Assuming responsibility for diabetes management: what age? What price?

Medical Neglect in Children and Adolescents with Diabetes Mellitus

Diabetes mellitus was a fatal disease for thousands of years, but the discovery of insulin in 1921 and major substantial improvements in care have made living with diabetes a chronic rather than fatal disease for many people, including children and adolescents. Diabetes mellitus is a lifestyle-altering diagnosis for the entire family. In some families, children and adolescents do not get the daily care they depend upon. This article reviews the consequences of medical neglect of children with diabetes and the optimal community response to concerns of medical neglect of diabetes. Criteria for placement in foster or substitute care are suggested.

Keeping parents connected in early emerging adulthood: Diabetes-related disclosure and solicitation

Emerging adults with Type 1 diabetes benefit when parents remain knowledgeable of their self-management. Yet how early emerging adults remain connected with parents while they experience normative declines in involvement and move out of the parental home is unclear. The present study examined how disclosure to, and solicitation from, parents may (a) be a way that emerging adults and parents remain connected, (b) occur with different methods of contact (i.e., face-to-face; non-face-to-face), and (c) associate with diabetes management differently for those living in versus outside of the parental home. Early emerging adults with Type 1 diabetes (N = 202; Mage = 18.81 years; 66% female) completed measures of their methods of contact with parents; diabetes-related disclosure to, and solicitation from, parents; and diabetes management as part of a 14-day daily diary. General linear models found that face-to-face contact was associated with greater disclosure to parents, for both those living in and out of the parental home. Individuals who lived outside the parental home used more non-face-to-face contact (e.g., texting) than those in the parental home. Multilevel models revealed that higher disclosure to mothers on a daily basis (within-persons) and to mothers and fathers overall (between-persons) was associated with better diabetes management similarly for those living in versus out of the parental home. Results suggest that face-to-face contact may be most effective for keeping parents "in the know" about diabetes management. Moreover, disclosure and solicitation continue to support diabetes management even as individuals move out of the parental home. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Self-Care and Self-Management Among Adolescent T2DM Patients: A Review

Uncontrolled hyperglycaemia can lead to macro- and microvascular complications. Adolescents with T2DM develop similar complications as in adults, including cardiovascular disease, stroke, myocardial infarction, renal insufficiency, and chronic renal failure. Although regular medical follow-up is essential to avoid long-term complications, patients with diabetes mellitus need to perform holistic self-care activities such as opting for a healthy diet, physical activity, self-monitoring, and proper medication. To the best of our knowledge, only a limited number of studies have focused on self-care activities and self-management, including self-care practices, supportive networks, and self-care education programs in adolescent with T2DM. Some of the studies focused on the appreciation of self-care in adolescents with T2DM. This review aimed to analyse self-care and self-management among adolescents with T2DM, and discuss the impact of self-care and self-management on glycaemic control. The difficulties faced by adolescents in self-managing their disease are also highlighted. Such information is essential for healthcare providers in promoting self-care practices among adolescents with T2DM. A thorough search of the literature was performed using three databases: Medline, Google Scholar, and Scopus. The articles focused on self-care and self-management of adolescents patients with T2DM aged between 12 and 19 years old were included. Findings from this review reveal that healthy food adaptation, adequate physical activity, proper medication practices, and regular glucose monitoring are the most common self-care practices. Parental involvement and clinician encouragement also contribute toward the practice of self-care and self-management among the adolescents with T2DM. In conclusion, independent self-management regimens and supportive networks for appropriate administration are vital factors to enhance clinical outcomes of adolescents with T2DM.

Close relationships and diabetes management across the lifespan: The good, the bad, and autonomy

Relationships are linked with positive and negative self-management and illness outcomes for individuals with type 1 diabetes. Explanations for these mixed associations have remained separated in psychosocial research in type 1 diabetes by relationship type (e.g. parent vs spouse) and individual's age (e.g. adolescence vs older adulthood). In this conceptual review, we present a novel perspective that close relationships across the lifespan may be beneficial for illness self-management when they support individuals' sense of autonomy, defined from a Basic Psychological Needs perspective. Processes of autonomy support are crucial for promoting illness management across all ages and relationship types.

Caregiving for children with type 1 diabetes and clinical outcomes in central India: The IDREAM study

AIMS

Parental care influences outcomes for children's type 1 diabetes (T1D). There is little evidence about the impact of parental caregiving in developing countries, where fixed dose human insulin (conventional) therapy and limited self-monitoring of blood glucose are common. This article investigates whether performance of key T1D management tasks by children or their caregivers impacts hemoglobin A1c (HbA1c).

METHODS

We surveyed the caregivers of 179 children with T1D routinely treated in a specialized diabetes clinic in Maharashtra, India to determine who performs key diabetes care tasks: child or parent. We used linear regression to estimate the relationship between parental caregiving and HbA1c, and how this association varies by child age and time since diagnosis.

RESULTS

Caregivers of older children were less involved in care tasks, though caregivers of 11- to 18-year olds performed more care for children diagnosed for a longer duration. Parental involvement in key insulin delivery tasks was associated with lower HbA1c levels for all children. These reductions were greatest among children 11 to 14 years old and diagnosed for less than 2 years: mean HbA1c levels were 8.5% (69 mmol/mol) if the caregiver, and 14.4% (134 mmol/mol) if the child, performed the tasks (P < .05).

CONCLUSION

Parents of children diagnosed with T1D early in life remain involved in care throughout the child's adolescence. Parents of children diagnosed in late childhood and early adolescence are significantly less involved in care, and this is associated with worse glycemic control. Clinics must know who performs care tasks and tailor diabetes education appropriately.

Improving School Experiences for Adolescents With Type 1 Diabetes

BACKGROUND

Diabetes mellitus (diabetes) is one of the most common metabolic diseases in children worldwide and the incidence of type 1 diabetes (T1D) is growing. T1D is complicated to manage and adolescents with diabetes face unique, age-specific challenges. The purpose of this article is to discuss ways in which schools can create a positive environment and improve the experiences and outcomes for adolescents with T1D.

METHODS

The Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed databases were searched and yielded a total of 27 articles that were used in this integrative literature review.

RESULTS

Common concerns identified by students with T1D and their parents included a lack of full-time school nurses, lack of teacher knowledge of diabetes, lack of access to diabetes tools, lack of freedom to perform diabetes self-care, lack of nutritional information in cafeterias, and lack of communication between parents and school personnel. Students who are unable to attend school on a daily basis may not be able to achieve their academic potential.

CONCLUSIONS

Implications for school health including specifics for school nurses, teachers, students, and school environment were identified.

The Lived Experience of Adolescent Females With Type 1 Diabetes

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Timing the transfer of responsibilities for anaphylaxis recognition and use of an epinephrine auto-injector from adults to children and teenagers: pediatric allergists' perspective

BACKGROUND

The optimal time for transferring responsibilities for anaphylaxis recognition and epinephrine auto-injector use from adults to children and teenagers has not yet been defined.

OBJECTIVE

To determine whether pediatric allergists have age-specific goals for beginning to transfer responsibilities for anaphylaxis recognition and epinephrine auto-injector use from parents and caregivers to children and teenagers at risk of anaphylaxis in the community.

METHODS

Members of the American Academy of Pediatrics Section on Allergy and Immunology (AAP-SOAI) were surveyed about when they typically begin to transfer these responsibilities from adults to children and teenagers.

RESULTS

Eighty-eight allergists responded to the survey, 97.7% of whom provided service to children and teenagers with food allergies. Few allergists expected to begin transferring responsibilities for anaphylaxis recognition and epinephrine auto-injector use to children younger than 9 to 11 years. By the time their patients reached age 12 to 14 years, however, most allergists expected them to be able to describe some anaphylaxis symptoms (95.4%), demonstrate how to use an epinephrine auto-injector trainer (93.1%), begin carrying self-injectable epinephrine (88.2%), recognize the need for epinephrine (88.1%), learn to self-inject epinephrine (84.5%), and be able to self-inject epinephrine (78.6%) (cumulative data). The allergists rated the following as "very important" readiness factors for beginning to transfer responsibilities: medical history, developmental level, and ability to demonstrate auto-injector technique.

CONCLUSION

Most pediatric allergists expected that by age 12 to 14 years, their patients should begin to share responsibilities with adults for anaphylaxis recognition and epinephrine auto-injector use; however, they individualized the timing based on assessment of patient readiness factors.

A concept analysis: assuming responsibility for self-care among adolescents with type 1 diabetes

PURPOSE

This concept analysis clarifies "assuming responsibility for self-care" by adolescents with type 1 diabetes.

METHODS

Walker and Avant's (2005) methodology guided the analysis.

RESULTS

Assuming responsibility for self-care was defined as a process specific to diabetes within the context of development. It is daily, gradual, individualized to person, and unique to the task. The goal is ownership that involves autonomy in behaviors and decision-making.

PRACTICE IMPLICATIONS

Adolescents with type 1 diabetes need to be assessed for assuming responsibility for self-care. This achievement has implications for adolescents' diabetes management, short- and long-term health, and psychosocial quality of life.

Health literacy and child health outcomes: a systematic review of the literature

OBJECTIVES

To review the relationship between parent and child literacy and child health outcomes and interventions designed to improve child health outcomes for children or parents with low literacy skills.

METHODS

We searched Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for articles published from 1980 through 2008 and included studies that reported original data, measured literacy and >or=1 health outcome, and assessed the relationship between literacy and health outcomes. Health outcomes included health knowledge, health behaviors, use of health care resources, intermediate markers of disease status, and measures of morbidity. Two abstractors reviewed each study for inclusion. Included studies were abstracted into evidence tables and were assessed by using an 11-item quality scale.

RESULTS

We reviewed 4182 new titles and abstracts published since 2003. Fifty-eight articles were retained for full review, and 13 met the inclusion criteria. Eleven articles from the systematic review from 1980 to 2003 met the inclusion criteria, giving us a total of 24 articles. Children with low literacy generally had worse health behaviors. Parents with low literacy had less health knowledge and had behaviors that were less advantageous for their children's health compared with parents with higher literacy. Children whose parents had low literacy often had worse health outcomes, but we found mixed results for the relationship of literacy to the use of health care services. Interventions found that improving written materials can increase health knowledge, and combining good written materials with brief counseling can improve behaviors including adherence. The average quality of the studies was fair to good.

CONCLUSIONS

Child and parent literacy seems associated with important health outcomes. Future research can help us understand under what circumstances this relationship is causal, how literacy and health outcomes are related in noncausal pathways, the relative importance of parent and child literacy, and what interventions effectively reduce health literacy-related disparities.

Stress management training in diabetes mellitus

Good diabetic control minimizes the risk of complications. Stress affects control directly through the release of hormones and indirectly by disrupting self-management activities. This review examines the impact of stress management interventions on glycaemic control. Qualifying studies since 1980 were identified using searches of Medline and PsycInfo databases. Ten were identified in adult populations, and four in adolescent populations. The general trend suggested that stress management interventions may be useful in management of diabetes. Further research will provide greater understanding of the particular benefits of various components of stress management training in relation to specific subgroups of the diabetic population.

Adherence to nasal positive airway pressure therapy among school-aged children and adolescents with obstructive sleep apnea syndrome

OBJECTIVES

Although many children with obstructive sleep apnea syndrome have complete resolution of obstructive sleep apnea syndrome after adenotonsillectomy, some patients have persistent obstructive sleep apnea syndrome requiring positive airway pressure treatment. Little is known about positive airway pressure adherence among school-aged children and adolescents.

PATIENTS AND METHODS

We retrospectively reviewed records from January 2000 through December 2004 to assess positive airway pressure adherence following a comprehensive patient- and parent-focused positive airway pressure education program for children 7 to 19 years of age with persistent obstructive sleep apnea syndrome subsequent to indicated adenotonsillectomy. A polysomnogram was obtained before and after initiation of positive airway pressure therapy. Adherence was defined as > 4 hours per night and > or = 5 nights per week of positive airway pressure use. Clock-counter meters determined hours per night and nights per week of positive airway pressure use; parents estimated hours per night of positive airway pressure use. Nonparametric tests assessed associations between adherence and various clinical parameters and symptoms.

RESULTS

Forty-six patients (56% male; 39% black, 61% white; mean age: 13.6 years; mean BMI: 39.8 kg/m2) were included. Two refused positive airway pressure. Meter readings were available for 27 patients (59%); positive airway pressure was used, on average, 7.0 hours per night, 73% of the week, and for a mean of 18.1 months. Nineteen (70%) were adherent regardless of age. There was good agreement between parental report and meter readings. Patients with greater improvement in apnea-hypopnea index were more likely to be adherent. Clinical parameters and symptoms improved after positive airway pressure therapy regardless of age or adherence.

CONCLUSIONS

In this retrospective study, positive airway pressure adherence and symptom improvement among school-aged children and adolescents was achieved with comprehensive patient and parent education and follow-up.

SELF-CARE IN CHILDREN WITH TYPE 1 DIABETES

PURPOSE

To provide insight into mothers' perceptions of their children's development of diabetes-related capabilities and identify factors that influence these capabilities.

STUDY DESIGN AND METHOD

Mothers' perceptions of children's self-care practices were solicited using an 84-item fixed choice instrument authored by this investigator. Items that were based on the literature and results of a preliminary qualitative study solicited information regarding self-care practices, independence in management, parental involvement, dietary adherence, precision in skills, attitude about diabetes, and ability to manage abnormal blood glucose levels. Descriptive statistics were used to analyze the data.

RESULTS

Forty-six boys and 42 girls aged 6 to 18 years were represented by the 88 mothers in this study. According to the mothers, children demonstrated higher levels of self-care abilities, independence, precision, and ability to manage blood glucose levels as they aged. The mothers believed, however, that older children had more negative attitudes about diabetes than did younger children. Girls learned skills earlier and were more independent in diabetes-related self-care, yet they had more difficulty than boys in adhering to dietary requirements. Some findings indicated the children engaged in behaviors that were potentially life-threatening or at least deleterious to their future health.

CLINICAL IMPLICATIONS

Nurses can use this study to help encourage parents to stay involved with their children's self-care practices into the adolescent years. Providing opportunities for communication with others who have type 1 diabetes should be encouraged. Knowledge of age and gender differences can help establish realistic expectations for self-care.

Type 1 Diabetes

Type 1 diabetes is a tremendously challenging and complex disease for children and families to manage. Advances in research are constantly bringing about changes in therapies and treatments with the hope of improving the quality of life for youth with type 1 diabetes and their families. Accurate diagnosis, education, treatment, and referral to a certified diabetes educator, endocrinologist, dietitian, social worker, and psychologist are needed to provide the child with the skills necessary to manage diabetes over a lifetime. Nurses and nurse practitioners must be informed of the most current treatments and research available for their patients so that they can encourage their patients to live full and healthy lives.

Social support and diabetes management in childhood and adolescence: influence of parents and friends

This paper reviews the empirical research literature on the role of social support in children and adolescents with diabetes. Studies on the role of parental involvement in diabetes management suggest that premature withdrawal of parental involvement is associated with poor diabetes outcomes, whereas continued parental support and monitoring is associated with better outcomes among adolescents. Research on social support from friends suggests that friends can be a unique source of support that complements parents' involvement and improves adolescents' diabetes management.

Increasing problem solving in adolescents with type 1 diabetes: the choices diabetes program

The purpose of this pilot study was to test the hypothesis that adolescents with type 1 diabetes can learn to become better problem solvers in diabetes self-care and thereby improve their metabolic control.

METHODS

Fifty-three adolescents aged 13 to 17 with type 1 diabetes were randomly assigned to either a 6-week problem-solving diabetes education program or to a control group (usual care). A1C levels were obtained as well as assessments of problem solving, frequency of behavior, level of responsibility, and 24-hour behavior recall at baseline and 6 months.

RESULTS

The experimental group participants showed significantly improved problem-solving test scores and A1C values from baseline to 6 months, changes not evident in the control group. At 6 months, the experimental group participants were doing blood glucose testing more often than those in the control group. However, there was no significant difference in problem-solving test scores or A1C values.

CONCLUSIONS

This 6-week intervention for adolescents with diabetes resulted in better problem-solving skills, more frequent blood glucose testing, and improved A1C values. The results suggest that a diabetes problem-solving program for adolescents can be effective in improving metabolic control.

The concept of self-management of type 1 diabetes in children and adolescents: an evolutionary concept analysis

AIM

An evolutionary concept analysis was undertaken to clarify the concept of self-management of type 1 diabetes in children and adolescents.

BACKGROUND

Several problems exist in the literature on self-management of type 1 diabetes in children and adolescents. There is no uniform terminology and there is no uniform definition of the concept. Also, there is no differentiation in the literature between self-management of diabetes in children and adults.

METHODS

Ninety-nine references were reviewed and analysed in the disciplines of nursing, medicine, and psychology. After separate analyses revealed no significant differences across disciplines, the analyses were combined to describe the attributes, antecedents, consequences, and surrogate and related concepts.

RESULTS

The three essential attributes of the concept were identified as process, activities, and goals. Self-management of type 1 diabetes in children and adolescents is an active and proactive process; it is daily, lifelong, and flexible, and it involves shifting and shared responsibility for diabetes care tasks and decision-making between child and parent. It is a process that involves collaboration with health care providers. Self-management of type 1 diabetes in children and adolescents also consists of varied and many activities related to giving insulin, monitoring metabolic control, regulating diet and exercise, to name just a few. The concept also involves goals, which may differ from one parent/child dyad to another. A working definition of the concept is suggested.

CONCLUSIONS

It is hoped that a more uniform definition of the concept will enable researchers to continue investigating antecedents and consequences of the concept in a way that allows for aggregating results.

[Analysis of difficulties related with the daily activities of adolescents and children with type-1 diabetes mellitus: mothers' accounts]

This descriptive study aimed at analyzing the difficulties faced by mothers of type-1 diabetic teenagers and children in view of the child's daily activities and based on the principle that emotional, social, personal and economic factors concerning the family interfere with achieving good metabolic control. Data were obtained by means of a semi-structured interview guide applied to 30 mothers. Data analysis followed the standards preconized for descriptive studies in which directed interviews are used. Results showed that: mothers have difficulties in dealing with children's daily activities such as social gatherings, in motivating them to develop physical activities, diet, school adjustment, relationship with the health team as well as with the children's behaviors regarding their brothers/sisters. Results indicated the need for planned and integrated work by a multiprofessional team with the families, considering all the aspects addressed in this study and their interdependence, aiming at a successful care to diabetic children and adolescents.

Development of the diabetes problem-solving measure for adolescents

PURPOSE

This paper describes the development and psychometric properties of the Diabetes Problem-Solving Measure for Adolescents (DPSMA).

METHODS

The DPSMA is a structured, interview-based questionnaire that examines how adolescents with type 1 diabetes solve diabetes-related self-management problems. Seventeen diabetes-related self-management problem vignettes were derived from a survey of adolescents and their parents. The vignettes were reviewed and finalized by a multidisciplinary team of diabetes experts. A sample of 43 adolescents, 13 to 17 years old, with type 1 diabetes, was used to establish the psychometric properties of the instrument.

RESULTS

The scale demonstrated acceptable internal consistency and interrater reliability. Predicted relationships with scores on concurrently administered measures of adherence, diabetes quality of life, and metabolic control provided support for construct validity.

CONCLUSIONS

The results suggest that the DPSMA has acceptable internal consistency, interrater reliability, and construct validity. It may be a useful tool to help healthcare providers understand the diabetes-related problem-solving abilities of their adolescent patients.

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

PURPOSE

To examine the following questions with regard to the initiation of a new intensive management program for adolescents with Type 1 diabetes mellitus: (a) What clinical and psychosocial factors are associated with achievement of metabolic control treatment goals after 1 year? and (b) What baseline clinical and psychosocial factors are associated with improvement in the quality of life after 12 months?

METHODS

Eighty-one subjects (of 83 who began; aged 14.3 +/- 2.0 years at entry; 48 females, 33 males; 95% white; diabetes duration 8.9 +/- 3.9 years) with Type 1 diabetes completed 12 months of follow-up in a study of intensified treatment of diabetes. Assessments at baseline and at 12 months used the Diabetes Quality of Life for Youth scale, the Self-efficacy for Diabetes Scale, the Children's Depression Inventory, the Issues in Coping with Diabetes Scale, and the Diabetes Family Behavior Scale. Data were analyzed using multiple and logistic regression.

RESULTS

From a baseline of >9%, HbA1c levels decreased to a mean of 7.8 +/- 0.7%, with 30% of the subjects achieving our treatment goal of <or=7.2%. Logistic regression demonstrated that achievement of goal levels of HbA1c were associated with better metabolic control at study entry (p = .05), participation in coping skills training (p = .003), and more parental participation in guidance and control (p = .05). Multiple regression analysis demonstrated that participation in coping skills training with lower impact of diabetes on quality of life at baseline and less depression at baseline contributed significantly to the variance (0.57) in quality of life at 12 months.

CONCLUSIONS

Providers need to pay particular attention to adolescents with poorer metabolic control and impact of diabetes on quality of life when they intensify their treatment because they are less likely to reach treatment goals. Furthermore, behavioral interventions such as coping skills training may help teens achieve their goals.

[Insulin self administration in children with diabetes mellitus, type 1]

The present descriptive study had the goals of characterizing type 1 diabetic children, according to socio-demographic variables and identifying the difficulties related to insulin self-management and home control. 34 type 1 diabetic children were interviewed at a big hospital. Results showed that 82.4% of children were white, 61.8% were female and 54.1% were from nine to eleven years of age, 67.7% were catholic, and 64% had the illness for 3 years. 35.3% of them learned insulin management with their mothers and 32.3% follow a schedule regarding insulin self-administration. Difficulties to perform home control are related to the available resources and lack of information. Results show the need for a planned work integrated by a multiprofessional team and directed to the children whose characteristics meet the mentioned aspects, considering their interdependence and aiming at achieving a successful career.

A summer vacation from diabetes: evidence from a clinical trial

PURPOSE

This study examined the metabolic trend and factors associated with an unexpected rise in HbA1c levels during the summer, with a return to baseline when school resumed, in 40 intensively treated adolescents with type 1 diabetes.

METHODS

Psychosocial data were collected using a variety of diabetes evaluation instruments. HbA1c was measured monthly.

RESULTS

HbA1c values increased by a mean of .73% from May to July and decreased by a mean of .75% from August to October. Lack of consistency in summer routines compared with school days was associated with a worsening in metabolic control during the summer months. Other factors associated with the summer increase in HbA1c included lower guidance scores on the Diabetes Family Behavior Scale, and higher impact and worry scores on the Diabetes Quality of Life for Youth Scale.

CONCLUSIONS

Interviews suggested that teenagers need to take a vacation from intensive diabetes care during the summer.

Comparison of mother-father perceptions of their child's self-management of diabetes

This study compared mothers' and fathers' perceptions of their children's self-management of diabetes. Participants included a subsample of 29 paired parents of children and youth with diabetes, ages 8-14, who attended a diabetes camp in the Midwest. Parents completed a self-report structured questionnaire that included content specific to self-management. Results showed high ratings for child responsibility for self-management, style of care delivery, and mother-father self-efficacy in managing specific tasks of diabetes self-management. Although overall ratings were similar, in the majority of measures mothers' ratings were higher than fathers' ratings. Areas of similarity and significant differences in perceptions are identified with implications for practice stated.

Parental involvement in diabetes management tasks: relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus

OBJECTIVES

The goal of this study was to identify parental behaviors that relate to adherence and metabolic control in a population of young adolescents with insulin-dependent diabetes mellitus (IDDM), and to understand the interrelationships among the variables of parental involvement, adherence to blood glucose monitoring, and glycemic control.

STUDY DESIGN

A cross-sectional design was used to investigate parental involvement in diabetes regimen tasks in 89 youth, aged 10 to 15 years, with IDDM. Levels of parental involvement in blood glucose monitoring (BGM) and insulin administration were evaluated through interviews. Assessment of adherence was made by physicians or nurses, independent of patient or parent reports of adherence. Glycemic control was assessed with glycosylated hemoglobin (HbA1c) (reference range, 4% to 6%).

RESULTS

There were significant differences in the mean HbA1c values between the older (13 to 15 years of age) (HbA1c = 8.9% +/- 1.03%) and younger (10 to 12 years) patients (HbA1c = 8.4% +/- 1.06%) (p < 0.02). Parental involvement in BGM was significantly related to adherence to BGM (number of blood sugar concentrations checked daily) in both groups of adolescent patients. The younger patients monitored their blood glucose levels more frequently than did the older patients, 39% of the younger patients checked sugar concentrations four or more times daily compared with only 10% of the older group (p < 0.007). In a multivariate model controlling for age, gender, Tanner staging, and duration of diabetes, the frequency of BGM was a significant predictor of glycemic control (R2 = 0.19, p < 0.02). Increased frequency of BGM was associated with lower HbA1c levels. When the frequency of BGM was zero or once a day, the mean HbA1c level was 9.9% +/- 0.44 (SE); when the frequency of BGM was two or three times a day, the mean HbA1c level was 8.7% +/- 0.17; and when the frequency of BGM was four or more times daily, the mean HbA1c level was 8.3% +/- 0.22.

CONCLUSIONS

Parental involvement in BGM supports more frequent BGM in 10- to 15-year-old patients with IDDM. This increased adherence to BGM is associated with better metabolic control (i.e., lower HbA1c levels). These findings suggest that encouraging parental involvement in BGM with 10- to 15-year-old patients with IDDM may help to prevent the well-documented deterioration in glycemic control and adherence to treatment that often occurs in later adolescence.

Psychometric properties and normative data for the parent version of the diabetes independence survey

The parent version of the Diabetes Independence Survey measures parents' perceptions of their children's mastery of 38 diabetes self-care skills. The instrument was administered to 648 parents of 622 children with insulin-dependent diabetes mellitus, ages 3 and 18 years, at seven different pediatric medical centers. Data confirming the internal consistency, interrater reliability, construct validity, and concurrent validity of the instrument are presented in this paper. Age-adjusted normative data for total scores on the instrument as well as item-by-item data on the ages at which mastery of each skill was reported by 25%, 50%, and 75% of parents also are discussed. The Diabetes Independence Survey can be used as a reliable, valid, and efficient research tool for assessing the growth and development of diabetes knowledge and skills among children and adolescents, and as a screening instrument and program evaluation tool for clinical purposes.

Family responses to children with diabetes and their influence on self-care

This study describes family responses to school-age children with diabetes and the influence of parents and siblings on self-care. Semistructured interviews of seven families living in a rural area of the Midwest were conducted. Major family responses included reminiscing about the time of diagnosis, changing the diet, scheduling daily routines, coping with and managing the diabetes, and worrying about insulin reactions. Mothers were the primary managers of the diabetes regimen. Blood-testing and self-injections were encouraged during less hurried times, particularly evenings and weekends.

Early onset diabetes: parents' views

During 1990-91 postal questionnaires were sent to the parents of 309 children living in the United Kingdom who developed diabetes before the age of 2 years during 1972-1981. The aim of the survey was to explore how they had coped with their child's condition. Completed questionnaires were returned by 85% of parents. The children had a mean age of 14 (range 9-19) years and diabetes for a mean duration of 13 (range 9-18) years. The cohort's mean age for starting self-injection was reported to be 8 years and most of the children (82%) were still attending full-time education. Diabetes-related difficulties of school were reported for 34% (95% C I 28-40) of the children and 70 (27%, 95% C I 22-32) were estimated to have missed more schooldays than their peers. With increasing duration of diabetes, parents expressed a reduction in anxiety about practical aspects of management such as injections and monitoring, but concern about hypoglycaemia and long-term vascular complications remained high. Parents of girls were more likely to express worries compared to parents of boys, and this excess was significant for worry about diet (chi 2 1df = 17.021, p < 0.001). The paediatric diabetes team caring for early diagnosed children should be aware of the need to discuss the long-term implications of the disorder and be sensitive to the transition period when the child takes progressively more responsibility for self management and the parent's role diminishes.

The relationship between self-care and metabolic control in children with insulin-dependent diabetes mellitus

To assess the relationship between insulin-dependent diabetes mellitus (IDDM) self-care management and metabolic control in school-aged children, 21 children ages 10 to 14 years with a duration of IDDM of 5.5 years (range 1 to 13 years) were studied. Self-care was defined as the activities that children with IDDM initiate and perform on their own in the management of their disease. Self-care activity was assessed by a revised Self-Care Questionnaire (SCQ), and metabolic control was determined by HbA1c levels obtained at the same time the SCQ was completed. A higher level of self-care management (higher SCQ) was hypothesized to correlate with better metabolic control (lower HbA1c). Regression analysis of SCQ and HbA1c supported the expected inverse relationship but not at a significant level. The only significant predictors of self-care activity and metabolic control were experience at a specialized camp for children with diabetes and race, with Caucasian children scoring higher in self-care and having lower HbA1c values than African American children.

The challenge of transferring responsibility for diabetes management from parent to child

To emancipate from their parents, children and adolescents with diabetes eventually must assume responsibility for self-care. The challenge that parents and health care professionals face is deciding when and how to transfer this responsibility from parent to child. Inappropriate transfer of self-care responsibility can precipitate poor metabolic control and strain parent-child relationships. By planning the gradual transfer of this responsibility based on children's cognitive abilities, maturity level, demonstrated self-care skills, and family environment factors, health care providers can minimize these problems.

Issues in the care of infants and toddlers with insulin-dependent diabetes mellitus

Infants and children in the preschool age group who have insulin-dependent diabetes mellitus present a unique set of problems to the health care provider and to their families. These management issues include difficulty in achieving maximal metabolic control; the limited ability of the child to communicate feelings and needs; a significant financial burden to many young families; and the increased family stress and altered psychodynamics seen in families with very young children with chronic illnesses. The lability of diet, exercise, emotions, and overall life-style seen in this age group exacerbates each of these problems markedly. This paper addresses the challenges that these children present; discusses the issues and controversies; and describes how the Diabetes Clinic at Michigan State University uses a combination of methodologies and disciplines to deal with these problem areas.