Risk and resilience of well-being in caregivers of young children in response to the COVID-19 pandemic

The COVID-19 pandemic is impacting communities worldwide, with direct effects of illness and mortality, and indirect effects on economies, workplaces, schools/daycares, and social life. However, we understand very little about the effects of this pandemic on families of young children. We used a risk and resilience model to evaluate the effects of the pandemic on mental health in diverse caregivers (N = 286) with children ages birth to 5. We evaluated the hypotheses that (a) pandemic stress and caregiver-reported child psychosocial concerns correlate with caregivers’ mental health symptoms and (b) caregivers’ pandemic-related self-efficacy and coping mediate these relationships. Caregivers completed surveys in April–May 2020 assessing pandemic stress (e.g., health, finances, and housing), child psychosocial problems, coping strategies, and self-efficacy to manage family needs. Our primary outcome was caregivers’ self-reported changes in mental health symptoms since the outbreak. Path analysis revealed that higher pandemic stress was associated with caregivers’ reduced confidence in meeting their family’s needs related to COVID-19, which correlated with worse caregiver mental health symptoms. Greater child psychosocial problems also predicted worse caregiver mental health symptoms. Findings suggest that pandemic stress, child psychosocial problems, and caregiver self-efficacy are interrelated in their influence on caregivers’ mental health. While further research is needed to examine strategies to foster resilience and buffer the pandemic’s effects on caregiver mental health, this is a first step in evaluating the psychosocial effects of this pandemic in families of young children. Clinical implications are discussed for a tiered response to mitigate the pandemic’s impacts on family functioning.

Metabolic Syndrome in Hispanic Youth: Results from the Hispanic Community Children's Health Study/Study of Latino Youth

BACKGROUND

Metabolic syndrome (MetS), a cluster of cardiovascular risk factors, is being diagnosed in youth. Specific diagnostic criteria used to define MetS influence prevalence estimates and populations considered at risk for cardiovascular disease. The National Cholesterol Education Program's Adult Treatment Panel III (ATP), the World Health Organization (WHO), and the International Diabetes Federation (IDF) provide three MetS definitions used in medical research. This study examined concordance among these definitions in 1137 children 10-16 years of age, who participated in the Hispanic Community Children's Health Study/Study of Latino Youth.

METHODS

Prevalence of MetS and of individual components was estimated using SAS. Mplus was used to test a single-factor model of MetS components (triglycerides, high-density lipoprotein cholesterol, systolic and diastolic blood pressure, waist circumference, and fasting glucose).

RESULTS

The ATP definition identified most MetS cases in 10-15 (N = 19, 4.7%) and 16-year-old girls (N = 3, 7.3%). The IDF definition identified most cases of MetS in 10-15 (N = 16, 3.1%) and 16-year-old boys (N = 2, 2.8%). Fewest cases of MetS were identified with the WHO definition across age and sex groups.

CONCLUSION

Only one participant was classified as having MetS across all three definitions. Confirmatory factor analysis indicated fasting glucose and systolic blood pressure did not reliably cluster with other risk factors that define MetS in Hispanic/Latino adolescents. We conclude that prevalence estimates of MetS in youth are unstable across current criteria, calling into question the accuracy of defining and diagnosing MetS in youth.

Effect of Relocation to the U.S. on Asthma Risk Among Hispanics

INTRODUCTION

Asthma prevalence is reportedly higher among U.S.-born relative to foreign-born Hispanics/Latinos. Little is known about rates of asthma onset before and after relocation to the U.S. in Latinos. Asthma rates were examined by U.S. residence and country/territory of origin.

METHODS

In 2015-2016, age at first onset of asthma symptoms was analyzed, defined retrospectively from a cross-sectional survey in 2008-2011, in relation to birthplace and U.S. residence among 15,573 U.S.-dwelling participants (aged 18-76 years) in the Hispanic Community Health Study/Study of Latinos.

RESULTS

Cumulative incidence of asthma through age 30 years ranged from 7.9% among Mexican background individuals to 29.4% among those of Puerto Rican background. Among those born outside the U.S. mainland, the adjusted hazard for asthma was 1.52-fold higher (95% CI=1.25, 1.85) after relocation versus before relocation to the U.S. mainland, with heterogeneity in this association by Hispanic/Latino background (p-interaction<0.0001). Among foreign-born Dominicans and Mexicans, rates of asthma were greater after relocation versus before relocation (adjusted hazard ratio [AHR] for after versus before relocation, 2.42, 95% CI=1.44, 4.05 among Dominicans; AHR=2.90, 95% CI=2.02, 4.16 among Mexicans). Puerto Ricans had modestly increased asthma onset associated with U.S. mainland residence (AHR=1.52, 95% CI=1.06, 2.17). No similar increase associated with U.S. residence was observed among Central/South American immigrants (AHR=0.94, 95% CI=0.53, 1.67). Asthma rates among Cuban immigrants were lower after relocation (AHR=0.45, 95% CI=0.24, 0.82).

CONCLUSIONS

The effect of relocation to the U.S. on asthma risk among Hispanics is not uniform across Hispanic/Latino groups.

Satisfaction With Communication in Primary Care for Spanish-Speaking and English-Speaking Parents

BACKGROUND AND OBJECTIVE

Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents.

METHODS

Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as "excellent" on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English.

RESULTS

Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing "excellent" vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter.

CONCLUSIONS

Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.

Association Between Bottle Size and Formula Intake in 2-Month-Old Infants

OBJECTIVE

To determine range of bottle sizes used and examine the relationship between bottle size and total daily consumption of infant formula.

METHODS

Cross-sectional analysis of baseline data collected as part of Greenlight, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics. The Greenlight study included healthy, term infants. For our analysis, parents of exclusively formula-fed infants reported volume per feed, number of feeds per day, and bottle size, which was dichotomized into small (<6 oz) or large (≥6 oz). We identified determinants of bottle size, and then examined relationships between bottle size and volume fed with log-transformed ordinary least squares regression, adjusting for infant age, sex, birth weight, current weight, race/ethnicity, and enrollment in Special Supplemental Nutrition Program for Women, Infants, and Children.

RESULTS

Of 865 participants in the Greenlight study, 44% (n = 378; 21.8% white, 40.6% black, 35.3% Hispanic, 2.4% other) of infants were exclusively formula fed at 2 months. Median volume per day was 30 oz (interquartile range 12), and 46.0% of infants were fed with large bottles. Adjusted for covariates, parents using larger bottles reported feeding 4 oz more formula per day (34.2 oz, 95% confidence interval 33.5-34.9 vs 29.7 oz, 95% confidence interval 29.2-30.3, P = .03).

CONCLUSIONS

Among exclusively formula-fed infants, use of a larger bottle is associated with parental report of more formula intake compared to infants fed with smaller bottles. If infants fed with larger bottles receive more formula, these infants may be overfed and consequently at risk for obesity.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship between acculturation and infant feeding styles in a Latino population

OBJECTIVE

To assess the relationship between parental acculturation and infant feeding style in a sample of Latino parents.

METHODS

A post hoc analysis was performed using data from an ongoing four-site randomized controlled trial to promote early childhood obesity prevention. Cross-sectional data of parent-child dyads at the 12-month well-child visit who self-reported their Latino ethnicity were analyzed. The Short Acculturation Scale for Hispanics (SASH) and a subset of the Infant Feeding Style Questionnaire (IFSQ) that assessed four primary feeding styles were administered. SASH level (low vs. high) with each feeding style was compared by analyses.

RESULTS

Complete SASH data were available for 398 of 431 Latino dyads. Median SASH score was 1.8 (IQR 1.4-2.7); 82% of participants had low acculturation (score < 3). Of the nine outcome variables, four were significantly associated with SASH: "Laissez-Faire/attention" (AOR: 2.3; 95% CI: 1.06-5.13; P = 0.004), "Laissez-Faire/diet quality" (AOR: 3.9; 95% CI: 1.7-8.75; P = 0.005), "Pressuring as soothing" (AOR: 3.6; 95% CI:1.63-8.05; P = 0.007), and "Restrictive/diet quality" (AOR: 0.4; 95% CI: 0.19-0.94; P = 0.031).

CONCLUSIONS

Latino parents with lower acculturation were more likely than those with higher acculturation to endorse feeding styles that are associated with child obesity. Further research is needed to determine why acculturation and feeding style relate.

A 3-year prospective study of parent-child communication in early adolescents with type 1 diabetes: relationship to adherence and glycemic control

OBJECTIVE

To examine changes in parent-child communication patterns and their relation to glycemic control and treatment adherence using observational data in a 3-year prospective multisite study of youth with type 1 diabetes aged 9-11 years at baseline and their families (n = 217).

METHODS

Adolescents and caregivers participated in a diabetes problem-solving discussion. Families were rated on negative and positive communication and interactions using the Interaction Behavior Code.

RESULTS

Maternal and paternal negative communication decreased over time, whereas adolescent and maternal positive communication and positive reciprocity increased. Baseline preadolescent youth and maternal positive communication predicted adherence 3 years later. Changes in family communication did not predict changes in glycemic control or adherence.

CONCLUSIONS

During the transition to adolescence, family communication changed in unexpected and positive ways. Additionally, the relationship of baseline family communication to subsequent adherence suggests the need to assess family communication concerning diabetes-related management during preadolescence.

Autonomy support and responsibility-sharing predict blood glucose monitoring frequency among youth with diabetes

OBJECTIVE

Adolescence poses a number of special challenges for youth and their families managing the Type 1 diabetes medical regimen. Little is known on how family and youth factors and management of the regimen change over the course of early adolescence and predict adherence to the regimen during this developmental period.

METHODS

Youth with Type 1 diabetes (n = 239) and their maternal caregivers completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency (BGMF) at 4 timepoints over a 3-year period.

RESULTS

Autonomy support and BGMF significantly decreased over time and responsibility for the diabetes regimen shifted from the caregiver toward youth over time. Significant changes in perceived family conflict over time differed depending on the reporter. Baseline BGMF, changes in caregiver autonomy support, and changes in responsibility for the regimen significantly predicted changes in BGMF over time.

CONCLUSIONS

This study documents changes in autonomy support, youth responsibility for the diabetes regimen, and BGMF during the transition into early adolescence. Higher levels of caregiver autonomy support preserve BGMF during a developmental period in which BGMF typically deteriorates.

School-based health promotion intervention: parent and school staff perspectives

BACKGROUND

The prevalence of childhood obesity is high, particularly among minority youth. The objective of this article was to evaluate parent and school staff perspectives of childhood health and weight qualitatively to guide the development of a school-based obesity prevention program for minority youth.

METHODS

Hispanic parents (N = 9) of first graders participated in 1 of 3 focus groups, consisting of 3 parents each. School staff (N = 7) participated in 1 focus group. All sessions were digitally recorded and transcribed verbatim. Using NVivo, 2 independent coders rated the transcriptions to identify themes and a third coder addressed commonalities and discrepancies in the coding schemes.

RESULTS

Parents and school staff have conflicting views over whose responsibility it is to provide nutritional education and participation in physical activity (PA). Parents felt the school should teach children about healthy nutrition, provide guidance in the cafeteria, and offer more structured PA in school. In contrast, school staff noted that parents have the primary responsibility of ensuring children get adequate nutrition and PA.

CONCLUSIONS

Despite contrasting views, parents and staff agreed with the need for comprehensive school-based obesity prevention efforts emphasizing parent and teacher collaboration to promote healthy school and home environments.

Diabetes self-management profile short form: a preliminary report

Effective family management of type 1 diabetes in childhood is critical to maintaining optimal glycemic control. The purpose of this study was to provide preliminary evidence for a reduced form of the Diabetes Self-Management Profile (DSMP) using Rasch modeling techniques. The study was a secondary analysis of DSMP data drawn from a previous study on patterns of self-management from 239 preadolescents with type 1 diabetes. Rasch modeling strategies were used to identify the most informative items and then a reduced score composite was correlated with hemoglobin A1c (A1c) and blood glucose monitoring (BGM) frequency. A short form of the DSMP was obtained using seven items that comprised all five subscales of the DSMP. The DSMP Short-Form (DSMP-SF) composite score correlated significantly with child's HbA1c and BGM frequency. The DSMP-SF may be considered a valid and effective screening interview alternative to the longer, original, DSMP, particularly when attempting to identify high-risk patients.

Decision-making in diabetes mellitus type 1

Decreased treatment adherence in patients with diabetes mellitus type 1 (type 1 DM) may reflect impairments in decision-making and underlying associated deficits in working memory and executive functioning. Other factors, including comorbid major depression, may also interfere with decision-making. The authors sought to review the clinically relevant characteristics of decision-making in type 1 DM by surveying the literature on decision-making by patients with type 1 DM. Deficiencies in decision-making in patients with type 1 DM or their caregivers contribute to treatment nonadherence and poorer metabolic control. Animal models of type 1 DM reveal deficits in hippocampal-dependent memory tasks, which are reversible with insulin. Neurocognitive studies of patients with type 1 DM reveal lowered performance on ability to apply knowledge to solve problems in a new situation and acquired scholarly knowledge, psychomotor efficiency, cognitive flexibility, visual perception, speed of information-processing, and sustained attention. Other factors that might contribute to poor decision-making in patients with type 1 DM, include "hypoglycemia unawareness" and comorbid major depression (given its increased prevalence in type 1 DM). Future studies utilizing novel treatment strategies to help patients with type 1 DM make better decisions about their disease may improve their glycemic control and quality of life, while minimizing the impact of end-organ disease.

Patterns and predictors of paternal involvement in early adolescents' type 1 diabetes management over 3 years

OBJECTIVE

To document trajectories of paternal involvement in diabetes management and examine bidirectional associations with diabetes outcomes across early adolescence.

METHODS

3-year prospective assessment of paternal involvement, diabetes self-management, and glycemic control among 136 youth (age 9-12 at baseline) and their mothers and fathers.

RESULTS

Unconditional growth curves demonstrated decreasing amount (maternal report: F(1,128) = 14.79; paternal report: F(1,111) = 12.95, ps < 0.01) and level of contribution (maternal report: F(1,131) = 23.6, p < .01) of paternal involvement. Controlling for covariates, lower youth self-management predicted an increasing slope in fathers' self-reported amount of involvement (b = -0.15 to -0.22, p < .05), and higher levels of fathers' self-reported level of contribution predicted a decreasing slope in youths' self-reported self-management (b = -0.01, p < .05).

CONCLUSIONS

Like mothers, fathers' involvement declines modestly during early adolescence. Different aspects of paternal involvement influence or are influenced by youths' self-management. Communication about ways to enhance fathers' involvement before this transition may help prevent or reduce declining diabetes management and control common in adolescence.

Internet psycho-education programs improve outcomes in youth with type 1 diabetes

OBJECTIVE

The purpose of this study was to determine the efficacy of two Internet-based psycho-educational programs designed to improve outcomes for youth with type 1 diabetes transitioning to adolescence.

RESEARCH DESIGN AND METHODS

The study was a multisite clinical trial of 320 youth (aged 11-14 years; 37% minority; 55% female) randomized to one of two Internet-based interventions: TeenCope or Managing Diabetes. Primary outcomes were HbA1c and quality of life (QOL). Secondary outcomes included coping, self-efficacy, social competence, self-management, and family conflict. Data were collected at baseline and after 3, 6, and 12 months online. Youth were invited to cross over to the other program after 12 months, and follow-up data were collected at 18 months. Analyses were based on mixed models using intent-to-treat and per-protocol procedures.

RESULTS

Youth in both groups had stable QOL and minimal increases in HbA1c levels over 12 months, but there were no significant differences between the groups in primary outcomes. After 18 months, youth who completed both programs had lower HbA1c (P = 0.04); higher QOL (P = 0.02), social acceptance (P = 0.01), and self-efficacy (P = 0.03) and lower perceived stress (P = 0.02) and diabetes family conflict (P = 0.02) compared with those who completed only one program.

CONCLUSIONS

Internet interventions for youth with type 1 diabetes transitioning to adolescence result in improved outcomes, but completion of both programs was better than only one, suggesting that these youth need both diabetes management education and behavioral interventions. Delivering these programs via the Internet represents an efficient way to reach youth and improve outcomes.

Type 1 diabetes eHealth psychoeducation: youth recruitment, participation, and satisfaction

Background

The Internet and other eHealth technologies offer a platform for improving the dissemination and accessibility of psychoeducational programs for youth with chronic illness. However, little is known about the recruitment process and yield of diverse samples in Internet research with youth who have a chronic illness.

Objective

The purpose of this study was to compare the demographic and clinical characteristics of youth with Type 1 diabetes on recruitment, participation, and satisfaction with 2 eHealth psychoeducational programs.

Methods

Youth with Type 1 diabetes from 4 sites in the United States were invited to participate (N=510) with 320 eligible youth consenting (mean age=12.3, SD 1.1; 55.3% female; 65.2% white; and mean A1C=8.3, SD 1.5). Data for this secondary analysis included demographic information (age, race/ethnicity, and income), depressive symptoms, and recruitment rates, including those who refused at point of contact (22.0%), passive refusers who consented but did not participate (15.3%), and those who enrolled (62.7%). Participation (80% lessons completed) and a satisfaction survey (ie, how helpful, enjoyable) were also analyzed. Chi-square or analysis of variance (ANOVA) analyses were used.

Results

There were significant differences in recruitment rates by income and race/ethnicity such that black, Hispanic, or mixed race/ethnicity and low-income youth were more likely to refuse passively compared to white and higher-income youth who were more likely to enroll (P<.001). Participation in program sessions was high, with 78.1% of youth completing at least 4 of 5 sessions. There were no significant differences in participation by program, age, gender, or race/ethnicity. Low-income youth were less likely to participate (P=.002). Satisfaction in both programs was also high (3.9 of 5). There were significant gender, race/ethnicity, and income differences, in that girls (P=.001), black, Hispanic, or mixed race/ethnicity youth (P=.02), and low-income youth (P=.02) reported higher satisfaction. There were no differences in satisfaction by program or age.

Conclusions

Results indicate that black, Hispanic, or mixed race/ethnicity youth and low-income youth with Type 1 diabetes are less likely to enroll in Internet-based research than white and higher-income youth; thus, creative recruitment approaches are needed. Low-income youth were less likely to participate, possibly due to access. However, once enrolled, youth of diverse race/ethnicity and low-income youth with Type 1 diabetes were as highly satisfied with the eHealth programs as white youth and those with higher income. Results suggest that eHealth programs have the potential to reach diverse youth and be appealing to them.

Design and methods for evaluating an early childhood obesity prevention program in the childcare center setting

BACKGROUND

Many unhealthy dietary and physical activity habits that foster the development of obesity are established by the age of five. Presently, approximately 70 percent of children in the United States are currently enrolled in early childcare facilities, making this an ideal setting to implement and evaluate childhood obesity prevention efforts. We describe here the methods for conducting an obesity prevention randomized trial in the child care setting.

METHODS/DESIGN

A randomized, controlled obesity prevention trial is currently being conducted over a three year period (2010-present). The sample consists of 28 low-income, ethnically diverse child care centers with 1105 children (sample is 60% Hispanic, 15% Haitian, 12% Black, 2% non-Hispanic White and 71% of caregivers were born outside of the US). The purpose is to test the efficacy of a parent and teacher role-modeling intervention on children's nutrition and physical activity behaviors. . The Healthy Caregivers-Healthy Children (HC2) intervention arm schools received a combination of (1) implementing a daily curricula for teachers/parents (the nutritional gatekeepers); (2) implementing a daily curricula for children; (3) technical assistance with meal and snack menu modifications such as including more fresh and less canned produce; and (4) creation of a center policy for dietary requirements for meals and snacks, physical activity and screen time. Control arm schools received an attention control safety curriculum. Major outcome measures include pre-post changes in child body mass index percentile and z score, fruit and vegetable and other nutritious food intake, amount of physical activity, and parental nutrition and physical activity knowledge, attitudes, and beliefs, defined by intentions and behaviors. All measures were administered at the beginning and end of the school year for year one and year two of the study for a total of 4 longitudinal time points for assessment.

DISCUSSION

Although few attempts have been made to prevent obesity during the first years of life, this period may represent the best opportunity for obesity prevention. Findings from this investigation will inform both the fields of childhood obesity prevention and early childhood research about the effects of an obesity prevention program housed in the childcare setting.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

NCT01722032.

Changes in executive functioning and self-management in adolescents with type 1 diabetes: a growth curve analysis

OBJECTIVE

To investigate the relation of changes in executive functioning to changes in diabetes self-management in a 2-year prospective study of a sample of youth aged 9-11 years at baseline (n = 239) with type 1 diabetes and their maternal caregivers.

RESEARCH DESIGN AND METHODS

Youth and maternal caregivers completed the Diabetes Self-Management Profile (DSMP) at baseline, 12 months, and 24 months. Maternal caregivers completed the Behavioral Rating Inventory of Executive Functioning (BRIEF) at the same time points to assess global executive functioning, and the domains of behavioral regulation and metacognition.

RESULTS

Youth reported self-management decreased over time (p < .01) while behavioral regulation (e.g., the child's ability to shift cognitive set and moderate emotions and behaviors via emotional control) increased (p < .05). Changes in behavioral regulation significantly predicted rate of change in youth-reported self-management (p < .01). Global executive functioning and metacognition (e.g., the child's ability to monitor, initiate, plan, organize, and sustain future-oriented problem solving and working memory) did not change over time and did not predict changes in self-management. Moreover, executive functioning and self-management did not predict changes in HbA1c.

CONCLUSIONS

Positive changes in behavioral regulation may enhance self-management of type 1 diabetes during the transition to adolescence.

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.

Changes in treatment adherence and glycemic control during the transition to adolescence in type 1 diabetes

OBJECTIVE

To test models of unidirectional and bidirectional change between treatment adherence and glycemic control in youth with type 1 diabetes.

RESEARCH DESIGN AND METHODS

We conducted a 2-year longitudinal, multisite study of 225 youth with type 1 diabetes recruited at the cusp of adolescence (aged 9-11 years) to describe the mutual influences of glycemic control as measured by HbA(1c) and treatment adherence as measured by blood glucose monitoring frequency (BGMF) during the transition to adolescence.

RESULTS

HbA(1c) increased from 8.2 to 8.6% (P < 0.001) and BGMF decreased from 4.9 to 4.5 checks per day (P < 0.02) during the 2-year period. Changes in the BGMF slope predicted changes in HbA(1c). A change (increase) in HbA(1c) was associated with a change (decrease) in BGMF of 1.26 (P < 0.001) after controlling for covariates.

CONCLUSIONS

The magnitude of the effect of declining treatment adherence (BGMF) on glycemic control in young adolescents may be even greater than declines observed among older adolescents. BGMF offers a powerful tool for targeted management of glycemic control for type 1 diabetes during the critical transition to adolescence.

Diabetes management and glycemic control in youth with type 1 diabetes: test of a predictive model

The objective of this study was to test a comprehensive model of biologic (pubertal status), family (communication and conflict), and psychological influences (behavioral autonomy) on diabetes management and glycemic control in a sample of youth (N = 226) with type 1 diabetes recruited during late childhood/early adolescence (ages 9-11 years). The study design was a prospective, multisite, multi-method study involving prediction of diabetes management and glycemic control 1 year post-baseline. The primary outcome measures included diabetes management behaviors based on the Diabetes Self-Management Profile (DSMP) administered separately to mothers and youth and glycemic control measured by glycated hemoglobin (HbA1c) obtained by blood samples and analyzed by a central laboratory to ensure standardization. Our hypothesized predictive model received partial support based on structural equation modeling analyses. Family conflict predicted less adequate glycemic control 1 year later (p < 0.05). Higher conflict predicted less adequate diabetes management and less adequate glycemic control. More advanced pubertal status also predicted less adequate glycemic control, but behavioral autonomy did not. Family conflict is an important, potentially clinically significant influence on glycemic control that should be considered in primary and secondary prevention in the management of type 1 diabetes in youth.

A comparison of two internet programs for adolescents with type 1 diabetes: design and methods

Implementing psycho-educational programs for youth with type 1 diabetes in clinical care and reaching diverse youth with type 1 diabetes is challenging due to youth, provider, and organizational barriers. This study was designed to compare the effectiveness of an internet coping skills training program with a control condition of internet diabetes education. Each program consists of 5 weekly interactive lessons; the coping skills training program also provides the ability for youth to interact with each other as well as a health coach. Approximately 300 youths with type 1 diabetes will be recruited to participate in this multi-site clinical trial. The primary outcomes are metabolic control, quality of life, and family conflict. Secondary outcomes include stress, coping, self-efficacy, and social competence. Usage, satisfaction, and cost will also be evaluated. In addition, mediators and moderators to intervention effects will be explored. An internet based psycho-educational program for youth with type 1 diabetes may be a promising approach that can be easily be integrated into clinical care.

Identification of self-management patterns in pediatric type 1 diabetes using cluster analysis

OBJECTIVES

This study identified three distinct patterns of self-management groups for a sample of 239 youth (9-11 years) with type 1 diabetes and their maternal and paternal caregivers, and assessed their relationship to glycemic control (HbA1c).

METHODS

Youth and their maternal and paternal caregivers were administered the diabetes self-management profile (DSMP) to assess self-management. Glycemic control was based on hemoglobin A1c.

RESULTS

Two-step cluster analysis identified three different self-management groups based on youth, maternal, and paternal reports. Analysis of variance indicated that the pattern of less optimal diabetes self-management was associated with worse glycemic control.

CONCLUSION

Our results objectively describe differences in patterns of self-management in youth with type 1 diabetes, that relate to glycemic control. Interventions based on these specific patterns of self-management may improve diabetes management and enhance glycemic control in children and adolescents with type 1 diabetes.

Fathers' involvement in preadolescents' diabetes adherence and glycemic control

OBJECTIVE

To examine the relationship of paternal involvement in diabetes care with adherence and glycemic control.

METHODS

One hundred and thirty-six mothers and fathers of preadolescents (aged 9-12 years) with type 1 diabetes reported on paternal involvement. Adherence was measured by interview and blood glucose meter downloads. Mothers' and fathers' ratings of paternal involvement in diabetes care were compared. We evaluated three structural equation models linking paternal involvement with adherence and glycemic control.

RESULTS

Mothers and fathers reported similar amounts of paternal involvement, yet mothers rated paternal involvement as more helpful. The data supported a model indicating links between more paternal involvement and higher HbA1c and between lower adherence and higher HbA1c. Mediation and moderation models were not supported.

DISCUSSION

Although paternal involvement was not directly associated with treatment adherence, it was associated with poorer glycemic control. Some fathers may increase their involvement in response to suboptimal glycemic outcomes.

Executive functioning, treatment adherence, and glycemic control in children with type 1 diabetes

OBJECTIVE

The primary aim of the study was to investigate the relationship among executive functioning, diabetes treatment adherence, and glycemic control.

RESEARCH DESIGN AND METHODS

Two hundred and thirty-five children with type 1 diabetes and their primary caregivers were administered the Diabetes Self-Management Profile to assess treatment adherence. Executive functioning was measured using the Behavior Rating Inventory of Executive Functioning and glycemic control was based on A1C.

RESULTS

Structural equation modeling indicated that a model in which treatment adherence mediated the relationship between executive functioning and glycemic control best fit the data. All paths were significant at P < 0.01.

CONCLUSIONS

These results indicate that executive functioning skills (e.g., planning, problem-solving, organization, and working memory) were related to adherence, which was related to diabetes control. Executive functioning may be helpful to assess in ongoing clinical management of type 1 diabetes.

Stress and body mass index each contributes independently to tumor necrosis factor-alpha production in prepubescent Latino children

This investigation extended prior work by determining if stress and body mass index (BMI) contributed independently to tumor necrosis factor-alpha (TNF-alpha) levels among prepubescent Latino children and if sex and family history of type 2 diabetes mellitus (T2DM) modified these relationships. Data were collected in South Florida from 112 nondiabetic school-aged Hispanic children, of whom 43.8% were obese (BMI >/= 95th percentile) and 51.8% presented with a family history of T2DM. Stressful life events were assessed via parental report using a life events scale. Plasma TNF-alpha levels were determined with enzyme-linked immunosorbent assay. The relative contributions of stress and BMI with TNF-alpha levels and the potential interaction effects of sex and family history of T2DM were analyzed with multiple linear regression analyses. Stress and BMI each accounted for a significant proportion of the unique variance associated with TNF-alpha. The association between stress and TNF-alpha was not modified by sex or family history of T2DM. These findings implicate BMI and stress as independent determinants of TNF-alpha (an inflammatory cytokine and adipocytokine) among Latino children. Future investigations should examine the potential roles of exercise, nutritional status, age, and growth hormone in explicating the relationship between TNF-alpha production and psychosocial distress and risk for infection among obese children.

Adherence and glycemic control among Hispanic youth with type 1 diabetes: role of family involvement and acculturation

OBJECTIVE

To assess whether family involvement and acculturation were related to adherence and glycemic control among Hispanic youth with type 1 diabetes (T1D).

METHODS

Hispanic youth with T1D (n = 111; M age = 13.33; 53% female) and parents completed questionnaires that assessed diabetes-related family involvement (distribution of responsibility for diabetes, family support for diabetes), acculturation (linguistic acculturation, generational status), and adherence. HbA1c levels indexed glycemic control.

RESULTS

Better adherence was associated with less adolescent independent responsibility, more family support for diabetes, and more recent immigration (fewer generations of the family living in US). Family support mediated the relationship between responsibility and adherence. Better glycemic control was associated with higher levels of parental education and adherence.

CONCLUSIONS

Family support for diabetes is important for adherence among Hispanic youth with T1D. Research should examine aspects of recent immigration that contribute to better adherence and the impact of supportive interventions on diabetes care.

Parent perspectives of diabetes management in schools

PURPOSE

The purpose of this study is to investigate parent reports of the diabetes care support their children receive in school, their concerns about diabetes management in school, and their knowledge of federal laws that protect children with diabetes. In addition, the study explores ethnic and socioeconomic status differences in diabetes management in school.

METHODS

An ethnically heterogeneous sample of 309 parents of children with diabetes was recruited from a community-based and a university-based diabetes outpatient clinic. Parents completed a survey assessing supports their child's school provides for diabetes care, worries about diabetes care in school, and awareness of federal laws that pertain to children with diabetes.

RESULTS

Many children did not have a written care plan or a nurse at school, but significantly more white children had these supports than Hispanic or black children. Most children were not allowed to check blood glucose levels or administer insulin in class. Most parents were worried about hyperglycemia and hypoglycemia in school, and most were not at all or only a little confident in the school's ability to care for diabetes. Most parents were not aware of federal laws, but high-income and white parents were more likely to be aware.

CONCLUSIONS

According to parents in the current study, children receive inadequate diabetes management support in schools. Minority children are less likely to receive supports than white children. Parents are worried about diabetes management in school, but most do not have the knowledge of federal laws necessary to protect their children.

Gender differences in TNF-alpha levels among obese vs nonobese Latino children

OBJECTIVE

To examine the relationships between TNF-alpha, obesity, and insulin resistance among prepubescent children.

DESIGN

Cross-sectional study.

SETTING AND SUBJECTS

Data were collected from 112 nondiabetic Latino schoolchildren from public schools in three South Florida communities. Of the enrolled participants, 43.8% were obese (BMI 95th percentile) and 51.8% presented with a family history of type 2 diabetes mellitus (T2DM). With one exception, all demonstrated normal glucose tolerance.

INTERVENTIONS

Plasma TNF-alpha levels were determined with enzyme-linked immunosorbance assay (ELISA). Homeostasis model assessment (HOMA-IR) was calculated as an index of insulin resistance. Mean levels of TNF-alpha among obese vs nonobese children were compared with a one-way analysis of variance with two groups, and the association between TNF-alpha and HOMA-IR was assessed with a Pearson's correlation.

RESULTS

Higher circulating TNF-alpha levels were revealed among nonobese vs obese children. Nonobese girls demonstrated higher TNF-alpha levels than obese girls, whereas there were no significant differences for boys. There were no significant differences after stratifying for family history of T2DM. There was a modest relationship between increased TNF-alpha levels and decreased insulin resistance.

CONCLUSIONS

The observed elevated circulating TNF-alpha concentrations among leaner participants may reflect an inflammatory process that has been associated with higher levels of physical fitness in both adults and prepubescent children. This effect may remain stronger for prepubescent girls, and the mechanism may be attenuated by the hormonal changes that occur with the onset of puberty.

Society of pediatric psychology task force report: recommendations for the training of pediatric psychologists

OBJECTIVE

To provide an overview of the types of training experiences considered most important to the development of competency in pediatric psychology.

METHODS

This is the work of a task force commissioned by the Society of Pediatric Psychology, Division 54 of the American Psychological Association.

RESULTS

Twelve topic areas, adapted from Roberts et al. (1998), deemed important for obtaining knowledge and expertise in pediatric psychology, were identified. These topics include life span developmental psychology; life span developmental psychopathology; child, adolescent, and family assessment; intervention strategies; research methods and systems evaluation; professional, ethical, and legal issues pertaining to children, adolescents, and families; issues of diversity; the role of multiple disciplines in service-delivering systems; prevention, family support, and health promotion; social issues affecting children, adolescents, and families; consultant and liaison roles; and disease process and medical management. Each area is briefly described and recommendations for obtaining training in these areas are offered.

CONCLUSIONS

The Society of Pediatric Psychology offers this document as a comprehensive review of the ideal types of training experiences most important to developing competencies in pediatric psychology. These recommendations can be used by graduate students and graduate programs in shaping a training plan for students interested in pediatric psychology training.

Aggression and cardiovascular response in children

OBJECTIVE

To examine cardiovascular response as a function of children's aggression after controlling for the effects of known risk factors.

METHOD

Participants were 140 children in second, fourth, and sixth grades. Teachers completed the Matthews Youth Test for Health, a measure that includes questions pertaining to children's aggression. Measures of blood pressure and heart rate were obtained during baseline, academic quiz, and recovery.

RESULTS

Increasing age and body mass index were associated with increased cardiovascular responses. Aggressive children exhibited higher heart rates at baseline and lower heart rate reactivity. Aggressive children with a positive parent history of hypertension exhibited the greatest cardiovascular response.

CONCLUSIONS

These results provide further support for the identification of behavioral factors that increase cardiovascular risk in children.

Parental self-efficacy and morbidity in pediatric asthma

This study investigated the relationship between parental self-efficacy and asthma-related morbidity. Participants included 139 parents of children (ages 5-8) who were diagnosed with asthma and were primarily from lower-income and minority backgrounds. Parents completed a 22-item measure of self-efficacy; factor analysis was conducted on this measure, yielding two factors: learned helplessness and self-efficacy. Correlational analyses indicated that higher scores on the learned helplessness factor were significantly related to increased asthma-related morbidity for the majority of morbidity variables. The self-efficacy factor was significantly related to days of school missed. Regression analyses conducted with the factor scores and the morbidity variables provide further support that the learned helplessness factor accounts for a significant amount of the variance in asthma morbidity for many of the variables studied, while the self-efficacy factor was related to only a few. Although improving health outcomes of children with asthma is a multifaceted process, the results of this study suggest that targeting parental self-efficacy, particularly with parents who are experiencing high levels of perceived learned helplessness, may be a helpful component of an intervention program with this population.

Early life stress and disease among offspring and siblings of individuals with type 1 diabetes mellitus

Major life events, recent life stressors, and childhood diseases were examined among children and adolescents who were offspring, siblings, or other relatives of persons with type 1 diabetes mellitus (DM). All youth were recruited as part of a multi-site nationwide trial on the prevention of type 1 DM; parents of 347 children (4 to 18 yr) completed measures that asked about children's life events, recent stressors, and childhood illnesses. Analyses compared age groups (young child, preadolescent, adolescent) and relative type (offspring, sibling, other relative). Findings revealed offspring and siblings did not differ from "other relatives" in terms of life events, recent life stress, and disease/illness variables. However, siblings were reported to have fewer major life events and fewer life stressors in the past 12 months than offspring; siblings also had fewer infectious diseases during the first two years of life compared to offspring. Few age-related differences were found. Overall, results suggest that offspring and siblings of persons with type 1 DM are not at a disadvantage in terms of early life stress or disease in comparison to youth who have other family members with diabetes. However, siblings may have some advantages relative to children who are offspring. The mechanisms underlying these relationships require further elucidation and study.

Psychosocial adjustment of patients arriving early at the emergency department after acute myocardial infarction

The psychosocial functioning of patients arriving at the emergency department with an acute myocardial infarction early enough to be candidates for treatment with thrombolytic agents was compared with that of those arriving later. Patients who arrived within 3 hours were significantly more anxious when assessed 1 week after admission and had a consistently worse pattern of psychosocial adjustment 3 months after hospital discharge than did those who arrived later. The implications of these findings for efforts to improve early arrival at the emergency department, as well as for medical and psychosocial outcomes after acute myocardial infarction, were considered.

Visual-motor tracking by hyperkinetic children

Two studies of a visual-motor tracking task purported to be an effective discriminator of subtypes of minimal brain dysfunction are presented. Performances of 16 psychiatric inpatients were compared with those of 14 hyperactive males and of 15 normal controls. A second study evaluated effects of practice and drug sensitivity on tracking. The task discriminated patients from normals but did not discriminate the groups of patients from each other. Interactions of practice, age, and diagnosis were found. Some degree of sensitivity of the task to stimulant medication was also obtained. Visual-motor tracking is a useful measure of stimulant drug action but does not measure a defect specific to hyperkinetic patients.