Executive Function in Adolescents With Type 1 Diabetes: Relationship to Adherence, Glycemic Control, and Psychosocial Outcomes

The impact of emotion regulation strategies on disordered eating behavior in children and adolescents with type 1 diabetes: a cross-sectional study

Objective

Difficulties in emotion regulation (DERs) can contribute to disordered eating behavior in children and adolescents with type 1 diabetes (T1D), although it is unknown how DERs may affect eating behavior in these children and adolescents. This study examined the relationship between disordered eating behaviors and emotion regulation in children and adolescents with T1D.

Methods

For this cross-sectional study, 128 patients (aged 8-16 years) were recruited to complete the Diabetes Eating Problem Survey-Revised (DEPS-R) and Difficulties in Emotion Regulation Scale (DERs).

Results

The mean age of the 128 patients (99 females) who completed the DEPS-R was 11.63 ± 2.27 years. The participants' mean DEPS-R score was 17.78 ± 8.56 points. Of the total sample, 61 participants' scores surpassed the established threshold, resulting in a DEPS-R positivity rate of 47.66%. The participants' mean total DERS score was 72.3 ± 21.15 points, and it was found that children and adolescents with T1D who had a positive DEPS-R screening result had significant differences in emotional regulation and that eating behavior disorders were positively correlated with emotional regulation and all dimensions scores.

Conclusions

The prevalence of disordered eating behavior is high among children and adolescents with T1D. DERs are related to disordered eating behavior in children and adolescents with T1D. The novel finding that DERs may be a predictor of eating problems lends preliminary support for the inclusion of DERs in future risk models and as a potential target for intervention.

A qualitative exploration of how to support PrEP adherence among young men who have sex with men

New HIV infections disproportionately affect young men who have sex with men (YMSM). PrEP is effective in preventing HIV acquisition; however, adherence is critical and is often suboptimal among YMSM. Interventions addressing the unique PrEP adherence challenges faced by YMSM are needed. We conducted qualitative interviews with 20 HIV-negative, YMSM (ages 15-24) with a PrEP indication and 11 healthcare professionals to inform adaption of a PrEP adherence intervention (Life-Steps for PrEP) for YMSM. We explored environmental, healthcare, and individual factors influencing uptake, adherence, attitudes, and perspectives (including desired modifications) on the Life-Steps intervention. Interviews were analyzed using content analysis. Of YMSM study participants (mean age 21.6) 55% were White, 15% Hispanic, and 5% Black. Most YMSM were PrEP-experienced (70%). Healthcare professionals (6 prescribers, 1 nurse, 2 health educators, 2 other/unspecified) averaged 6.9 years of experience caring for YMSM. All described stigma as a barrier to PrEP; YMSM expressed concern around being perceived as "risky" and concern about inadvertent PrEP disclosure if family/friends found their medication, or if parental insurance was used. Difficulty with planning for potential adherence challenges were identified by both groups. YMSM highlighted benefits of a nurse-led intervention (i.e., adding "legitimacy"), but stressed need for nonjudgmental, "savvy" interventionists. YMSM expressed a desire for comprehensive YMSM-specific sexual health information. These findings informed modification and expansion of Life-Steps content. Results highlight key potential barriers, many of which center around privacy. Content that addresses PrEP stigma, disclosing PrEP use, navigating insurance, and planning ahead in a nonjudgmental environment by trusted providers emerged as important components of a YMSM-focused delivery of Life-Steps for PrEP.

Cognitive disengagement syndrome in children with type 1 diabetes: important implications for clinical outcomes

AIMS

Children with type 1 diabetes (T1D) are prone to a variety of psychiatric disorders, however, to date, no study has examined cognitive disengagement syndrome (CDS) in children with T1D. The present study aimed to evaluate the frequency of CDS symptoms in children with T1D and whether it is related to glycemic control.

METHODS

This cross-sectional study included 74 children with T1D and 88 healthy (control) children, aged 8-14 years. All children were evaluated through a semi-structured psychiatric interview, the Kent-EGY test, porteus maze test, stroop test TBAG form, Barkley child attention scale, and Conners' parent rating scale-revised-short form.

RESULT

Children with T1D had considerably higher rates of elevated CDS symptoms than control children (35.1% vs. 10.2%, p < 0.001). Children with T1D performed poorly on attention and cognitive tests. High levels of CDS symptomatology were strongly associated with earlier diabetes onset age, longer disease duration, a higher percentage of diabetic ketoacidosis at diagnosis, higher HbA1c levels, and higher daily insulin dosages. Also, T1D patients with elevated CDS symptoms had lower IQ and attention scores and worse cognitive function performance compared to participants with low levels of CDS symptomatology.

CONCLUSIONS

Elevated CDS symptoms are significantly higher in children with T1D and are associated with poorer diabetes control. The routine psychiatric examination of children with T1D should also include a screening for CDS, particularly in patients with poor glycemic control.

Learning experience design of an mHealth self-management intervention for adolescents with type 1 diabetes

Type 1 diabetes (T1D) is a lifelong and chronic condition that can cause severely compromised health. The T1D treatment regimen is complex, and is a particular challenge for adolescents, who frequently experience a number of treatment adherence barriers (e.g., forgetfulness, planning and organizational challenges, stress). Diabetes Journey is a gamified mHealth program designed to improve T1D self-management through a specific focus on decreasing adherence barriers and improving executive functioning skills for adolescents. Grounded in situativity theory and guided by a sociotechnical-pedagogical usability framework, Diabetes Journey was designed, developed, and evaluated using a learning experience design approach. This approach applied design thinking methods within a Successive Approximation Model design process. Iterative design and formative evaluation were conducted across three design phases, and improvements were implemented following each phase. Findings from the user testing phase indicate Diabetes Journey is a user-friendly mHealth program with high usability that holds promise for enhancing adolescents' T1D self-management. Implications for future designers and researchers are discussed regarding the social dimension of the sociotechnical-pedagogical usability framework. An extension to the framework is proposed to extend the social dimension to include socio-cultural and contextual considerations when designing mHealth applications. Consideration of the pedagogical and sociocultural dimensions of learning is imperative when developing psychoeducational interventions.

General Anxiety, Diabetes-Specific Anxiety, and Quality of Life in Adolescents With Type 1 Diabetes

PURPOSE

The purpose of the study was to identify the differential associations between general anxiety, diabetes-specific anxiety, and diabetes-specific quality of life (QOL).

METHODS

A cross-sectional study was conducted of 146 adolescents with type 1 diabetes (T1DM) ages 13 to 17 during the COVID-19 pandemic. Participants completed self-report questionnaires assessing demographic characteristics, general anxiety, diabetes-specific anxiety, depressive symptoms, and diabetes-specific QOL.

RESULTS

The final sample of 146 adolescents was mostly male, non-Hispanic White, mean age of 14.5 ± 1.27, having diabetes for more than 1 year, and using insulin pumps. Higher diabetes-specific anxiety was associated with poorer general treatment-related QOL, but general anxiety was not. General anxiety, diabetes-specific anxiety, and depressive symptoms were significantly associated with diabetes-specific treatment-related QOL, worry-specific QOL, and poorer communication-related QOL.

CONCLUSIONS

There may be a differential impact of general anxiety and diabetes-specific anxiety in adolescents with T1DM. Diabetes-specific anxiety may be a more important factor in adolescents reporting poorer general treatment-related QOL, worry-related QOL, and communication-related QOL, while general anxiety and diabetes-specific anxiety appear to similarly impact poorer diabetes-specific treatment-related QOL. Diabetes-specific anxiety may be a more important component of QOL in adolescents. Targeted interventions may be required to effectively improve QOL.

Associations of Executive Function With Diabetes Management and Glycemic Control in Adolescents With Type 1 Diabetes

Aims

The aims of this study were to assess domains of executive function in relation to diabetes management and glycemic control in adolescents with type 1 diabetes and to compare adolescent self-report and parent proxy-report of adolescent executive function.

Methods

Adolescents with type 1 diabetes (N = 169, 46% female, age 15.9 ± 1.3 years) and their parents completed self-report and parent proxy-report versions of the Behavior Rating Inventory of Executive Function (BRIEF).

Results

Self-report and parent proxy-report BRIEF T scores were moderately to strongly correlated; parent proxy scores were significantly higher than self-report scores. Executive function problems (Global Executive Composite T score ≥60) occurred in 9% of adolescents by self-report and 26% by parent proxy-report. For almost all Metacognition Index scales, elevated (T score ≥60) parent proxy scores were associated with lower adherence, lower adolescent diabetes self-efficacy, and more parent involvement in diabetes management. Elevated scores on several Metacognition Index scales were associated with less pump use (Plan/Organize by self-report, Initiate by parent proxy-report, and Monitor by parent proxy-report) and higher A1C (Plan/Organize by self-report and parent proxy-report and Organization of Materials by parent proxy-report). The only significant associations for the Behavioral Regulation Index scales occurred for adherence (by parent proxy-report) and diabetes self-efficacy (by self-report and parent-report).

Conclusion

Adolescents with type 1 diabetes who have problems with metacognition may need additional support for diabetes self-management.

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.

Cognitive Function in Adolescents and Young Adults With Youth-Onset Type 1 Versus Type 2 Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVE

Poor cognition has been observed in children and adolescents with youth-onset type 1 (T1D) and type 2 diabetes (T2D) compared with control subjects without diabetes. Differences in cognition between youth-onset T1D and T2D, however, are not known. Thus, using data from SEARCH for Diabetes in Youth, a multicenter, observational cohort study, we tested the association between diabetes type and cognitive function in adolescents and young adults with T1D (n = 1,095) or T2D (n = 285).

RESEARCH DESIGN AND METHODS

Cognition was assessed via the National Institutes of Health Toolbox Cognition Battery, and age-corrected composite Fluid Cognition scores were used as the primary outcome. Confounder-adjusted linear regression models were run. Model 1 included diabetes type and clinical site. Model 2 additionally included sex, race/ethnicity, waist-to-height ratio, diabetes duration, depressive symptoms, glycemic control, any hypoglycemic episode in the past year, parental education, and household income. Model 3 additionally included the Picture Vocabulary score, a measure of receptive language and crystallized cognition.

RESULTS

Having T2D was significantly associated with lower fluid cognitive scores before adjustment for confounders (model 1; P < 0.001). This association was attenuated to nonsignificance with the addition of a priori confounders (model 2; P = 0.06) and Picture Vocabulary scores (model 3; P = 0.49). Receptive language, waist-to-height ratio, and depressive symptoms remained significant in the final model (P < 0.01 for all, respectively).

CONCLUSIONS

These data suggest that while youth with T2D have worse fluid cognition than youth with T1D, these differences are accounted for by differences in crystallized cognition (receptive language), central adiposity, and mental health. These potentially modifiable factors are also independently associated with fluid cognitive health, regardless of diabetes type. Future studies of cognitive health in people with youth-onset diabetes should focus on investigating these significant factors.

Incentives conditioned on tenofovir levels to support PrEP adherence among young South African women: a randomized trial

Introduction

HIV incidence remains high among African adolescent girls and young women (AGYW), who would benefit from pre‐exposure prophylaxis (PrEP). Strategies to increase PrEP adherence and persistence need to be evaluated in African AGY, including incentives conditional on high adherence.

Methods

The 3Ps for Prevention Study was a 12‐month prospective cohort of 200 women ages 16 to 25 initiating PrEP in South Africa from 2017 to 2018. Participants received retrospective feedback about drug levels at Months 1, 2 and 3; half was randomized to receive a 200 Rand shopping voucher ($13 US) at Months 2, 3 and 4, conditioned on high intracellular tenofovir diphosphate (TFV‐DP) levels in dried blood spots (≥500 fmol/punch at Month 1, ≥700 fmol/punch at Months 2 and 3). The primary analysis was intention‐to‐treat, comparing the proportion with high PrEP adherence (≥700 fmol/punch) at Month 3 by randomized group, based on 100% efficacy among men who have sex with men.

Results

Median age of the 200 women was 19 years (interquartile range [IQR] 17, 21); 86% had a primary sexual partner. At Month 3, the mean TFV‐DP level was 822 fmol/punch (SD 522) in the incentive group and 689 fmol/punch (SD 546) in the control group (p = 0.11). Forty‐five (56%) of 85 women in the incentive group and 35 (41%) of 85 women in the control group had TFV‐DP levels ≥700 fmol/punch (RR 1.35; 95% CI 0.98, 1.86; p = 0.067), which declined to 8% and 5% in the incentive and control groups at Month 12 (no significant difference by arm). 44% refilled PrEP without gaps, 14% had a gap of ≥3 weeks in coverage subsequently restarted PrEP and 54% accepted at the final dispensing visit at Month 9. No new HIV infections were observed after PrEP initiation.

Conclusions

Among South African AGYW initiating PrEP, drug levels indicated high PrEP adherence in almost half of women at Month 3, with a non‐statistically significant higher proportion with high adherence among those in the incentive group. Over half persisted with the 12‐month PrEP programme although high adherence declined after Month 3. Strategies to support PrEP adherence and persistence and longer‐acting PrEP formulations are needed.

Associations of diabetes self-management characteristics, HbA1c, and psychosocial outcomes with depressive symptoms in a contemporary sample of adolescents with type 1 diabetes

AIMS

We sought to examine the associations between diabetes self-management, HbA1c, and psychosocial outcomes with the frequency of depressive symptoms.

METHODS

We surveyed 301 teens (50% male, 22% non-white), mean age of 15.0±1.3 years, diabetes duration of 6.5±3.7 years. Biomedical variables: daily frequency of blood glucose monitoring of 4.5±1.9, 63% insulin pump use, mean HbA1c 8.5±1.1% (69±12 mmol/mol); 15% of the sample achieved the target HbA1c of <7.5% (<58 mmol/mol).

RESULTS

Nearly 1 in 5 (18%, n=54) adolescents reported significant depressive symptoms and, of those participants, slightly under half reported moderate/severe depressive symptoms. Teens with moderate/severe depressive symptoms (CES-D scores ≥24) were more likely to be female, have parents without a college education, and not utilize insulin pumps. Teens with more depressive symptoms reported higher diabetes family conflict, higher diabetes burden, and lower quality of life. In the group reporting no depressive symptoms (10%), scores on psychosocial variables and diabetes treatment variables were the most favorable.

CONCLUSION

In our sample, the presence of depressive symptoms appears to relate to both diabetes treatment and quality of life. In addition, studying teens without depressive symptoms can help us learn more about protective factors that potentially buffer against depressive symptoms and that are associated with better outcomes.

A Digital Health Intervention (SweetGoals) for Young Adults With Type 1 Diabetes: Protocol for a Factorial Randomized Trial

BACKGROUND

Many young adults with type 1 diabetes (T1D) struggle with the complex daily demands of adherence to their medical regimen and fail to achieve target range glycemic control. Few interventions, however, have been developed specifically for this age group.

OBJECTIVE

In this randomized trial, we will provide a mobile app (SweetGoals) to all participants as a "core" intervention. The app prompts participants to upload data from their diabetes devices weekly to a device-agnostic uploader (Glooko), automatically retrieves uploaded data, assesses daily and weekly self-management goals, and generates feedback messages about goal attainment. Further, the trial will test two unique intervention components: (1) incentives to promote consistent daily adherence to goals, and (2) web health coaching to teach effective problem solving focused on personalized barriers to self-management. We will use a novel digital direct-to-patient recruitment method and intervention delivery model that transcends the clinic.

METHODS

A 2x2 factorial randomized trial will be conducted with 300 young adults ages 19-25 with type 1 diabetes and (Hb)A_1c ≥ 8.0%. All participants will receive the SweetGoals app that tracks and provides feedback about two adherence targets: (a) daily glucose monitoring; and (b) mealtime behaviors. Participants will be randomized to the factorial combination of incentives and health coaching. The intervention will last 6 months. The primary outcome will be reduction in A_1c. Secondary outcomes include self-regulation mechanisms in longitudinal mediation models and engagement metrics as a predictor of outcomes. Participants will complete 6- and 12-month follow-up assessments. We hypothesize greater sustained A_1c improvements in participants who receive coaching and who receive incentives compared to those who do not receive those components.

RESULTS

Data collection is expected to be complete by February 2025. Analyses of primary and secondary outcomes are expected by December 2025.

CONCLUSIONS

Successful completion of these aims will support dissemination and effectiveness studies of this intervention that seeks to improve glycemic control in this high-risk and understudied population of young adults with T1D.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04646473; https://clinicaltrials.gov/ct2/show/NCT04646473.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/27109.

The Relationship Between Executive Functioning, Type 1 Diabetes Self-Management Behaviors, and Glycemic Control in Adolescents and Young Adults

PURPOSE OF REVIEW

Understanding barriers to self-management behaviors and glycemic stability may inform specific needs for behavior change in adolescents and young adults with type 1 diabetes (T1D). The current review aims to systematically synthesize the literature on the relationships between executive functioning, self-management, and A1C in adolescents and young adults with T1D. Fifteen studies were retained in the current review. Study quality assessment for the majority of the studies were "Fair" or "Good."

RECENT FINDINGS

This review highlights several advances in research design, including use of longitudinal designs, data from multiple informants, and use of objective measures. Adolescents and young adults reported that more executive functioning weaknesses were related to decreased self-management behaviors and higher A1C. The current review demonstrated that self-perceived executive functioning weaknesses negatively impact self-management behaviors and A1C. Future research is needed to determine the utility of objective measures in assessing the relationships between executive functioning, T1D self-management, and A1C.

Executive dysfunction is associated with poorer health-related quality of life in adolescents with type 1 diabetes: differences by sex

PURPOSE

Type 1 diabetes (T1D) is one of the most complex and demanding chronic diseases in adolescents. Given the detrimental impact of problems with executive function (EF; the ability to initiate, plan, and monitor behavior) on health outcomes in adolescents with T1D, most studies have examined common diabetes-specific outcomes related to self-management and glycemic control. This study aims to investigate the impact of executive dysfunction on health-related quality of life (HRQoL; an individual's perceived impact of illness and treatment on daily functioning) in adolescents with T1D from a multi-informant perspective.

METHODS

In this cross-sectional study, 169 adolescents (mean ± SD age 15.9 ± 1.3 years) and their parents reported on adolescent EF and HRQoL (assessed by the BRIEF and PedsQL, respectively). Parent-youth interview and chart review provided demographic and clinical characteristics. Statistical analyses encompassed bivariate correlations, t-tests, chi-squared tests, and multivariable analyses.

RESULTS

Adolescent self-reports and parent proxy-reports identified 13% and 32% of adolescents, respectively, as having executive dysfunction. Poorer adolescent EF was associated with poorer adolescent HRQoL by both adolescent self-report and parent proxy-report, respectively. In significant multivariable models, adjusted for adolescent age, sex, diabetes duration, and glycemic control, 21% and 24% of the variance in adolescent self-reported and parent proxy-reported HRQoL were explained by adolescent self-reported and parent proxy-reported executive dysfunction. A significant interaction of sex with adolescent self-report of executive dysfunction indicated that executive dysfunction had a greater negative impact on HRQoL in females than males (p < .01).

CONCLUSIONS

Findings suggest that the impact of EF problems in adolescents with T1D goes beyond diabetes-specific outcomes and focuses attention on the need to evaluate and preserve HRQoL.

Brain Function Differences in Children With Type 1 Diabetes: A Functional MRI Study of Working Memory

Glucose is a primary fuel source to the brain, yet the influence of dysglycemia on neurodevelopment in children with type 1 diabetes remains unclear. We examined brain activation using functional MRI in 80 children with type 1 diabetes (mean ± SD age 11.5 ± 1.8 years; 46% female) and 47 children without diabetes (control group) (age 11.8 ± 1.5 years; 51% female) as they performed a visuospatial working memory (N-back) task. Results indicated that in both groups, activation scaled positively with increasing working memory load across many areas, including the frontoparietal cortex, caudate, and cerebellum. Between groups, children with diabetes exhibited reduced performance on the N-back task relative to children in the control group, as well as greater modulation of activation (i.e., showed greater increase in activation with higher working memory load). Post hoc analyses indicated that greater modulation was associated in the diabetes group with better working memory function and with an earlier age of diagnosis. These findings suggest that increased modulation may occur as a compensatory mechanism, helping in part to preserve working memory ability, and further, that children with an earlier onset require additional compensation. Future studies that test whether these patterns change as a function of improved glycemic control are warranted.

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

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

The Role of Self-regulation Failures and Self-care in the Link Between Daily Sleep Quality and Blood Glucose Among Adults with Type 1 Diabetes

BACKGROUND

Sleep, a process that restores the body's ability to self-regulate, may be one important factor affecting self-care behaviors and blood glucose (BG) levels. The link between sleep quality, self-care behaviors, and BG levels may occur by sleep-altering daily self-regulatory failures.

PURPOSE

This study examined whether the relation between sleep quality and self-care behaviors occurred through self-regulation failures and whether the relation between sleep quality and BG levels occurred through self-regulation failures and self-care behaviors sequentially.

METHODS

One hundred and ninety-nine adults with type 1 diabetes (T1D) completed an online questionnaire for 14 days in which they reported sleep quality, self-regulation failures, and self-care behaviors. BG levels were gathered from glucometers. Analyses involved multilevel mediation models and focused on daily within-person and between-person variability of sleep quality.

RESULTS

Better daily sleep quality was associated with higher self-care behaviors at both within-person and between-person levels, and self-regulation failures mediated the association between daily sleep quality and daily self-care behaviors at both within-person and between-person levels. Better daily sleep quality was associated with better BG levels at the within-person level and self-regulation behaviors and self-care behaviors sequentially mediated the association between daily sleep quality and daily BG levels at the within-person level.

CONCLUSION

This study provides a process account of the importance of daily sleep quality of adults with T1D, as well as one potential mechanism-self-regulation-that may explain the effect of sleep quality on diabetes outcomes.

Adolescent Interventions to Manage Self-Regulation in Type 1 Diabetes (AIMS-T1D): randomized control trial study protocol

BACKGROUND

Self-regulation (SR), or the capacity to control one's thoughts, emotions, and behaviors in order to achieve a desired goal, shapes health outcomes through many pathways, including supporting adherence to medical treatment regimens. Type 1 Diabetes (T1D) is one specific condition that requires SR to ensure adherence to daily treatment regimens that can be arduous and effortful (e.g., monitoring blood glucose). Adolescents, in particular, have poor adherence to T1D treatment regimens, yet it is essential that they assume increased responsibility for managing their T1D as they approach young adulthood. Adolescence is also a time of rapid changes in SR capacity and thus a compelling period for intervention. Promoting SR among adolescents with T1D may thus be a novel method to improve treatment regimen adherence. The current study tests a behavioral intervention to enhance SR among adolescents with T1D. SR and T1D medical regimen adherence will be examined as primary and secondary outcomes, respectively.

METHODS

We will use a randomized control trial design to test the impact of a behavioral intervention on three SR targets: Executive Functioning (EF), Emotion Regulation (ER), and Future Orientation (FO); and T1D medical regimen adherence. Adolescents with T1D (n = 94) will be recruited from pediatric endocrinology clinics and randomly assigned to treatment or control group. The behavioral intervention consists of working memory training (to enhance EF), biofeedback and relaxation training (to enhance ER), and episodic future thinking training (to enhance FO) across an 8-week period. SR and treatment regimen adherence will be assessed at pre- and post-test using multiple methods (behavioral tasks, diabetes device downloads, self- and parent-report). We will use an intent-to-treat framework using generalized linear mixed models to test our hypotheses that: 1) the treatment group will demonstrate greater improvements in SR than the control group, and 2) the treatment group will demonstrate better treatment regimen adherence outcomes than the control group.

DISCUSSION

If successful, SR-focused behavioral interventions could improve health outcomes among adolescents with T1D and have transdiagnostic implications across multiple chronic conditions requiring treatment regimen adherence.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03688919; registered September 28, 2018.

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

Background

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

Method

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

Results

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

Conclusion

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

HIV pre-exposure prophylaxis for adolescent girls and young women in Africa: from efficacy trials to delivery

INTRODUCTION

Adolescent girls and young women (AGYW) in Africa have high HIV incidence despite scale-up of HIV testing and HIV treatment. Placebo-controlled trials of tenofovir-based pre-exposure prophylaxi (PrEP) in diverse populations demonstrated that PrEP works with close to 100% effectiveness if taken with high, but not perfect, adherence. Divergent efficacy estimates among African AGYW led to demonstration and implementation projects to better understand motivations for HIV prevention, uptake, adherence and persistence to PrEP. To inform PrEP programmes, the design and initial findings from PrEP demonstration projects for AGYW are reviewed.

DISCUSSION

Early lessons from PrEP implementation projects among young African women include: (1) awareness and demand creation with positive messaging about the benefits of PrEP are critical to motivate AGYW to consider this novel prevention technology and to foster awareness among peers, partners, parents and guardians to support AGYW's effective PrEP use; (2) PrEP initiation is high in projects that are integrating PrEP into youth-friendly clinics, family planning clinics and mobile clinics; (3) young African women at risk are initiating PrEP, based on behavioural characteristics, history of intimate partner violence, depression and 30% prevalence of chlamydia and/or gonorrhoea; (4) provision of youth-friendly PrEP delivery programmes that integrate reproductive health services, including contraception and the diagnosis and treatment of sexually transmitted infections, increase health impact; (5) messages that emphasize the necessity for high adherence while at potential risk of HIV exposure and support strategies that addresses AGYW's adherence challenges are essential; and, (6) a substantial proportion of AGYW do not persist with PrEP, and strategies are needed to help AGYW assess their ongoing need, motivation and challenges with persisting with PrEP.

CONCLUSIONS

PrEP is feasible to implement in integrated reproductive health service delivery models to reach African AGYW. While PrEP demonstration projects indicate that women with behavioural risks and high rates of sexually transmitted diseases are initiating PrEP; effective strategies to support AGYW's adherence and persistence with PrEP are needed. Lessons learned from oral PrEP delivery, a novel first generation HIV prevention product, are relevant to longer-acting and less adherence-dependent strategies which are currently in clinical trials.

The Empowerment of Adolescents with Type 1 Diabetes Is Associated with Their Executive Functions

Background

Adolescence is a difficult period for young people with type 1 diabetes mellitus (T1DM), both in psychological and clinical terms. Empowerment therapy may support these patients, provided they are ready to change and have adequate executive functions to facilitate this change. Therefore, we hypothesise that the readiness of adolescents with T1DM to change is related to clinical features and/or their executive functions.

Methods

Using the Diabetes Empowerment Scale and the Behavioural Rating Inventory of Executive Function, we evaluated patients with T1DM duration of more than one year from three Polish diabetes centres of the PolPeDiab study group (N = 146). We related the data to features associated with disease and treatment and compared the results to those of adolescents without diabetes (N = 110).

Results

We observed that adolescents with T1DM had a higher rate of abnormal results in executive function tests than their peers without diabetes (p > 0.05). Diabetes empowerment in this group of patients decreased with disease duration (r = -0.25, p = 0.006) and increased with deteriorating metabolic control (HbA1c; r = 0.25, p = 0.006). The greater the deficiencies in executive functions among adolescents with T1DM, the greater their readiness to change. The relationship between executive functions and diabetes empowerment is partially gender-differentiated.

Conclusions

To conclude, we propose individualized diabetes education in this group of patients based on the assessment of readiness to change and executive functions.

Assessing Executive Function in Adolescence: A Scoping Review of Existing Measures and Their Psychometric Robustness

Background: There is much research examining adolescents' executive function (EF) but there is little information about tools that measure EF, in particular preference of use, their reliability and validity. This information is important as to help both researchers and practitioners select the most relevant and reliable measure of EF to use with adolescents in their context. Aims: We conducted a scoping review to: (a) identify the measures of EF that have been used in studies conducted among adolescents in the past 15 years; (b) identify the most frequently used measures of EF; and (c) establish the psychometric robustness of existing EF measures used with adolescents. Methods: We searched three bibliographic databases (PsycINFO, Ovid Medline, and Web of Science) using key terms "Adolescents," "Executive Functions," and "measures". The search covered research articles published between 1st January 2002 and 31st July 2017. Results: We identified a total of 338 individual measures of EF from 705 eligible studies. The vast majority of these studies (95%) were conducted in high income countries. Of the identified measures, 10 were the most used frequently, with a cumulative percent frequency accounting for nearly half (44%) the frequency of usage of all reported measures of EF. These are: Digit Span (count = 160), Trail Making Test (count = 158), Behavior Rating Inventory of Executive Function (count = 148), Wisconsin Card Sorting Test (count = 140), Verbal Fluency Tasks (count = 88), Stroop Color-Word Test (count = 78), Classical Stroop Task (count = 63), Color-Word Interference Test from Delis-Kaplan battery (count = 62), Rey-Osterrieth Complex Figure Test (count = 62), and Original Continuous Performance Test (count = 58). In terms of paradigms, tasks from Span (count = 235), Stroop (count = 216), Trails (count = 171), Card sorting (count = 166), Continuous performance (count = 99), and Tower (count = 94) paradigms were frequently used. Only 48 studies out of the included 705 reported the reliability and/or validity of measures of EF used with adolescents, but limited to studies in high income countries. Conclusion: We conclude that there is a wide array of measures for assessing EF among adolescents. Ten of these measures are frequently used. However, the evidence of psychometric robustness of measures of EF used with adolescents remains limited to support the validity of their usage across different contexts.

Executive functioning and quality of life in acromegaly

Introduction

Active acromegaly is a rare chronic endocrine disorder caused by excessive growth hormone (GH). Clinical studies suggest that cognitive performance is impaired in acromegaly – particularly executive function as well as short- and long-term memory. This study compared the quality of life (QoL) and executive functioning in acromegaly patients vs healthy controls.

Materials and methods

This was an observational case–control study on 38 subjects divided into 19 acromegaly patients and 19 matched controls. The groups were evaluated for QoL, attention, and executive function. All subjects completed Acromegaly Quality of Life Questionnaire (AcroQoL), Trail Making Test (parts A and B), Stroop, and phonemic fluency tests.

Results

Acromegaly patients had an AcroQoL global score that was significantly lower than controls. There were significant differences between the acromegaly group and the control group in terms of the physical effects (P=0.001) and appearance (P<0.001) but not for personal relationships (P=0.421). Acromegaly patients performed worse in the trail making test part B. They provided significantly fewer words than healthy subjects in phonemic fluency testing. Although patients performed generally worse than controls, no significant differences were noted in the trail making test part A, Stroop test, and the constrained phonemic fluency.

Conclusion

Acromegaly patients display worse executive functioning than healthy controls and have a decreased QoL.

Adolescent Emotional Control Moderates Benefits of a Multicomponent Intervention to Improve Type 1 Diabetes Adherence: A Pilot Randomized Controlled Trial

Objective

We previously tested via randomized controlled trial a novel intervention for adolescents with type 1 diabetes and above-target glycemic control that combined web-delivered incentives for self-monitoring of blood glucose (SMBG) and brief web counseling with working memory training and parental contingency contracting training. Results showed improved SMBG and decreased glycosylated hemoglobin (HbA1c) at 6- and 12-month follow-ups. However, it has not been elucidated if improvements in SMBG mediated the immediate benefits of this treatment on HbA1c nor if this intensive intervention uniquely benefited a subgroup of adolescents with higher problems in emotional control.

Methods

Adolescents with type 1 diabetes and above-target glycemic control (n = 61) were randomized to receive the 6-month intervention (n = 30) or usual care (n = 31). Adolescents completed the Behavior Rating Inventory of Executive Function-Self-Report, problems with emotional control subscale at baseline, and provided meter downloads to assess frequency of SMBG and completed an HbA1c blood draw at baseline and 6 months later.

Results

At 6-month follow-up, improvements in SMBG mediated the effects of receiving the treatment on having lower average HbA1c. Further, problems in emotional control moderated the benefits of the intervention on improvements in SMBG and in turn HbA1c. Only adolescents with above average problems in emotional control evidenced improvements in SMBG in response to treatment, which then explained lower HbA1c levels at 6-month follow-up.

Conclusions

This multicomponent, web-delivered intervention provided unique benefits for improving SMBG and lowering HbA1c in teens with higher problems in emotional control.

Neurophysiological Evidence for a Compensatory Activity during a Simple Oddball Task in Adolescents with Type 1 Diabetes Mellitus

OBJECTIVE

The poor metabolic control in type 1 diabetes mellitus (T1D) has a negative impact on the developing brain. Hyperglycemia and glycemic fluctuations disrupt mainly executive functions. To assess a hypothesized deficit of the executive functions, we evaluated visual processing and reaction time in an oddball task.

METHODS

Oddball visual event-related potentials (ERPs), reaction time, and pattern-reversal visual evoked potentials (VEPs) were examined in a cohort of twenty-two 12- to 18-year-old T1D patients without diabetic retinopathy at normal glycemia and in nineteen 10- to 21-year-old healthy controls.

RESULTS

The P100 peak time of the VEPs was significantly prolonged in T1D patients compared with the control group (p < 0.017). In contrast to the deteriorated sensory response, the area under the curve of the P3b component of the ERPs was significantly larger (p = 0.035) in patients, while reaction time in the same task did not differ between groups (p = 0.713).

CONCLUSIONS

The deterioration on a sensory level, enhanced activity during cognitive processing, and balanced behavioral response support the view that neuroplasticity counterbalances the neural impairment by enhanced cognitive processing to achieve normal behavioral performance in T1D adolescents.

Self- and Social-Regulation in Type 1 Diabetes Management During Late Adolescence and Emerging Adulthood

PURPOSE OF REVIEW

This paper aims to examine how self-regulation (i.e., cognition, emotion) and social-regulation (i.e., parents, friends, romantic partners) are interrelated risk and protective factors for type 1 diabetes management during late adolescence and emerging adulthood.

RECENT FINDINGS

Problems in cognitive (e.g., executive function) and emotional (e.g., depressive symptoms) self-regulation are associated with poorer management, both at the between- and within-person levels. Better management occurs when parents are supportive and when individuals actively regulate the involvement of others (e.g., seek help, minimize interference). Friends both help and hinder self-regulation, while research on romantic partners is limited. Facets of self- and social-regulation are important risk and protective factors for diabetes management during emerging adulthood. At this time when relationships are changing, the social context of diabetes may need to be regulated to support diabetes management. Interventions targeting those with self-regulation problems and facilitating self- and social-regulation in daily life may be useful.

Exploring the intersection of executive function and medication adherence in school-age children with asthma

Asthma is one of the most common chronic diseases of childhood. For children with persistent asthma, asthma control is largely related to controller medication adherence. With increasing calls for children to be involved in their own asthma management, there is a gap in our knowledge about the executive functioning of children with asthma.

OBJECTIVE

The purpose of this study was to explore the relationship between executive function, asthma, and medication adherence among school-age children with asthma.

METHODS

Thirty-one children ages 7 to 11 years (M = 8.9 ± 1.51) and one of their parents were enrolled in this study. Parents reported on asthma control while children reported on asthma control, medication beliefs, medication adherence, and completed an executive function battery that assessed inhibition, updating, shifting and planning.

RESULTS

Compared to the reference sample, children in this study had significantly lower composite scores in inhibition, t (31) = -3.84, p =. 001, and shifting, t (30) = -3.73, p =. 001. Controlling for age and asthma control, hierarchical regression analyses revealed that shifting accounted for 16% of the variance in child-reported medication adherence.

CONCLUSIONS

This study revealed lowered executive functioning scores among school-age children with persistent asthma. Furthermore, it appears executive functioning and controller medication adherence are intertwined and warrant future exploration.