes self-management, level of parental support for diabetes autonomy, level of youth mastery and responsibility for diabetes management, and diabetes-related family conflict.

RESULTS

Longitudinal mixed-effects logistic regression indicated that testing blood glucose more frequently, better self-management, and less diabetes-related family conflict were indicators of health resilience.

CONCLUSIONS

Multiple individual and family-level factors predicted risk for future health complications. Future research should develop interventions targeting specific individual and family-level factors to sustain glycemic control within recommended targets, which reduces the risk of developing future health complications during the transition to adolescence and adulthood.

Condition Self-Management in Pediatric Spina Bifida: A Longitudinal Investigation of Medical Adherence, Responsibility-Sharing, and Independence Skills

OBJECTIVE

This study aimed to evaluate rates of medical adherence, responsibility, and independence skills across late childhood and adolescence in youth with spina bifida (SB) and to explore associations among these disease self-management variables.

METHOD

111 youth with SB, their parents, and a health professional participated at two time points. Informants completed questionnaires regarding medical adherence, responsibility-sharing, and child independence skills.

RESULTS

Youth gained more responsibility and independence skills across time, although adherence rates did not follow a similar trajectory. Increased child medical responsibility was related to poorer adherence, and father-reported independence skills were associated with increased child responsibility.

CONCLUSIONS

This study highlights medical domains that are the most difficult for families to manage (e.g., skin checks). Although youth appear to gain more autonomy across time, ongoing parental involvement in medical care may be necessary to achieve optimal adherence across adolescence.

Staying Positive: Positive Affect as a Predictor of Resilience in Adolescents With Type 1 Diabetes

BACKGROUND

Adolescents with Type 1 Diabetes (T1D) are at increased risk for diminished quality of life, deteriorating glycemic control, and psychological symptoms, yet some adolescents are able to adapt to the challenges associated with having diabetes exceptionally well. We sought to examine positive affect as a protective process predicting resilience over time in youth with T1D.

METHOD

Adolescents and their mothers completed questionnaire data, and HbA1c was obtained from adolescents' medical records at baseline and after 6 months. Adolescents were coded for observed positive mood during a videotaped interaction with their mothers.

RESULTS

Positive mood, including both self-report and observed mood, was associated with glycemic control, psychological symptoms, and quality of life. In addition, positive mood predicted improvements in glycemic control and externalizing problems over 6 months.

CONCLUSIONS

Positive affect emerged as a protective process for resilient outcomes in adolescents with T1D, suggesting novel targets for intervention in this high-risk population.

Profile of mood states in adult type 1 diabetes mellitus men and women with disease onset in childhood and in adulthood

INTRODUCTION

Although diabetes may not be associated with psychopathology, it may be associated with less severe disturbances in psychosocial functioning. Emotional problems in relation to type 1 diabetes are usually analysed as symptoms of psychiatric conditions but not as states of mood. The aim was to compare profiles of mood states in adult patients with childhood-onset and adulthood-onset type 1 diabetes mellitus and to outline possible gender-specific differences.

SUBJECTS AND METHODS

A total of 214 adult type 1 diabetic patients were randomly selected from the Lithuanian Diabetes Registry. The mood states were compared in 105 (42 men and 63 women) patients with type 1 diabetes diagnosed during 0-18 years of life and in 109 (61 men and 48 women) diagnosed in adulthood. The scores of tension-anxiety, depression-dejection, anger-hostility, vigour-activity, fatigue-inertia and confusion-bewilderment were evaluated using the Profile of Mood States.

RESULTS

Depression-dejection was higher in adulthood-onset diabetic women than in childhood-onset (p=0.005) diabetic patients. In childhood-onset diabetic patients depression-dejection (p=0.046) and confusion-bewilderment (p=0.033) were higher in women than in men. Adulthood-onset women with diabetes had higher tension-anxiety (p=0.027), depression-dejection (p=0.001), and confusion-bewilderment (p=0.004) scores than men. Multiple logistic analyses showed that adulthood-onset period of type 1 diabetes is associated with higher levels of depression-dejection [OR=1.1; 95% confidence intervals (CI) 1.01-1.19, p=0.025], longer diabetes duration (OR=2.00; 95% CI 1.27-2.03, p=0.012), higher HbA1c level (OR=1.15; 95% CI 1.02-1.3, p=0.023), and female gender (OR=2.51; 95% CI 1.29-2.90, p=0.021).

CONCLUSIONS

Profile of mood states in adult women with type 1 diabetes is worse than in men. Adulthood-onset type 1 diabetic women have higher depression-dejection than do childhood-onset diabetic patients. Adulthood-onset period of type 1 diabetes is associated with higher levels of depression-dejection, longer diabetes duration and female gender.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An integrative review of self-efficacy measurement instruments in youth with type 1 diabetes

PURPOSE

The purpose of this study is to assess the extant literature on instruments used to measure self-efficacy in youth with type 1 diabetes (T1DM) and their caregivers and to critically evaluate these measurements.

METHODS

An integrative review (2003-2013) was conducted searching PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and US National Library of Medicine PubMed service (PubMed) databases using key words diabetes, type 1 diabetes, and self-efficacy. The authors reviewed the resulting 294 references for inclusion criteria of (a) sample of youth with T1DM or sample of caregivers of youth with T1DM, (b) description of the self-efficacy instrument as primary research, and (c) the instrument measured self-efficacy specifically related to diabetes management. Forty-five articles out of the initial 294 met criteria.

RESULTS

Of the 45 articles, 10 different self-efficacy instruments were identified. The primary theoretical framework used was Bandura's social cognitive theory and model of self-efficacy. Most participants were white middle-class T1DM youth. Evaluations to assess validity often were not reported; however, a majority of studies reported high internal consistency of the instruments.

CONCLUSIONS

Sample homogeneity could limit the applicability of results to certain patient populations. Further psychometric analysis, including validity assessments, should be conducted in more diverse samples. Development of valid and reliable instruments for measuring self-efficacy that are sensitive to change across a wider caregiver base over time is necessary. While this review examined reliable and valid instruments used in research, future opportunities include evaluation of measuring self-efficacy in T1DM youth exposed to recent advances in diabetes management technologies.

Randomized clinical trial of clinic-integrated, low-intensity treatment to prevent deterioration of disease care in adolescents with type 1 diabetes

OBJECTIVE

To evaluate the efficacy of two office-based treatments designed to prevent deterioration in glycemic control in young adolescents with type 1 diabetes in a randomized clinical trial. An individualized, more intensive family teamwork Coping skills program was compared with a diabetes Education treatment.

RESEARCH DESIGN AND METHODS

A baseline assessment was followed by four brief treatment sessions and immediate posttesting over the course of 1.5 years. Families of 226 early adolescents (ages 11-14) were randomized to receive either individualized coping skills education or diabetes education as adjunctive treatment to quarterly medical appointments. Continued follow-up occurred at 3.5-month intervals for a long-term follow-up of up to 3 years. A post hoc Usual Care group facilitated comparisons of glycemic control.

RESULTS

Growth curve analysis showed that both treatment groups successfully prevented deterioration in adolescent disease care and simultaneously improved adolescent and parent quality of life that included indicators of more effective communication and reduced adherence barriers-without a concomitant increase in diabetes-related or general family conflict. However, contrary to expectation, the Education group was more efficacious than the Coping group in improvement of disease adherence and glycemic control over a 3-year follow-up.

CONCLUSIONS

Low-intensity office-based quarterly treatment can maintain or improve disease care adherence in early adolescence when provided to adolescent/parent dyads. Better outcomes are achieved when treatment goals and techniques match the needs of the targeted population.

Longitudinal associations between sex, diabetes self-care, and health-related quality of life among youth with type 1 or type 2 diabetes mellitus

OBJECTIVE

To examine the longitudinal associations between sex, diabetes self-care, and the health-related quality of life (HRQL) of children and adolescents with type 1 or type 2 diabetes.

STUDY DESIGN

The sample included 910 participants with type 1 and 241 participants with type 2, ages 10-22 years at baseline, from the SEARCH for Diabetes in Youth Study, a longitudinal observational study. The primary outcome measure was the Pediatric Quality of Life Inventory. Repeated measures, mixed-model regression analysis was conducted with the use of data from baseline and at least one follow-up assessment, spanning approximately 4 years.

RESULTS

HRQL was greater among those with type 1 versus type 2 diabetes. Among participants with type 1, greater (better) Pediatric Quality of Life Inventory total scores over time were related to greater parent education (P = .0007), lower glycated hemoglobin values (P < .0001), and greater physical activity during the past 7 days (P = .0001). There was a significant interaction between sex and age (P < .0001); girls' HRQL remained stable or decreased over time, whereas males' HRQL increased. For participants with type 2 diabetes, there was no significant interaction by age and sex, but lower total HRQL was related to being female (P = .011) and greater body mass index z-scores (P = .014).

CONCLUSIONS

HRQL in this cohort varied by diabetes type. The interaction between sex and age for type 1 participants, coupled with poorer HRQL among female than male participants with type 2 diabetes, suggests the impacts of diabetes on HRQL differ by sex and should be considered in clinical management. Encouraging physical activity and weight control continue to be important in improving HRQL.

Maternal depressive symptoms and disease care status in youth with type 1 diabetes

OBJECTIVE

The current study assessed relations among maternal depressive symptoms, poorer youth diabetes adherence, and glycemic control. Specifically, hypothesized mediating links of lowered expectations of parental involvement, less parental monitoring, and more conflict were examined.

METHOD

Participants included 225 mothers and their young adolescents, aged 11-14 years (M = 12.73 years, SD = 1.2) diagnosed with T1D. Maternal depressive symptoms and outcome expectancies for maternal involvement were evaluated with self-report questionnaires. Multisource, parent/youth, and multimethod assessment of adherence, parental monitoring, and conflict were evaluated during a baseline assessment from a larger randomized clinical trial.

RESULTS

The first hypothesized structural equation model demonstrated a good fit and indicated that more maternal depressive symptoms were directly associated with less parental monitoring and more conflict, which in turn each were associated with poorer adherence and glycemic control. Although higher involvement expectancies were associated with more monitoring and less conflict, they were not associated with other model variables. A second alternative model also fit the data well; poorer youth adherence was associated with more conflict that in turn related to maternal depressive symptoms.

CONCLUSIONS

Two models were tested by which maternal depressive symptoms and poorer youth adherence were interrelated via less monitoring and more conflict. Follow-up longitudinal evaluation can best characterize the full extent of these relations.

Developmental processes associated with longitudinal declines in parental responsibility and adherence to type 1 diabetes management across adolescence

OBJECTIVE

To identify whether changes in pubertal status and self-efficacy for diabetes management are associated with longitudinal declines in parental responsibility for diabetes, and to determine whether these factors moderate associations between declining parental responsibility and deteriorating adherence across adolescence.

METHODS

Adolescents (N = 252; 53.6% females) with type 1 diabetes, mothers, and 188 fathers participated in a 2.5-year longitudinal study. Self-reports of pubertal status, adolescent efficacy, parental responsibility, and adherence were completed every 6 months (6 time points).

RESULTS

Latent growth curve modeling revealed that longitudinal increases in efficacy and pubertal maturation were uniquely associated with longitudinal declines in parental responsibility. Declines in parental responsibility were related to deterioration in adherence especially when adolescents did not report concomitant growth in self-efficacy.

CONCLUSIONS

Transfer of responsibility for diabetes management across adolescence may be more optimal when adolescents' increased independence is titrated to their changing self-efficacy beliefs.

An exploratory study of positive and incongruent communication in young children with type 1 diabetes and their mothers

BACKGROUND

The incidence of type 1 diabetes is increasing in young children. However, they are overlooked in treatment adherence and intervention research despite evidence that parents often experience difficulty securing their treatment cooperation, especially with the diet. We investigated positive and incongruent (i.e. the co-occurrence of contradictory verbal and non-verbal messages) communication in the mother-child dyad and their association with child adjustment and dietary adherence outcomes.

METHODS

Participants were 23 6- to 8-year-old children with type 1 diabetes and their mothers. We conducted dietary adherence interviews with mothers and performed nutritional analyses to assess children's consumption of extrinsic sugars (e.g. confectionary). Mothers completed a standardized assessment of child psychological adjustment. Mothers and children engaged in a videotaped problem-solving task related to the dietary regimen, with maternal and child utterances and non-verbal behaviours analysed for positive dyadic and incongruent communication.

RESULTS

Positive dyadic communication correlated with lower levels of child incongruent communication, fewer behavioural problems and better overall adjustment. Higher levels of maternal and child incongruent communication correlated with more behavioural and emotional problems and poorer overall adjustment. Higher levels of maternal incongruent communication correlated with poorer dietary adherence.

CONCLUSIONS

Results converged to form a conceptually and empirically coherent pattern in that behavioural indices of poorer communication in both mother and child consistently correlated with poorer child adjustment outcomes. This study shows that specific features of dyadic, child and maternal communication could be targeted in developmentally sensitive interventions to promote positive communication in the home management of type 1 diabetes care for young children.