Psychological care of children and adolescents with diabetes

Psychometric validation of the MIND Youth Questionnaire (MY-Q) to assess quality of life in Spanish patients with type 1 diabetes between 12 and 25 years old

AIM

Validate in Spanish the Monitoring Individual Needs in Diabetes Youth Questionnaire (MY-Q), a multi-dimensional self-report HRQoL questionnaire designed for paediatric diabetes care.

DESIGN AND METHODS

After translation, 209 patients diagnosed with type 1 diabetes, between 12 and 25 years old were assessed. The patients belonged to 12 hospitals in Spain.

RESULTS

Exploratory factor analysis including one-factor up to seven-factor solutions were tested. The three-factor solution (Negative Impact of Diabetes, Empowerment and Control of Diabetes and Worries) was the most parsimonious model with adequate fit: χ²(723)=568.856 (p<0.001), CFI=0.913, RMSEA=0.072 [0.064, 0.080], SRMR=0.075. The three-factor solution and the grouping of the items followed a clear rationale. Cronbach's alpha was 0.816 for Negative Impact, 0.700 for Empowerment and Control and 0.795 for Worries. The study of the relationship between the MY-Q dimensions and socio-demographics variables show a relationship between age and the MY-Q: F(6,410)=10.873 (p<0.001), η²=0.137. Participants younger than 14 years old showed greater scores on Empowerment and Control when compared to participants between 14 and 17 years old (p=0.021); statistically significant differences were found for the participants 18 years old or older, who showed lower levels of Worries than the younger patients. Concurrent validity found that the dimension of Negative Impact of Diabetes was positively related to WHO-5, and the PedsQL Diabetes Module.

CONCLUSION

The Spanish version of the MY-Q to measure HRQoL in patients with type 1 diabetes between the ages of 12 and 25, has adequate psychometric properties and conceptual and semantic equivalence with the original version in Dutch.

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

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

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

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

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

The Counseling, Self-Care, Adherence Approach to Person-Centered Care and Shared Decision Making: Moral Psychology, Executive Autonomy, and Ethics in Multi-Dimensional Care Decisions

This article argues that standard models of person-centred care (PCC) and shared decision making (SDM) rely on simplistic, often unrealistic assumptions of patient capacities that entail that PCC/SDM might have detrimental effects in many applications. We suggest a complementary PCC/SDM approach to ensure that patients are able to execute rational decisions taken jointly with care professionals when performing self-care. Illustrated by concrete examples from a study of adolescent diabetes care, we suggest a combination of moral and psychological considerations to support the claim that standard PCC/SDM threatens to systematically undermine its own goals. This threat is due to a tension between the ethical requirements of SDM in ideal circumstances and more long-term needs actualized by the context of self-care handled by patients with limited capacities for taking responsibility and adhere to their own rational decisions. To improve this situation, we suggest a counseling, self-care, adherence approach to PCC/SDM, where more attention is given to how treatment goals are internalized by patients, how patients perceive choice situations, and what emotional feedback patients are given. This focus may involve less of a concentration on autonomous and rational clinical decision making otherwise stressed in standard PCC/SDM advocacy.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Use of the national quality registry to monitor health-related quality of life of children with type 1 diabetes: a pilot study

The management of diabetes is complicated, as treatment affects the everyday life of both children and their families. To enable optimal care for children with type 1 diabetes, it is important to highlight health-related quality of life (HrQoL) as well as medical outcomes to detect psychological problems that otherwise could be missed. The aim was to study HrQoL in children and adolescents with type 1 diabetes dependent on gender, age and co-morbidity and to study the consistency between children's self-reporting and parents' proxy reporting. The cross-sectional data were collected using the questionnaire DISABKIDS Chronic Generic Measure and the DISABKIDS diabetes module. Parents in the proxy report perceived their children's HrQoL to be lower than children themselves. Boys reported their HrQoL to be better than girls. Results show that living with an additional disease has an impact on the HrQoL, which is an important factor to consider in the quality registry. Assessing HrQoL on a routine basis may facilitate detection and discussion of HrQoL-related questions in the national quality registry.

Assessing diabetes-related quality of life of youth with type 1 diabetes in routine clinical care: the MIND Youth Questionnaire (MY-Q)

AIM

It is recommended to assess health-related quality of life (HRQoL) in teenagers with diabetes as part of their ongoing medical care. Here, we describe the development and psychometric evaluation of the Monitoring Individual Needs in Diabetes Youth Questionnaire (MY-Q), a multi-dimensional self-report HRQoL questionnaire designed for use in pediatric diabetes care.

DESIGN AND METHODS

In expert meetings, characteristics and domains of interest were defined. Existing questionnaires were reviewed, topics selected, and new items added, resulting in the 36-item MY-Q. To test face validity, we interviewed 22 teenagers. In addition, 84 teenagers with type 1 diabetes (age 10-18 yr) completed the MY-Q and Pediatric Quality of Life Inventory (PedsQL) generic and diabetes-modules to examine psychometric properties. Hemoglobin A1c (HbA1c) values were obtained by chart audit.

RESULTS

The MY-Q consists of seven subscales (social impact, parents, diabetes control perceptions, responsibility, worries, treatment satisfaction, and body image and eating behavior) as well as general HRQoL and emotional well-being. Cronbach's alpha for the total scale was 0.80. Strong correlations between MY-Q total and PedsQL generic and diabetes-module scores (r = 0.58 and r = 0.71, p < 0.001) confirmed concurrent validity. Higher HbA1c was associated with lower diabetes control perceptions (r = -0.35, p = 0.001), worries (r = -0.24, p = 0.029), and body image and eating behavior (r = -0.26, p = 0.019) scores. Younger age was associated with higher diabetes control perceptions (r = -0.26, p = 0.020) and body image and eating behavior (r = -0.23, p = .038), and lower responsibility (r = 0.25, p = 0.027) scores.

CONCLUSION

The MY-Q is the first HRQoL questionnaire designed for use in clinical care. It has acceptable measurement properties and seems suitable for implementation in routine care of teenagers with diabetes.

Assessment of psychosocial variables by parents of youth with type 1 diabetes mellitus

PURPOSE

To evaluate the impact of type 1 diabetes (T1D) on family functioning and child-rearing practices from parents' point of view, to assess parents' health-related quality of life and to explore the relations between psychosocial variables and diabetes care outcomes in youth with diabetes.

METHODS

This research was part of the cross-sectional multicenter Brazilian Type 1 Diabetes Study, conducted between December 2008 and December 2010 in 28 public clinics of 20 cities across four Brazilian geographical regions. Psychosocial questions were addressed to 1,079 parents of patients with T1D through an interview (89.3% mothers, 52.5% Caucasians, 38.6 ± 7.6 years old). Overall, 72.5% of the families were from low or very low socioeconomic levels. Parents were also submitted to health-related quality of life instruments (EQ-5D+EQ-VAS). Clinical data from the last medical appointment were collected by a physician using standardized chart review forms. The demographic, educational and socioeconomic profiles were also obtained and HbA1c levels registered.

RESULTS

Discomfort and anxiety/depression were the main complaints in EQ-5D, and were significantly more frequent in mothers (37.3% and 53.4%, respectively) than in fathers (25.7% and 32.7%, respectively). The mother was the only parent involved in diabetes care in 50.5% of the cases. The majority of parents (78.5%) mentioned changes in family functioning after the diagnosis, although they neither treated their diabetic children differently from the others (76.3%), nor set prohibitions (69.1%) due to diabetes. The majority was worried about diabetes complications (96.4%) and felt overwhelmed by diabetes care (62.8%). Parents report of overwhelming was significantly associated with anxiety/depression, as measured by the EQ-5D questionnaire. Less than half of the patients had already slept over, and the permission to do it increased as a function of children's age. Nearly half of the parents (52%) admitted to experiencing difficulties in setting limits for their children/adolescents. HbA1c levels in patients from this group (9.7 ± 2.5%) were significantly higher than those of children/adolescents whose parents reported no difficulties towards limit-setting (8.8 ± 2.1%). Parents whose children/adolescents reported the occurrence of hypoglycemic episodes in the last month complained significantly more about anxiety/depression (55.1%) than parents from patients who did not report it (45.7%). Also a significantly greater proportion of parents whose children/adolescents had been hospitalized due to hyperglycemia reported anxiety /depression (58.7%) than those whose children/adolescents had not been hospitalized (49.8%).

CONCLUSIONS

After the diagnosis of T1D, the lifestyle of all family members changes, what interferes with their quality of life. Mothers are still the primary caregivers for children/adolescents with diabetes. Difficulty to set limits for children/adolescents may be a risk for poor metabolic control. The study demonstrates the importance of family context in the adjustment of young patients to T1D. The specific needs of T1D patients and their impact on a family routine must be considered for future improvement on therapy elements and strategies.

The reliability of the disabled children's quality-of-life questionnaire in Swedish children with diabetes

AIM

To determine the reliability of the disabled children's quality-of-life measure (DISABKIDS) chronic generic questionnaire and diabetes module in children. The questionnaire is being evaluated for repeated routine health-related quality-of-life (HrQoL) assessment and in association with the Swedish national paediatric diabetes registry (Swediabkids), which is a tool for regular clinical use.

METHODS

Children and parents completed the questionnaire during a routine visit to the diabetes clinic. In total, 120 families completed the test and retest. Split-half reliability correlation and intraclass correlation (ICC) coefficients were calculated. Bland & Altman plots were calculated on the generic HRQoL domain.

RESULTS

Both child and parent versions showed good internal consistency. Test-retest ICC coefficients for the generic HrQoL module were 0.913 for the children and 0.820 for the parent version. All generic domains independently showed good reliability. The diabetes module had a score of 0.855 for children and 0.823 for parents. Split-half correlation for generic and diabetes modules was 0.930 and 0.848 for children, 0.953 and 0.903 for parents. Bland and Altman plots showed substantial agreement between the two administrations for both children and parents.

CONCLUSION

The DISABKIDS questionnaire is a reliable instrument for the repeated measurements of HrQoL in children with diabetes.

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

Background

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

Methods

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

Results

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

Conclusions

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

Psychological screening in adolescents with type 1 diabetes predicts outcomes one year later

AIMS

Adolescents with type 1 diabetes are at increased risk for depression and anxiety, which can adversely affect diabetes management, glycemic control, and quality of life (QOL). However, systematic psychological screening is rarely employed. We hypothesized that higher depression and anxiety screener scores would predict higher HbA1c, less frequent blood glucose monitoring (BGM), and poorer QOL one year later. Raw screener scores were expected to be more robust predictors than cutoff scores.

METHODS

150 adolescents age 13-18 with type 1 diabetes completed depression and anxiety screeners. One year later, blood glucose meters were downloaded to assess BGM frequency, HbA1c values were obtained, and caregivers rated the participants' QOL. Separate regressions were conducted for each outcome, including demographic and medical covariates.

RESULTS

Higher depression scores predicted less frequent BGM (b=-0.05, p<.05) and poorer QOL (b=-0.71, p<.01), and higher state anxiety scores predicted higher HbA1c (b=0.07, p<.05). Continuous screener scores identified risk for 12-month outcomes more robustly than clinical cut-off scores.

CONCLUSIONS

Psychological screeners predict diabetes outcomes one year later. Future clinical research studies should explore whether psychological screening and referral for appropriate intervention can prevent deteriorations in diabetes management and control commonly seen during adolescence.

Depressive symptoms and unmet psychological needs of Dutch youth with type 1 diabetes: results of a web-survey

OBJECTIVE

To examine rates of depression and (un)met psychological needs in youth with type 1 diabetes.

METHODS

An open-access web-survey was conducted, collecting data on demographics, self-reported HbA1c, depressive symptoms [Child Depression Inventory (CDI)], wished and received psychological care in youth with type 1 diabetes (9-19 years).

RESULTS

The survey was completed by 233 youth; 17.2% reported elevated depressive symptoms on the CDI, girls more than boys (p = 0.003). Half of the youth did not talk about their feelings with their pediatrician or nurse. Of those youth with elevated depressive symptoms, 28% received psychological care, 25% wished to see a psychologist and 47% did not think it was necessary to receive psychological support.

DISCUSSION

This web-survey confirms the high prevalence of elevated depressive symptoms in youth with type 1 diabetes and the urgency to address their psychological needs. Screening for depressive symptoms in the context of periodic outpatient consultation could improve early detection and treatment of emotional problems.

A multi-disciplinary education process related to the discharging of children from hospital when the child has been diagnosed with type 1 diabetes--a qualitative study

Background

Worldwide, insulin-dependent type 1 diabetes is one of the most frequently diagnosed long-term endocrine disorders found in children and the incidences of this diseased is still increasing. In Sweden the routines are, according to national guidelines, when the child is diagnosed with type 1 diabetes, the child and its family remains at the hospital for about two weeks. There is limited knowledge about how a diabetes team handles a child and its family from admission to discharge, therefore the purpose of this study was to seek a deeper understanding of how the diabetes team's parent/child education process works, from admission to discharge, among families with a child newly diagnosed with type 1 diabetes.

Methods

Qualitative data collection was used. Four focus-group interviews, with a sample of three diabetes teams from different paediatric hospitals in the south western part of Sweden, were conducted and the data recorded on tape and then analysed using qualitative content analysis.

Results

The results indicate that achieving a status of self-care on the part of the patient is the goal of the diabetes education programme. Part of the programme is aimed at guiding the child and its parents towards self-help through the means of providing them with knowledge of the disease and its treatment to enable the whole family to understand the need for cooperation in the process. To do this requires an understanding, by the diabetes team, of the individualities of the family in order to gain an overall picture.

Conclusion

The results of this study show that the diabetes education programme is specifically designed for each family using the internationally recommended clinical practice guidelines with its specific aims and objectives. Achieving the families' willingness to assist in the self-care of the child care is the goal of the parent education process. To achieve this, the paediatric diabetes specialist nurse and the diabetes specialist paediatrician immediately and deliberately start the process of educating the family using a programme designed to give them the necessary knowledge and skills they will need to manage their child's type 1 diabetes at home.

Follow-up results on monitoring and discussing health-related quality of life in adolescent diabetes care: benefits do not sustain in routine practice

OBJECTIVE

We previously demonstrated that adding monitoring and discussion of health-related quality of life (HRQoL) of adolescents with type 1 diabetes to routine periodic consultations positively impacts psychosocial well-being and satisfaction with care. The current study examines whether these positive effects are maintained 1 year after the intervention was terminated and patients received regular care again, with no formal HRQoL assessment.

PATIENTS AND METHODS

Forty-one adolescents with type 1 diabetes were followed for 1 year after the initial HRQoL intervention, in which their HRQoL had been assessed and discussed as part of period consultations using the PedsQL. Changes in physical and psychosocial well-being [Child Health Questionnaire-Child Form 87 (CHQ-CF87), diabetes family conflict scale (DFCS), Center for Epidemiological Studies scale for Depression (CES-D)], satisfaction with care [Patients' Evaluation of the Quality of Diabetes (PEQ-D) care], and glycemic control (HbA(1c)) were determined 12 months after the HRQoL intervention had ended.

RESULTS

One year after the HRQoL intervention, mean scores on CHQ subscales: behavior (p = 0.001), mental health (p = 0.004), and self-esteem (p < 0.001) had decreased, whereas the family activities subscale remained stable. Adolescents were less satisfied with their care (p = 0.012), and HbA(1c) values had increased significantly 12 months postintervention (p = 0.002).

CONCLUSIONS

The beneficial effects of an office-based HRQoL intervention in adolescents with diabetes largely disappear 1 year after withdrawing the HRQoL assessment procedure. This finding underscores the importance of integrating standardized evaluation and discussion of HRQoL in routine care for adolescents with diabetes.

Self-perceived health and burden of diabetes in teenagers with type 1 diabetes: psychometric properties of the Swedish measure 'check your health'

The aim of this study was to test the psychometric properties of the instrument 'Check your health' in teenagers with type 1 diabetes. The instrument measures 'self-reported health' and 'burden of diabetes'. A convenience sample of 199 teenagers, 12-17 years of age, completed the questionnaires 'Check your health' and DisabKids when visiting the diabetes clinic. Forty-seven patients completed the questionnaires at home a second time. In the reliability test, the correlation between test and retest was found to be satisfactory, (0.94-0.62, except for social burden, 0.41). Convergent validity was moderate (0.62-0.38), while the instrument showed good discriminant validity. Self-reported health and burden of diabetes were different in boys and girls, in patients with good or poor metabolic control or who reported high and low disease severity. The domain burden of diabetes turned out to be very sensitive.

CONCLUSION

The instrument 'Check your health' showed clinical utility in teenagers with diabetes. Reliability and validity tests of the measure showed promising results in Swedish teenagers, and it can probably be used in clinical settings. To further strengthen the convergent validity, it should be compared with other QoL instruments, and to obtain normative values, it has to be used in a larger context.

Cognitive functions and glycemic control in children and adolescents with type 1 diabetes

BACKGROUND

The relationship between metabolic control and cognitive function in adolescents with type 1 diabetes (DM type 1) is not clear. We compared the quality of glycemic control (GC) and cognitive measures in adolescents with DM type 1 to find out if the quality of diabetes management is related to cognitive impairment.

METHOD

We assessed executive functions (EFs) and other neuropsychological and psychosocial variables in 70 adolescent patients with DM type 1 and 20 age-matched controls. Patients were divided into two groups according to their last hemoglobin A1c (HbA1c): acceptable (HbA1c 5.9-8.0%, mean 6.9%, 36 patients, mean age 14 years) and non-optimal (HbA1c 8.2-11.6%, mean 9.3%, 34 patients, mean age 15.6 years).

RESULTS

We found impaired EFs, mainly problems of concept formation (p=0.038), cognitive flexibility (p=0.011) and anticipation (p=0.000), in the patients with DM type 1. Both groups did not differ in intelligence, most assessed EFs and adjustment to chronic illness (Youth Self-Report; YSR). Younger patients (<15 years) were cognitively less flexible. GC was worse in older patients and in patients with longer duration of the disease. We also found significant differences between patients with diabetes and controls concerning somatic complaints, internalizing problems (Child Behavior Checklist; CBCL) and social activity (CBCL and YSR).

CONCLUSIONS

DM type 1 is associated with cognitive deficits in adolescents independent of the quality of metabolic control and the duration of the disease. These deficits are probably related to the disease, especially in patients with early-onset diabetes.

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

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

Chronic sorrow in parents of children with type 1 diabetes

AIM

This paper reports on a study exploring parents' longer-term experiences of having a child with type 1 diabetes.

BACKGROUND

Parents of children with type 1 diabetes may experience a grief reaction at diagnosis similar to that normally associated with bereavement, but little is known about their long-term emotional adaptation. Chronic sorrow, a sustained but intermittent grief reaction, is identified in adults with diabetes but has not previously been explored in relation to parents.

METHODOLOGY

In-depth interviews were conducted in 2007 with a convenience sample of 17 parents of children with type 1 diabetes 7-10 years after diagnosis. Data were explored within a theoretical framework of grief, loss, adaptation, and change.

FINDINGS

Parents had adapted to the needs of diabetes management but most had not 'come to terms' with the diagnosis. They experienced a resurgence of grief at critical times during their child's development and some, particularly mothers, became upset during their interviews, even though these took place 7-10 years after their child's diagnosis. Mothers elaborated more on their emotions than fathers, but continuing feelings associated with grief, such as anger and guilt, were expressed by both fathers and mothers.

CONCLUSION

Greater understanding of parents' long-term emotional responses and recognition that grief may never resolve in these parents may enable healthcare professionals to provide appropriate and timely support at critical times.

Explaining the adjustment of adolescents with type 1 diabetes: role of diabetes-specific and psychosocial factors

OBJECTIVE

The aim of this study was to explain adjustment (diabetes-related quality of life, general well-being, and psychopathology) in adolescents with type 1 diabetes by testing the direct, mediating, and moderating effects of diabetes-specific and psychosocial factors, using an adapted version of the Disability-Stress-Coping model of Wallander and Varni.

RESEARCH DESIGN AND METHODS

A total of 437 adolescents (54.5% girls; age range 11-19 years) with type 1 diabetes (mean +/- SD diabetes duration 6.13 +/- 3.78 years) were recruited from 25 hospitals in the Netherlands. Questionnaires were completed by the adolescents and their family members. Metabolic control was assessed by measuring A1C in all participants in one laboratory.

RESULTS

Diabetes stress mediated between A1C and adjustment, after controlling for protective factors, and explained an additional 16% variance in quality of life and a 15% variance in general well-being, whereas a 19% additional variance in psychopathology was explained by both diabetes-related and general stress. No moderating effects were identified after controlling for the main effects of all risk and protective factors in the model.

CONCLUSIONS

Both diabetes-related and general stress are critical predictors of the adjustment of adolescents with type 1 diabetes. Protective factors such as self-worth and social support may mediate the effects of generic stress and thus should be encouraged. Diabetes-related stress has the potential to displace the effects of protective factors and thus may play a critical role in the development of maladjustment in adolescents with type 1 diabetes.

Blocking of beta-2 adrenergic receptors hastens recovery from hypoglycemia-associated social withdrawal

OBJECTIVE

Hypoglycemia is associated with a variety of adverse behaviors including fatigue, confusion and social withdrawal. While these clinical symptoms are well characterized, the mechanism of their cause is not understood. Here we investigated how insulin-induced hypoglycemia causes social withdrawal.

RESEARCH DESIGN AND METHODS

Male 8-12-week-old C57BL/6J mice were injected intraperitoneally (IP) with or without and/or insulin, norepinephrine (NE) and epinephrine (Epi), terbutaline and butoxamine with subsequent measurement of blood glucose, social withdrawal and plasma catecholamines.

RESULTS

Insulin generated (0.75h post-injection) significant hypoglycemia with blood glucose nadirs of 64+/-4 and 48+/-5mg/dl for 0.8 and 1.2units/kg of insulin, respectively. Insulin (0.8 or 1.2units/kg) caused near total social withdrawal at 0.75h with full recovery not occurring until 4h (0.8units/kg) or 8h (1.2units/kg) post-insulin injection. Insulin also caused a marked elevation in plasma catecholamines. Basal 12h fasting NE and Epi were 287+/-38 and 350+/-47pg/ml, respectively. Insulin at 0.8units/kg increased plasma NE and Epi to 994+/-73 and 1842+/-473pg/ml, respectively. Administration of exogenous NE or Epi caused social withdrawal similar in magnitude to insulin. Importantly, administration of the beta-2 adrenergic receptor agonist terbutaline also caused social withdrawal while administration of the beta-2 adrenergic receptor antagonist butoxamine blocked NE-induced social withdrawal. Finally, butoxamine blocked insulin-induced social withdrawal.

CONCLUSIONS

These data demonstrate that hypoglycemia-associated social withdrawal is dependent on catecholamines via a beta-2 receptor-mediated pathway.

Monitoring and discussing health-related quality of life in adolescents with type 1 diabetes improve psychosocial well-being: a randomized controlled trial

OBJECTIVE

To test the effects of monitoring and discussing of health-related quality of life (HRQoL) in adolescents with type 1 diabetes in a multicenter randomized controlled trial.

RESEARCH DESIGN AND METHODS

Four centers were randomly assigned to the HRQoL intervention (46 adolescents) or control (45 adolescents) group, with three regular visits scheduled within 12 months in both groups. In the HRQoL intervention group, HRQoL of adolescents was assessed using the Pediatric Quality of Life Inventory, and outcomes were discussed face-to-face during the consultation. The control group received care as usual. Mean differences between the groups at 12 months in physical and psychosocial well-being (Child Health Questionnaire [CHQ]-CF87/PF50, Diabetes-Specific Family Conflict Scale, and Center for Epidemiological Studies Scale for Depression), satisfaction with care (Patients' Evaluation of the Quality of Diabetes Care), and A1C were determined, controlling for baseline scores.

RESULTS

Mean scores on the CHQ subscales of psychosocial health (P < 0.001), behavior (P < 0.001), mental health (P < 0.001), and family activities (P < 0.001) improved in the HRQoL intervention group, except for adolescents with the highest A1C values. Adolescents in the HRQoL intervention group reported higher self-esteem (CHQ) at follow-up (P = 0.016), regardless of A1C, and were more satisfied with care (P = 0.009) than control subjects. No significant differences between the two groups over time were observed in A1C levels.

CONCLUSIONS

Periodic monitoring and discussion of HRQoL in adolescents with diabetes is appreciated and has positive effects on their psychosocial well-being, except for those in poorest control.

Pontos básicos de um programa de educação ao paciente com diabetes melito tipo 1

O número de portadores de diabetes melito tipo 1 (DM1) está aumentando globalmente, entretanto, a maior parte dos pacientes apresenta controle glicêmico insatisfatório. Esta revisão na literatura foi realizada com três questões de pesquisa: Quais as recomendações e diretrizes de educação em diabetes existentes? Existem evidências para recomendar a adaptação de determinado programa segundo a faixa etária dos pacientes? Os programas de educação são efetivos na melhora dos níveis de HbA1c? Foram revisados 40 artigos, publicados entre 2000 e 2007, sobre educação em DM1 em crianças, adolescentes, adultos e usuários de bomba de infusão contínua de insulina, além de incluir o resumo das diretrizes da IDF, da ADA, da SBD, da AADE, do IDC, e outras peculiaridades para o contexto de saúde pública e privada. O portador de diabetes e sua família devem ser treinados a fazer decisões efetivas de autocuidado em sua rotina diária. O aprimoramento do paciente no automanejo aproxima o valor da HbA1c ao adequado para sua faixa etária. A educação individual e a em grupo apresentam equivalência na melhora do controle metabólico. Existe uma correlação positiva entre o tempo de educação e o controle da glicemia.