Glycemic control, coping, and internalizing and externalizing symptoms in adolescents with type 1 diabetes: a cross-lagged longitudinal approach

Associations of Coping Strategies With Glycemic and Psychosocial Outcomes Among Adolescents With Type 1 Diabetes Experiencing Diabetes Distress

BACKGROUND

Many adolescents with type 1 diabetes experience diabetes distress which is associated with suboptimal glycemic and psychosocial outcomes. The ways in which adolescents respond to diabetes distress may serve as a risk or protective factor for these outcomes, but few studies have examined the coping strategies adolescents use to manage diabetes distress.

PURPOSE

To examine the association of coping strategies with glycemic and psychosocial outcomes among adolescents experiencing diabetes distress.

METHODS

Participants included 198 adolescents with elevated diabetes distress who completed baseline data for a randomized controlled trial (Mage = 15.3 ± 1.4, 58% female, 58% non-Hispanic White, MA1c = 9.1 ± 2.1%). Adolescents reported on their use of coping strategies related to diabetes stressors, including primary control engagement coping (e.g., problem-solving), secondary control engagement coping (e.g., positive thinking), and disengagement coping (e.g., avoidance). Adolescents also completed measures of diabetes distress, quality of life, and resilience. HbA1c data were extracted from electronic medical records and at-home kits.

RESULTS

Higher use of primary control engagement coping was associated with better glycemic and psychosocial outcomes. Secondary control engagement coping was associated with better psychosocial outcomes but not glycemic outcomes. Greater use of disengagement coping strategies was associated with poorer glycemic and psychosocial outcomes. All associations were significant after adjusting for adolescent sex, age, race/ethnicity, and continuous glucose monitor use.

CONCLUSIONS

These results build on prior findings by including a more diverse sample of adolescents and highlight the value of promoting engagement coping strategies and discouraging the use of disengagement coping strategies among adolescents experiencing diabetes distress.

CLINICAL TRIAL INFORMATION

NCT03845465.

Effectiveness of psychodynamic treatment: Comparing trajectories of internalizing and externalizing psychopathology of adolescents in treatment, healthy and physically ill adolescents

Effectiveness of psychodynamic therapy for adolescents in reducing internalizing and externalizing psychopathology was determined by comparing treated adolescents (86 sessions) with the normative developmental progression in two groups without treatment: healthy and diabetic adolescents. In a three-wave longitudinal study, n = 531 adolescents (n = 303 patients, n = 119 healthy, n = 109 diabetics) and their mothers filled out psychopathology questionnaires (Youth Self-Report and Child Behavior Checklist). Latent growth curve modeling and multilevel modeling were used to analyze and compare within-person symptoms changes across groups. Analyses showed a significant reduction over the course of treatment for internalizing (Cohen's d = .90-.92) and externalizing (d = .58-.72) symptoms, also when the developmental progression of both control groups was accounted for (d = .48-.76). Mothers reported lower levels than their children in internalizing symptoms (p ≤ .01) while this discrepancy increased over time for treated adolescents (p = .02). Results established the effectiveness of psychodynamic treatment for adolescents both with externalizing and internalizing symptoms in comparison with growth and change in nonclinical samples. Cross-informant differences and age-specific trajectories require attention in psychotherapy treatment and research.

Virtual reality's impact on children with type 1 diabetes: a proof-of-concept randomized cross-over trial on anxiety, pain, adherence, and glycemic control

AIMS

 Assess the effectiveness of virtual reality (VR) technology, in reducing pain and anxiety, and improving adherence and glycemic control among children with type 1 diabetes (T1D).

METHODS

Children with T1D, managed with continuous glucose monitoring and insulin pumps, were recruited for a randomized cross-over trial. Children were randomized to one of two interventions for diabetes management: group 1 used VR glasses first and group 2 listened to vocal-guided affective imagery first (audio). After 1 month, the interventions were crossed over. The outcome measures included pain and anxiety assessment, adherence, glycemic control, and patient-reported outcome measures (PROMs) of VR satisfaction and effectiveness.

RESULTS

 Forty children, mean age 11.4 ± 1.8 years, were participated. During the VR part, the monthly mean pain score compared to the baseline improved in both groups by 30% (p = 0.03). A 14% reduction in the state anxiety score was observed from baseline to 1 month in both groups (p = 0.009). Glycemic control measures including time in range, time above range, and glucose management indicator improved in both groups during VR part (p < 0.004 for all), compared to audio part. After one month, the patient-reported outcome measure (PROM) of satisfaction and effectiveness was sixfold higher after 1 month in group 1 compared to group 2 (p = 0.002). Adherence improved for both groups.

CONCLUSIONS

VR was shown to be effective in reducing pain and anxiety, improving adherence, PROM, and glycemic control among children with T1D. We suggest incorporating VR technology in pediatric diabetes clinics to facilitate and improve coping and management of diabetes.

TRIAL REGISTRATION

Trial registration number and date of registration for prospectively registered trials:ClinicalTrials.gov Identifier: NCT05883267, May 10th, 2023.

Prevalence and Multidimensional Model of Disordered Eating in Youths With Type 1 Diabetes: Results From a Nationwide Population-Based Study

OBJECTIVE

The aim of this study was to report nationwide data of the prevalence of disordered eating behaviors (DEBs) in adolescents with type 1 diabetes (T1D) and to evaluate a multidimensional model of eating problems, analyzing how psychopathological problems are associated with DEBs and with metabolic control.

METHODS

This study was carried out using a cross-sectional design with a sample of 1,562 patients with T1D (812 male), aged 11-19 years. Participants were recruited from multiple pediatric diabetes centers (N = 30) located in northern, central, and southern Italy, and they individually completed the Diabetes Eating Problem Survey-Revised (DEPS-r) and the Youth Self-Report (YSR). Sociodemographic and clinical data were also gathered. Multiple-group structural equation modeling was used to investigate the relationships between internalizing/externalizing symptoms, DEBs, and glycosylated hemoglobin (HbA1c) values.

RESULTS

A total of 29.7% of the participants reported DEBs (DEPS-r scores ≥20), 42.4% reported insulin manipulation (IM). The prevalence of DEBs was higher for female participants (p ≤ .001). The model explains 37% of the variance in disordered eating, 12% in IM, and 21% in HbA1c values. Body mass index, externalizing symptoms, and internalizing symptoms were significantly and positively associated with DEBs, which in turn were significantly and positively associated with HbA1c values (all p ≤ .001). Externalizing (p ≤ .001) and internalizing (p ≤ .01) symptoms were also directly associated with HbA1c values.

CONCLUSION

Given the relevant prevalence of DEBs, their significant positive association with psychopathological symptoms, and their relationship with worse diabetes outcomes, regular psychological screening and support is needed to ensure the best care of adolescents with T1D.

Psychological consequences of the COVID-19 pandemic in people with type 1 diabetes: A systematic literature review

OBJECTIVE

A comprehensive picture of the data on the impact of COVID-19 on the mental health of individuals with type 1 diabetes (T1D) is currently lacking. The purpose of this systematic review was to synthesize extant literature reporting on the effects of COVID-19 on psychological outcomes in individuals with T1D and to identify associated factors.

METHODS

A systematic search was conducted with PubMed, Scopus, PychInfo, PsycArticles, ProQuest, and WoS using a selection procedure according to the PRISMA methodology. Study quality was assessed using a modified Newcastle-Ottawa Scale. In all, 44 studies fulfilling the eligibility criteria were included.

RESULTS

Findings suggest that during the COVID-19 pandemic, people with T1D had impaired mental health, with relatively high rates of symptoms of depression (11.5-60.7%, n = 13 studies), anxiety (7-27.5%, n = 16 studies), and distress (14-86.6%, n = 21 studies). Factors associated with psychological problems include female gender, lower income, poorer diabetes control, difficulties in diabetes self-care behaviors, and complications. Of the 44 studies, 22 were of low methodological quality.

CONCLUSIONS

Taking appropriate measures to improve medical and psychological services is needed to support individuals with T1D in appropriately coping with the burden and difficulties caused by the COVID-19 pandemic and to prevent mental health problems from enduring, worsening, or having a long-term impact on physical health outcomes. Heterogeneity in measurement methods, lack of longitudinal data, the fact that most included studies did not aim to make a specific diagnosis of mental disorders limit the generalizability of the findings and have implications for practice.

Prevalence of disordered eating behaviors in adolescents with type 1 diabetes: Results of multicenter Italian nationwide study

OBJECTIVE

To assess the prevalence of disordered eating behaviors (DEBs) in a large sample of Italian adolescents with type 1 diabetes and to explore potential demographic, clinical, and psychological differences (understood as emotional and behavioral problems) among adolescents with and without DEBs.

METHOD

Adolescents (11-19 years) with type 1 diabetes completed the Diabetes Eating Problems Survey-revised (DEPS-r) and the Youth Self Report (YSR). Demographic and clinical data were also collected.

RESULTS

Of 690 adolescents with type 1 diabetes (mean age 14.97 ± 1.81, n = 337 girls) assessed in this study, 28.1% (21% boys, 35% girls) were DEPS-r positive (score ≥ 20). Girls had higher DEPS-r total scores (p < .0001, d = .42) than boys, although no age differences were found in mean DEPS-r total scores (p = .961). In both genders, adolescents with DEBs had significantly higher zBMI (p < .0001, d = .52) and HbA1c values (p < .0001, d = .54) and showed more emotional and behavioral problems (both as internalizing and externalizing problems) than those without DEBs (all p < .0001). These differences were largely confirmed in all age groups. Adolescents reporting insulin misuse had higher HbA1c values (p = .001, d = .26), higher DEPS-r mean scores (p < .0001, d = 1.07), and greater psychological problems (all p < .001) than those who did not.

DISCUSSION

DEBs are prevalent among adolescents with type 1 diabetes, and those with eating problems showed adverse clinical and psychological conditions. Routine screening for DEBs and of general psychological condition should be a fundamental part of diabetes care, especially during adolescence.

PUBLIC SIGNIFICANCE STATEMENT

This nationwide study indicated that DEBs are common in adolescents with T1D, and those suffering from them show poorer clinical conditions and higher emotional and behavioral problems. As such, it offers important contributions for those working with EDs and in the T1D field, as it provides a deeper understanding of the co-occurring DEBs-emotional/behavioral problems in youths with T1D and highlights the importance of continuous monitoring of their psychological condition by a multidisciplinary team.

Does clinically relevant psychopathology in adolescents necessarily require treatment or does it "grow out"?

OBJECTIVE

To determine the treatment effect of psychodynamic therapy for adolescents in comparison to normative developmental progression in two groups without treatment: healthy adolescents and adolescents with juvenile diabetes.

RESEARCH DESIGN AND METHODS

In a 3-wave longitudinal study, n = 531 adolescents (n = 303 treated adolescents, n = 119 healthy, n = 109 with diabetes) and their parents filled out psychopathology questionnaires (Youth Self-Report [YSR] and Child Behaviour Checklist [CBCL]). Growth curve modeling (GCM) was used to examine within-person change in psychopathology while controlling for stable between-person differences.

RESULTS

GCM analyses revealed significant within-person reductions in patients' YSR and CBCL (d = 1.02-1.99) at the end of treatment. When accounted for the control groups' developmental progression (d = .14-.94), patients' within-person change remained significantly higher (d = .48-.82). In all three groups, parents rated the severity of psychopathology significantly lower, and within-person change significantly higher than the adolescents him/herself.

CONCLUSIONS

Psychodynamic therapy led to a significant symptom reduction in treated adolescents and was superior to development-related symptom changes occurring in the two control groups. Hence, clinically relevant symptoms in adolescents do not "grow out", but require psychotherapeutic treatment. Differences between adolescents and their parents in the evaluation of symptom severity and change require attention in psychotherapy treatment and research.

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.

Psychological interventions for adherence, metabolic control, and coping with stress in adolescents with type 1 diabetes: a systematic review

BACKGROUND

The aim of this review was to summarize and identify the variations in the effectiveness of psychological interventions on adherence, metabolic control, and coping with stress in adolescents with type 1 diabetes (T1D).

METHODS

An electronic search of literature was performed using PubMed (NLM), Embase (Ovid), CINAHL Plus (EBSCOhost), PsycINFO (Ovid), and Google Scholar. The search was limited to include articles reported the effect of one of the psychological interventions: cognitive behavioral therapy (CBT), coping skills training (CST), stress management, or psychotherapy intervention. The report included peer-reviewed articles published in English from January 1990 until May 2019 in adolescents with T1D, and summarizes the results of 24 studies that met the inclusion criteria.

RESULTS

Psychological interventions showed differential effects on adherence, metabolic control, and coping with stress in adolescents with T1D. Behavioral interventions using principles of CBT appear to have a superior positive effect on regimen adherence compared with other types of psychological protocols. In contrast, metabolic control was significantly improved with the implementation of CST and some forms of CBT. Stress management and psychotherapy interventions showed significant promises for adolescents to cope with their diabetes-related daily stressors.

CONCLUSIONS

However, the findings may add some promises to diabetes management in adolescents, additional research to understand the effect of these interventions is needed.

Disturbed Eating Behaviors in Adolescents and Emerging Adults With Type 1 Diabetes: A One-Year Prospective Study

OBJECTIVE

Disturbed eating behavior (DEB) is prevalent in youth with type 1 diabetes and is accompanied by an increased risk for complications, morbidity, and mortality. Prospective studies on DEB in the challenging transition to adulthood are scarce. This longitudinal study examined DEB over a 1-year period and investigated the directionality of effects linking DEB to diabetes-specific functioning and depressive symptoms in adolescents and emerging adults.

RESEARCH DESIGN AND METHODS

Three hundred youth (16-28 years old) with type 1 diabetes participated in a two-wave longitudinal study. Questionnaires measured DEB (Diabetes Eating Problem Survey-Revised [DEPS-R]), self-management, diabetes distress, and depressive symptoms. HbA_1c values were obtained from physicians. Mixed ANOVA and cross-lagged analysis were used to examine prospective changes and directionality of effects, respectively.

RESULTS

Mean DEB remained stable in the total sample, but significant individual differences were observed based on the cutoff score of the DEPS-R: 19% displayed persistent DEB and 8% increased and 7.3% decreased in DEB over time. The remaining individuals scored low on DEB over time. These four groups were differentiated based on insulin restriction, omission, diabetes-specific functioning, and depressive symptoms. Cross-lagged analyses indicated that DEB predicted relative increases in depressive symptoms over time, whereas reciprocal associations with glycemic control were found.

CONCLUSIONS

This longitudinal study highlights the substantial impact DEB may have in the transition to adulthood, with a substantial portion of youth with type 1 diabetes being at risk for clinical DEB. Prospective pathways linking DEB to functioning were found, emphasizing the clinical relevance of assessing DEB over time.

Teacher and child perceptions of relationship quality and ethnic minority children's behavioral adjustment in upper elementary school: A cross-lagged approach

In this study, cross-lagged longitudinal modeling was used to examine associations between teacher-child relationship quality and children's behavioral adjustment in a sample of sixth grade ethnic minority children. In comparison to previous cross-lagged studies, children were older and cross-informant models were used. Both teachers (N = 12) and children (N = 226) reported on the relationship quality (Closeness, Conflict, and Dependency or Negative Expectations), and children's behavioral adjustment (Externalizing Problems, Internalizing Problems, and Prosocial Behavior) at the beginning and the end of the school year. Children's externalizing behavior at the beginning of the school year was consistently and positively associated with conflict at the end of the school year. Interestingly, dependency at time 1 was associated with children's behavioral adjustment at time 2, whereas for closeness and conflict associations were the other way around (i.e., children's behavior at time 1 was associated with teacher-child closeness and conflict at time 2). Taken together, our results seem to indicate that bidirectional associations between teacher-child relationships and behavioral adjustment apply to older, ethnic minority children as well.

Stress and Coping Predicts Adjustment and Glycemic Control in Adolescents with Type 1 Diabetes

BACKGROUND

Adolescents with type 1 diabetes are at increased risk for deteriorating glycemic control, poor quality of life, and depressive symptoms. Stress and coping are related to these outcomes in adolescents with diabetes, yet few studies have examined these constructs longitudinally.

PURPOSE

This study aimed to describe stress and coping in adolescents with type 1 diabetes and to examine coping strategies as predictors of adolescent adjustment (i.e., depressive symptoms, quality of life) and glycemic control.

METHODS

Adolescents with type 1 diabetes completed measures of diabetes-related stress, coping, symptoms of depression, and quality of life at baseline, 6 months, and 12 months. Data on glycemic control were collected from the adolescents' medical charts.

RESULTS

The adolescents' use of primary control coping (e.g., problem solving) and secondary control engagement coping (e.g., positive thinking) strategies predicted significantly fewer problems with quality of life and fewer depressive symptoms over time. In contrast, the use of disengagement coping strategies (e.g., avoidance) predicted more problems with quality of life and depressive symptoms. Coping was not a significant predictor of glycemic control. Coping mediated the effects of diabetes-related stress on depressive symptoms and quality of life.

CONCLUSIONS

The ways in which adolescents with type 1 diabetes cope with diabetes-related stress predict quality of life and symptoms of depression but not glycemic control. Through the use of screening to identify adolescent's diabetes-related stress and targeted interventions to improve coping strategies, there is potential to improve outcomes.

Sweet and Sensitive: Sensory Processing Sensitivity and Type 1 Diabetes

OBJECTIVE

Sensory processing sensitivity (SPS) is a recently proposed construct that refers to a genetically influenced tendency to more strongly and deeply process a variety of information. The aim of the study was to examine whether SPS is associated with an autoimmune disease such as type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

Participants were 128 adolescents (62 with T1D and 66 comparisons [without autoimmune disease]) and their parents who completed the Highly Sensitive Person Scale (HSPS) questionnaire, assessing SPS level.

RESULTS

Higher levels of SPS were found in the T1D group than in the comparison group. Furthermore, the frequency of SPS trait was significantly higher in the T1D group than in the comparison group.

CONCLUSIONS

T1D is associated with higher levels of SPS. Hence, there is a need to develop interventions, treatments, and care focused on the needs of T1D patients with SPS temperament, aimed at better treatment adherence. Furthermore, longitudinal research is needed to evaluate whether SPS is a risk factor in the development of T1D.

The Role of Peers for Diabetes Management in Adolescents and Emerging Adults With Type 1 Diabetes: A Longitudinal Study

OBJECTIVE

The increasing importance of peers in adolescence and emerging adulthood has been widely acknowledged. However, longitudinal research linking the peer context to diabetes management and outcomes is scarce. The present longitudinal study in a large sample of youths with type 1 diabetes related both positive and negative peer variables to diabetes outcomes over a time interval of 1 year.

RESEARCH DESIGN AND METHODS

Our sample consisted of 467 adolescents (14-17 years of age) and emerging adults (18-25 years of age) with type 1 diabetes who participated in a two-wave longitudinal study. Questionnaires tapped into peer support, extreme peer orientation, parental responsiveness, diabetes-related distress, and treatment adherence. HbA_1c values were obtained from the treating physicians of patients. Cross-lagged analysis from a structural equation modeling approach was performed to assess the directionality of effects.

RESULTS

Peer support negatively predicted diabetes-related distress over time. Extreme peer orientation positively predicted treatment distress over time. Parental responsiveness negatively predicted food distress over time. Treatment adherence negatively predicted extreme peer orientation, treatment distress, and HbA_1c values over time. For emerging adults specifically, there was a reciprocal relationship between HbA_1c values and extreme peer orientation because they positively predicted each other.

CONCLUSIONS

This study highlights the importance of peers in predicting the functioning of youths with type 1 diabetes. Additionally, treatment adherence at baseline was found to negatively predict extreme peer orientation, treatment distress, and worse glycemic control over time. In sum, the current study underscores the importance of the peer context for adolescents and emerging adults with type 1 diabetes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Labor market consequences of growing up with a sibling with type 1-diabetes

Economic research on child health and future labor market outcomes has mainly focused on children with impaired health themselves, and only recently begun to assess spillover effects for siblings. Yet, the challenge to accommodate a family's routines within the requirements of a complex and time-consuming disease is most likely to spillover on siblings. While the burden of ill health and managing a disease may have adverse effects, living with a disease may still give families useful experiences and skills that favor future labor market outcomes. Therefore, the potential labor market impacts of growing up with a sick sibling could be both positive and negative. This study investigates differences in the progression of annual labor earnings between siblings of children with type 1-diabetes and population controls. The data is based on detailed Swedish longitudinal registers, covering annual labor earnings in the years 1990-2010 for 764 siblings of 764 children with diabetes and 5506 population controls born in 1962-1971, and follow individuals between ages 19-48. The results indicate that brothers of children with type 1-diabetes have lower earnings growth than controls, while sisters' earnings growth appears unaffected. Consequently, spillovers from one family member to another might differ within a family.

Collaborative and Overinvolved Parenting Differentially Predict Outcomes in Adolescents With Type 1 Diabetes

OBJECTIVE

The current study examined the impact of collaborative and intrusive parenting on depression and glycemic control in children with Type 1 diabetes (T1D). Research examining the association between parenting and child adjustment in this population has been limited by a reliance primarily on questionnaire data and cross-sectional analyses. To address these gaps, the current study used an observational coding system to measure the effects of parenting on child adjustment over a 1-year period.

METHOD

Youth (10 to 16 years old) with T1D and their mothers (N = 81) were recruited from an outpatient pediatrics diabetes clinic. Mothers' symptoms of anxiety and depression and children's depressive symptoms were assessed by self- reports; parenting behaviors were assessed via video-recorded observations coded using the Iowa Family Interaction Rating Scales; and adolescents' glycosylated hemoglobin (HbA1c) was obtained from medical records.

RESULTS

Bivariate correlations and linear regression analyses revealed that higher levels of observed collaborative parenting were related to significantly lower HbA1c 12 months later, and higher levels of observed overinvolved parenting were related to significantly greater child depressive symptoms 12 months later. Further, age and treatment type moderated the relation between overinvolved parenting and child depressive symptoms.

CONCLUSIONS

Collaborative and overinvolved parenting appears important for adolescents in predicting both psychological and health-related outcomes over time. Parenting behaviors may serve as an important target for future interventions to enhance adjustment in these children. (PsycINFO Database Record

Socioeconomic status and glycemic control in adult patients with type 2 diabetes: a mediation analysis

OBJECTIVE

The purpose of this study is to examine the contribution of health behaviors (self-management and coping), quality of care, and individual characteristics (depressive symptoms, self-efficacy, illness representations) as mediators in the relationship between socioeconomic status (SES) and glycemic control.

METHODS

A sample of 295 adult patients with type 2 diabetes was recruited at the end of a diabetes education course. Glycemic control was evaluated through glycosylated hemoglobin (HbA1c). Living in poverty and education level were used as indicators of SES.

RESULTS

Bootstrapping analysis showed that the significant effects of poverty and education level on HbA1c were mediated by avoidance coping and depressive symptoms. The representation that diabetes is unpredictable significantly mediated the relationship between living in poverty and HbA1c, while healthy diet mediated the relationship between education level and HbA1c.

CONCLUSIONS

To improve glycemic control among patients with low SES, professionals should regularly screen for depression, offering treatment when needed, and pay attention to patients' illness representations and coping strategies for handling stress related to their chronic disease. They should also support patients in improving their self-management skills for a healthy diet.

Metabolic Control and Illness Perceptions in Adolescents with Type 1 Diabetes

BACKGROUND

Disturbed eating behavior and psychosocial variables have been found to influence metabolic control, but little is known about how these variables interact or how they influence metabolic control, separately and combined.

OBJECTIVE

To explore associations between metabolic control (measured by HbA1c) and eating disorder psychopathology, coping strategies, illness perceptions, and insulin beliefs in adolescents with type 1 diabetes.

METHODS

A total of 105 patients (41.9% males) with type 1 diabetes (12-20 years) were interviewed with the Child Eating Disorder Examination. In addition, self-report psychosocial questionnaires were completed. Clinical data, including HbA1c, was obtained from the Norwegian Childhood Diabetes Registry.

RESULTS

Significant gender differences were demonstrated. Among females, HbA1c correlated significantly with eating restriction (.29, p < .05), the illness perception dimensions consequences, personal control, coherence, and concern (ranging from .33 to .48), and the coping strategy ventilating negative feelings (-.26, p < .05). Illness perception personal control contributed significantly to HbA1c in a regression model, explaining 23% of the variance among females (β .48, p < .001). None of the variables were significantly associated with HbA1c among males.

CONCLUSIONS

Illness perceptions appear to be important contributors to metabolic control in females, but not males, with type 1 diabetes.

Parental resolution and the adolescent's health and adjustment: The case of adolescents with type 1 diabetes

This study examines the association between parents' resolution of their adolescent child's diagnosis of type 1 diabetes and the health and mental adjustment of the adolescents themselves. Parents of 75 adolescents with type 1 diabetes were interviewed using the Reaction to Diagnosis Interview. Parents and adolescents completed questionnaires regarding the child's physical health, self-management of the disease, and behavioral and emotional problems. Physicians reported adolescents' HbA1c levels. Results showed that adolescents whose fathers were resolved with the diagnosis exhibited better diabetes self-management and adolescents whose mothers were resolved with the diagnosis exhibited fewer internalizing and externalizing problems. The findings highlight the different role of mothers and fathers in the treatment of adolescents with diabetes and provide a basis for clinical intervention that focuses not only on adolescent health, but also on parental state of mind regarding the resolution with the disease.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

What clinical differences distinguish depressed teens with and without comorbid externalizing problems?

OBJECTIVE

This study examined differences in co-occurring symptoms, psychosocial correlates, health care utilization and functional impairment in youth who screened positive for depression, stratified by whether or not they also self-reported externalizing problems.

METHODS

The AdoleSCent Health Study examined a random sample of youth ages 13-17 enrolled in a health care system. A total of 2291 youth (60.7% of the eligible sample) completed a brief depression screen: the two-item Patient Health Questionnaire. The current analyses focus on a subset of youth (n=113) who had a follow-up interview and screened positive for possible depression on the Patient Health Questionnaire 9 using a cutoff score of 11 or higher [1]. Youth were categorized as having externalizing behavior if their score was ≥ 7 on the Pediatric Symptom Checklist (PSC) externalizing scale [2,3]. χ(2) tests and Wilcoxon rank sum tests were used to compare groups.

RESULTS

Differences between groups included that youth with depression and externalizing symptoms had a higher rate of obesity and had higher self-reported functional impairment than youth with depression symptoms alone.

CONCLUSIONS

Adding screening for externalizing problems to existing recommendations for depression screening may help primary care providers to identify a high-risk depressed group of youth for referral to mental health services.

Goal disturbance and coping in children with type I diabetes mellitus: relationships with health-related quality of life and A1C

OBJECTIVE

Our first objective was to compare the health-related quality of life (HRQoL) of children with type 1 diabetes mellitus (8-12 years) with that of a healthy reference group, and to compare glycated hemoglobin (A1C) values of these children to recommended guidelines. Our second objective was to examine how goal disturbance and coping behaviour were related to HRQoL and A1C.

METHOD

Forty-three children, 8-12 years of age, completed a set of questionnaires that assessed generic and diabetes-specific HRQoL, goal disturbance and coping behaviour. Demographic and clinical characteristics were extracted from medical records.

RESULTS

Children with type 1 diabetes reported lower psychosocial HRQoL than healthy references (d=-0.48), especially on emotional functioning (d=-0.58). Goal disturbance was associated with lower generic HRQoL. Furthermore, the coping strategies avoidance, emotional reaction and wishful thinking were negatively associated with lower generic and disease-specific HRQoL (r ranged from -0.33 to -0.65), whereas acceptance was positively associated with disease-specific HRQoL (r=0.36). The average A1C was with 8.1% significantly above the recommended guidelines of 7.5%. Moreover, the coping strategies avoidance (r=0.31) and emotional reaction (r=0.32) were positively associated with higher blood glucose levels.

CONCLUSIONS

The psychosocial HRQoL of children with type 1 diabetes was affected, which was directly associated with the inability to reach personal goals (goal disturbance). An accepting coping strategy might solve these HRQoL problems and additionally improve A1C values.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.

Coping with asthma: is the physician able to identify patient's behaviour?

INTRODUCTION

The strategies patients use to manage their asthma (coping) have been found to be associated with clinical and patient-reported outcomes.

OBJECTIVES

The aim of this large cross-sectional survey is to assess the use of coping methods employed by patients with asthma and to explore the ability of general practitioners (GPs) to correctly identify these strategies.

METHODS

A modified Coping Orientations to Problem Experienced Questionnaire was completed by patients with asthma and their physicians.

RESULTS

The survey was completed by 3089 GPs (69% male; mean age 55 ± 6) and by 6264 patients (52% male; mean age 45 + 14). Active strategies were reported as the predominant method of coping by 51-59% of patients, whilst passive/avoidant techniques accounted for 12-28%. GPs believed the active coping methods were employed primarily by 35-45% of patients and the passive/avoidant methods by 8-26%. Physicians were able to identify the specific strategy used by a patient in 34%-64% of cases. The ability to identify the use of active strategies rather than the passive/avoidant was significantly higher (T test 8,250, p < 0.0001). Coefficient of concordance between GPs' and patients' answers was fair.

CONCLUSIONS

These results revealed the extent of maladaptive coping strategies used by patients and the tendency for physicians to underestimate these. These observations may well represent two obstacles in improving asthma clinical outcomes.

Coping, self-management, and adaptation in adolescents with type 1 diabetes

BACKGROUND

Adolescents with type 1 diabetes experience stress related to treatment management, feeling different from peers, and deciding to tell others about their diabetes.

PURPOSE

This study examined the relationship of stress reactivity and coping with self-management, quality of life, and metabolic control in an ethnically diverse sample of adolescents with type 1 diabetes.

METHODS

Adolescents (n = 327) completed measures of coping and stress reactivity, self-management, and quality of life. Glycosylated hemoglobin data were collected from medical records.

RESULTS

Low-income and minority status were related to lower levels of primary control coping (e.g., problem solving) and secondary control coping (e.g., acceptance), and higher levels of disengagement coping (e.g., avoidance). Self-management mediated the relationship between coping and stress reactivity with quality of life and metabolic control. Race/ethnicity and income moderated the relationship between coping and self-management goals.

CONCLUSIONS

Results indicate differences in coping related to income and race/ethnicity and demonstrate the impact of coping on self-management and health outcomes in adolescents with type 1 diabetes.

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

OBJECTIVE

Less parental monitoring of adolescents' diabetes self-care and more family conflict are each associated with poorer diabetes outcomes. However, little is known about how these two family factors relate with one another in the context of self-care and glycemic control. Diabetes self-care was evaluated as a mediator of the associations among parental monitoring, family conflict, and glycemic control in early adolescents with type 1 diabetes.

METHODS

Adolescent-parent dyads (n = 257) reported on the frequency of parental monitoring, family conflict, and diabetes self-care. Hemoglobin A1c was abstracted from medical charts. Structural equation modeling was used for mediation analysis.

RESULTS

A mediation model linking parental involvement and family conflict with A1c through diabetes self-care fit the data well. Monitoring and conflict were inversely correlated (β = -0.23, p < .05) and each demonstrated indirect associations with A1c (standardized indirect effects -0.13 and 0.07, respectively) through their direct associations with self-care (β = 0.39, p < .001 and β = -0.19, p < .05, respectively). Conflict also was positively associated with higher A1c (β = 0.31, p < .01).

CONCLUSIONS

Elevated family conflict and less parental monitoring are risk factors for poorer glycemic control, and diabetes self-care is one mediator linking these variables. Interventions to promote parental monitoring of diabetes management during early adolescence may benefit from emphasizing strategies to prevent or reduce family conflict.

Emotional processing and self-control in adolescents with type 1 diabetes

OBJECTIVE

This study examined whether emotional processing (understanding emotions), self-control (regulation of thoughts, emotions, and behavior), and their interaction predicted HbA1c for adolescents with type 1 diabetes over and above diabetes-specific constructs.

METHODS

Self-report measures of self-control, emotional processing, self-efficacy for diabetes management, diabetes-specific negative affect, and adherence, and HbA1c from medical records were obtained from 137 adolescents with type 1 diabetes (M age = 13.48 years).

RESULTS

Emotional processing interacted with self-control to predict HbA1c, such that when adolescents had both low emotional processing and low self-control, HbA1c was poorest. Also, both high emotional processing and self-control buffered negative effects of low capacity in the other in relation to HbA1c. The interaction of emotional processing × self-control predicted HbA1c over diabetes-specific self-efficacy, negative affect, and adherence.

CONCLUSIONS

These findings suggest the importance of emotional processing and self-control for health outcomes in adolescents with diabetes.

Themes elicited during motivational interviewing to improve glycaemic control in adults with Type 1 diabetes mellitus

AIMS

To elicit the barriers and motivators to better diabetes self care in patients with Type 1 diabetes.

METHODS

We obtained a purposive sample of 47 patients with Type 1 diabetes and persistent suboptimal glycaemic control from a randomized controlled trial of nurse-delivered psychological interventions. Each participant's second session of motivational interviewing was analysed using content analysis.

RESULTS

Four major themes emerged: emotions of living with Type 1 diabetes, perceived barriers to diabetes management, motivators for change and methods of coping. Increased assistance and support from family and healthcare teams, the prospect of improved emotional and physical well-being and feelings of success were described as factors that might motivate participants to practice more effective self care.

CONCLUSIONS

An enhanced awareness of the range of psychological concepts in diabetes may enable a better therapeutic relationship between clinicians and patients.

Coping with chronic illness in childhood and adolescence

Chronic illnesses and medical conditions present millions of children and adolescents with significant stress that is associated with risk for emotional and behavioral problems and interferes with adherence to treatment regimens. We review research on the role of child and adolescent coping with stress as an important feature of the process of adaptation to illness. Recent findings support a control-based model of coping that includes primary control or active coping (efforts to act on the source of stress or one's emotions), secondary control or accommodative coping (efforts to adapt to the source of stress), and disengagement or passive coping (efforts to avoid or deny the stressor). Evidence suggests the efficacy of secondary control coping in successful adaptation to chronic illness in children and adolescents, disengagement coping is associated with poorer adjustment, and findings for primary control coping are mixed. Avenues for future research are highlighted.

Self-classification as an adult in patients with type 1 diabetes: relationships with glycemic control and illness coping

OBJECTIVE

Previous community research has demonstrated the link between adult self-classification and health behaviors. The present study investigated the extent to which individuals with type 1 diabetes (ages 18-30 years) classified themselves as adults as compared with individuals without diabetes. Adult self-classification was examined in relation to illness coping and glycemic control.

METHODS

A total of 194 patients and 287 control individuals participated. Adult self-classification was assessed using a single item, coping was assessed using the Diabetes Coping Measure, and glycemic control was determined by HbA(1c) values.

RESULTS

Compared with control participants, more patients classified themselves as adults. Furthermore, adult self-classification was positively related to glycemic control. Structural equation modeling indicated that coping mediated the relationship between adult self-classification and glycemic control.

CONCLUSION

Individuals with diabetes classified themselves as adults more often than did their peers without diabetes, possibly due to their need to master their lives when confronted with diabetes. Adult self-classification appeared to function as a resource for glycemic control through its relationship with specific coping strategies.

PRACTICE IMPLICATIONS

The present study underscores the need to assess adult self-classification in individuals with diabetes. Our findings call for a developmentally tailored transition from pediatric to adult care.