Evaluating barriers and facilitators to healthcare providers' use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework

OBJECTIVE

Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services.

METHODS

The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis.

RESULTS

Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers.

CONCLUSIONS

Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.

Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors

OBJECTIVES

Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms.

METHODS

Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression.

RESULTS

DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management.

CONCLUSIONS

Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.

Interventions Across the Translational Research Spectrum: Addressing Disparities Among Racial and Ethnic Minoritized Youth with Type 1 Diabetes

Racial and ethnic minoritized youth with type 1 diabetes (T1D) are at elevated risk for health disparities. Few intervention studies have been conducted for these youth and evidence to support best practices to address their needs is lacking. Existing evidence supports the use of brief trials of diabetes technology with structured support from clinic staff, culturally tailored interventions such as language-congruent clinical care, and use of community health workers as promising directions to improve health outcomes. Clinicians and researchers should work collaboratively with community members to improve the quality of T1D intervention science for racial and ethnic minoritized youth.

Racial Residential Segregation and the Health of Black Youth With Type 1 Diabetes

OBJECTIVES

Black youth with type 1 diabetes (T1D) are at heightened risk for suboptimal glycemic control. Studies of neighborhood effects on the health of youth with T1D are limited. The current study investigated the effects of racial residential segregation on the diabetes health of young Black adolescents with T1D.

METHODS

A total of 148 participants were recruited from 7 pediatric diabetes clinics in 2 US cities. Racial residential segregation (RRS) was calculated at the census block group level based on US Census data. Diabetes management was measured via self-report questionnaire. Hemoglobin A1c (HbA1c) information was gathered from participants during home-based data collection. Hierarchical linear regression was used to test the effects of RRS while controlling for family income, youth age, insulin delivery method (insulin pump versus syringe therapy), and neighborhood adversity.

RESULTS

HbA1c was significantly associated with RRS in bivariate analyses, whereas youth-reported diabetes management was not. In hierarchical regression analyses, whereas family income, age, and insulin delivery method were all significantly associated with HbA1c in model 1, only RRS, age, and insulin delivery method were significantly associated with HbA1c in model 2. Model 2 explained 25% of the variance in HbA1c (P = .001).

CONCLUSIONS

RRS was associated with glycemic control in a sample of Black youth with T1D and accounted for variance in HbA1c even after controlling for adverse neighborhood conditions. Policies to reduce residential segregation, along with improved screening for neighborhood-level risk, hold the potential to improve the health of a vulnerable population of youth.

Naturalistically observed interpersonal problems and diabetes management in older adolescents and young adults with type 1 diabetes

OBJECTIVE

This study investigated the links between naturalistically observed and self-reported interpersonal problems, diabetes management, and glucose levels in older adolescents and young adults with type 1 diabetes.

DESIGN

Sixty-eight older adolescents and young adults (aged 17-20 years) participated in a cross-sectional study that consisted of three home visits and a daily diary segment.

MAIN OUTCOME MEASURES

Participants wore the Electronically Activated Recorder (EAR) for four days to capture interpersonal problems and wore a continuous glucose monitor for blood glucose levels. Researchers also collected HbA1c values, conducted an interview to assess diabetes management, and collected participant-reported severity of interpersonal problems.

RESULTS

High EAR-observed interpersonal problems were associated with poor diabetes management. Multiple regression analyses revealed that high EAR-observed interpersonal problems continued to explain variance in poor diabetes management after including self-reported interpersonal problems and covariates.

CONCLUSION

These findings corroborate literature suggesting that negative interactions are associated with type 1 diabetes management. This study is the first to use the EAR to capture naturalistically observed interactions in this population and identify its utility beyond self-reports. These findings highlight the importance of considering naturalistically observed interactions when developing interventions to promote better diabetes management in older adolescents and young adults.

The effect of an mHealth intervention for adolescents with Type 1 diabetes and their parents

BACKGROUND

Past research has demonstrated that adolescents with Type 1 diabetes (T1D) typically have a decline in health outcomes as they begin to assume more self-management activities. Mobile app interventions have been suggested as one possible way to improve this behavior.

PURPOSE

The primary aim of this study was to address declines in health outcomes by pilot testing the satisfaction, use and feasibility of an app-based family communication intervention aimed to assist in adolescent self-management of T1D.

METHODS

Thirty-three adolescent-parent pairs were enrolled in and completed the 12-week pilot study. Participants were randomized 2:1 to intervention (app use) or control group. Pre/post quantitative and qualitative data were collected, including HbA1c and surveys. Paired-sample t-tests and ANOVA statistics were conducted.

RESULTS

The parents and adolescents reported high satisfaction with the app, and that it was easy to use. Results showed HbA1c stability in the intervention group and significant worsening in the control group. There were also significant improvements in adherence to diabetes management and quality of life for the parents in the intervention group. The adolescents did not show any improvement in quality-of-life measures.

CONCLUSION

This study suggests that the app intervention is acceptable, shows promise for improving health outcomes for adolescents with T1D, and may improve family communication. The public health implications of this work are that app interventions have a potential role in positively influencing chronic disease outcomes. Additional research with a more extensive and diverse sample is needed to determine generalizability.

An mHealth-Based Intervention for Adolescents With Type 1 Diabetes and Their Parents: Pilot Feasibility and Efficacy Single-Arm Study

Background

Type 1 diabetes (T1D) affects more than 165,000 individuals younger than 20 years in the United States of America. The transition from parent management to parent-child team management, with the child taking on increased levels of self-care, can be stressful and is associated with a deterioration in self-management behaviors. Therefore, a mobile app intervention, MyT1DHero, was designed to facilitate diabetes-specific positive parent-adolescent communication and improve diabetes-related outcomes. The MyT1DHero intervention links an adolescent with T1D and their parent through 2 separate app interfaces and is designed to promote positive communication regarding T1D management.

Objective

The aim of this pilot study was to determine (1) the initial efficacy of the MyT1DHero intervention in improving diabetes outcomes in adolescents, specifically the hemoglobin A_1c (HbA_1c) levels, diabetes care adherence, and quality of life, and (2) the adolescents’ overall satisfaction with this intervention.

Methods

This pilot study included 30 adolescent-parent pairs who used the MyT1DHero app in a 12-week single-arm clinical trial. Participants were recruited from the local pediatric endocrinology subspecialty clinic via snowball sampling. HbA_1c levels, diabetes care adherence, quality of life, family conflict, and satisfaction levels were measured and analyzed using paired sample two-sided t tests and linear regression analyses.

Results

The final analysis included 25 families. The mean age of the adolescents was 12.28 (SD 1.62) years. Half of the participants (13/25) reported a diabetes diagnosis of less than 5 years. After 12 weeks of the intervention, diabetes care adherence significantly improved (before the study: mean 3.87 [SD 0.59]; after the study: mean 4.19 [SD 0.65]; t₂₁=–2.52, P=.02, d=0.52) as did quality of life (before the study: mean 4.02 [SD 0.84]; after the study: mean 4.27 [SD 0.73]; t₂₄=2.48, P=.01, d=0.32). HbA_1c levels (before the study: mean 8.94 [SD 1.46]; after the study: mean 8.87 [SD 1.29]; t₂₄=0.67, P=.51, d=0.04) and family conflict (before the study: mean 2.45 [SD 0.55]; after the study: mean 2.61 [SD 0.45]; t₂₃=0.55, P=.14, d=0.32) changed in the hypothesized direction, but the change was not significant. However, higher use of the mobile app was associated with more improvement in HbA_1c levels (F_1,20=9.74, P<.005; R²=0.33). Overall, the adolescents were satisfied with the app intervention.

Conclusions

In a 12-week pilot study of the mobile app intervention designed to facilitate parent-adolescent communication for improving diabetes outcomes, significant benefits were demonstrated in self-care adherence and quality of life. A randomized controlled trial with a longer intervention is needed to replicate these findings and to determine the stability of the intervention effects.

Trial Registration

ClinicalTrials.gov NCT03436628; https://clinicaltrials.gov/ct2/show/NCT03436628

Optimizing Recruitment of Black Adolescents into Behavioral Research: A Multi-Center Study

OBJECTIVES

Adolescents of color are underrepresented in behavioral health research. Study aims were to quantify the amount and types of outreach effort needed to recruit young Black adolescents with type 1 diabetes and their primary caregiver into a clinical trial evaluating a parenting intervention and to determine if degree of recruitment difficulty was related to demographic, diabetes-related, or family characteristics.

METHODS

Data were drawn from a multi-center clinical trial. Participants (N = 155) were recruited from seven pediatric diabetes clinics. Contact log data were used to quantify both number/type of contacts prior to study enrollment as well as length of time to enrollment. Families were coded as having expedited recruitment (ER) or prolonged recruitment (PR). Baseline study data were used to compare ER and PR families on sociodemographic factors, adolescent diabetes management and health status and family characteristics such as household organization and family conflict.

RESULTS

Mean length of time to recruit was 6.6 months and mean number of recruitment contacts was 10.3. Thirty-nine percent of the sample were characterized as PR. These families required even higher levels of effort (mean of 9.9 months to recruit and 15.4 contacts). There were no significant between-group differences on any baseline variable for ER and PR families, with the exception of family income.

CONCLUSIONS

Researchers need to make persistent efforts in order to successfully enroll adolescents of color and their caregivers into clinical trials. Social determinants of health such as family resources may differentiate families with prolonged recruitment within such samples.

Effects of family and neighborhood risks on glycemic control among young black adolescents with type 1 diabetes: Findings from a multi-center study

While individual and family risk factors that contribute to health disparities in children with type 1 diabetes have been identified, studies on the effects of neighborhood risk factors on glycemic control are limited, particularly in minority samples. This cross-sectional study tested associations between family conflict, neighborhood adversity and glycemic outcomes (HbA1c) in a sample of urban, young Black adolescents with type 1 diabetes(mean age = 13.4 ± 1.7), as well as whether neighborhood adversity moderated the relationship between family conflict and HbA1c. Participants (N = 128) were recruited from five pediatric diabetes clinics in two major metropolitan US cities. Diabetes-related family conflict was measured via self-report questionnaire (Diabetes Family Conflict Scale; DFCS). Neighborhood adversity was calculated at the census block group level based on US census data. Indictors of adversity were used to calculate a neighborhood adversity index (NAI) for each participant. Median family income was $25,000, suggesting a low SES sample. In multiple regression analyses, DFCS and NAI both had significant, independent effects on glycemic control (β = 0.174, P = 0.034 and β = 0.226 P = 0.013, respectively) after controlling for child age, family socioeconomic status and insulin management regimen. Tests of effects of the NAI and DFCS interaction on HbA1c found no significant moderating effects of neighborhood adversity. Even within contexts of significant socioeconomic disadvantage, variability in degree of neighborhood adversity predicts diabetes-related health outcomes in young Black adolescents with type 1 diabetes. Providers should assess social determinants of health such as neighborhood resources that may impact adolescents' ability to maintain optimal glycemic control.

Toward the Development of a Culturally Humble Intervention to Improve Glycemic Control and Quality of Life among Adolescents with Type-1 Diabetes and Their Families

Type-1 Diabetes (T1D) is a prevalent and costly disorder associated with substantial morbidity that differentially impacts low-income and/or minority adolescents and their families. The primary study objective was to develop a guiding model to inform culturally humble interventions for Mid-southern youth with T1D presenting with multiple correlates of suboptimal glycemic control and their families. In order to develop a clinic specific guiding model, conceptualizations of health, the need/type of intervention thought to be most helpful, the optimal structure, and strategies to improve the cultural/regional fit was ascertained from (A) youth with T1D (n = 13) and caregivers (n = 11) via qualitative interviews and, (B) pediatric endocrinologists and nurse practitioners (n = 6), and (C) nurses, diabetes educators, dietitians, and social workers (n = 9) via focus groups. Qualitative themes were synthesized to guide the treatment development model whereby Quality of Life and Glycemic Control would be directly enhanced by interventions to promote Coping, Support, Education, and Improved Psychosocial Functioning and indirectly through improved Adherence and T1D Autonomy delivered in a culturally humble way that affirms youths' T1D identify. These finding suggest that existing evidence-based treatments may provide a great fit for low-income, and/or minority youth with T1D and their families living in the mid-south, provided these interventions are delivered in culturally humble manner.

Managing Outliers in Adolescent Food Frequency Questionnaire Data

OBJECTIVE

The goal of this study was to explore the impact of 5 decision rules for removing outliers from adolescent food frequency questionnaire (FFQ) data.

DESIGN

This secondary analysis used baseline and 3-month data from a weight loss intervention clinical trial.

PARTICIPANTS

African American adolescents (n = 181) were recruited from outpatient clinics and community health fairs.

VARIABLES MEASURED

Data collected included self-reported FFQ and mediators of weight (food addiction, depressive symptoms, and relative reinforcing value of food), caregiver-reported executive functioning, and objectively measured weight status (percentage overweight).

ANALYSIS

Descriptive statistics examined patterns in study variables at baseline and follow-up. Correlational analyses explored the relationships between FFQ data and key study variables at baseline and follow-up.

RESULTS

Compared with not removing outliers, using decision rules reduced the number of cases and restricted the range of data. The magnitude of baseline FFQ-mediator relationships was attenuated under all decision rules but varied (increasing, decreasing, and reversing direction) at follow-up. Decision rule use increased the magnitude of change in FFQ estimated energy intake and significantly strengthened its relationship with weight change under 2 fixed range decision rules.

CONCLUSIONS AND IMPLICATIONS

Results suggest careful evaluation of outliers and testing and reporting the effects of different outlier decision rules through sensitivity analyses.

Improving Diabetes Management in Emerging Adulthood: An Intervention Development Study Using the Multiphase Optimization Strategy

Background

Poor diabetes self-management in emerging adulthood (age 18-25 years) is associated with poorer diabetes health and diabetes complications. Emerging adults’ focus on individuation and independence underlies their poor diabetes outcomes, offering a lever for behavior change. Self-determination theory (SDT) suggests that interventions leveraging emerging adults’ innate developmental need for autonomy may offer a route to improving diabetes outcomes by increasing feelings of responsibility for and control over diabetes self-management activities.

Objective

This research project will use the multiphase optimization strategy to test the efficacy of three autonomy-supportive intervention components to elicit a clinically significant improvement in metabolic control, assessed by a 0.5% improvement in hemoglobin A_1c (HbA_1c), among older adolescents and emerging adults (16-25 years) with poorly controlled type 1 diabetes (T1D; HbA_1c≥9.0%).

Methods

A question prompt list (QPL) is a tool to empower patients to assume a more active role during medical visits by asking questions and stating concerns. The motivation enhancement system (MES) is a brief counseling intervention that uses motivational interviewing communication strategies to build intrinsic motivation and self-efficacy for self-management. Text message reminders to complete diabetes care tasks may increase self-efficacy for diabetes self-management. After refining these intervention components for emerging adults, we will conduct a component selection experiment using an eight-arm full factorial design: 2 (QPL yes or no)×2 (MES yes or no)×2 (Text yes or no). Participants will complete 3 study visits: baseline, treatment end at 2 months, and a follow-up at 6 months. The primary outcome is metabolic control, which will be measured via HbA_1c. Secondary outcomes include diabetes management and diabetes clinic attendance. SDT constructs of intrinsic motivation, self-efficacy, and the quality of the patient-provider relationship (ie, relatedness) are hypothesized mediators. Depression symptoms and emerging adults’ gender are hypothesized moderators. We will use the mixed-effects linear model for the analysis of variance of a factorial design to analyze continuous longitudinal experimental data; the generalized linear model will be used with categorical outcomes (eg, treatment attendance). The experiment was powered to detect the main effects of the intervention on the primary outcome.

Results

A total of 20 participants have enrolled and completed a qualitative interview after reviewing one or more intervention components. Analysis of interview data are underway, with a report of these results anticipated in the fall of 2020. The clinical trial will be launched in the fall 2020, with participants enrolled through May 2023 and data collection continuing through November 2023.

Conclusions

At the end of this experiment, we will have empirical evidence to support a large-scale, multisite effectiveness trial of an intervention package that has been optimized for older adolescents and emerging adults with poorly controlled T1D.

Trial Registration

ClinicalTrials.gov NCT04066959; https://clinicaltrials.gov/ct2/show/NCT04066959

International Registered Report Identifier (IRRID)

DERR1-10.2196/20191

Adaptation of an Evidence-Based Diabetes Management Intervention for Delivery in Community Settings: Findings From a Pilot Randomized Effectiveness Trial

Objective

To adapt an evidence-based intervention targeting diabetes management in adolescents with poorly controlled type 1 diabetes for use in a community setting by community health workers (CHWs) and to conduct pilot testing of the new intervention, REACH for Control (RFC). The study was conducted as a collaboration between university researchers and a federally qualified health center. Methods In a pilot effectiveness trial, feasibility and acceptability of RFC were evaluated based on participant enrollment, treatment dose, and consumer satisfaction. RFC effects on adolescent adherence, health outcomes, and quality of life were also assessed. The trial used a parallel group design. Families were randomized to 6 months of RFC plus standard medical care (n = 26) or standard care (SC) only (n = 24). Data were collected at baseline and 7-month posttest. A mixed-methods approach was used to analyze data.

Results

Qualitative analyses suggested that caregivers viewed RFC and delivery of a home-based intervention by CHWs positively. Furthermore, adolescents who received RFC had statistically significant (p = .05) and clinically meaningful improvements in hemoglobin A1c (HbA1c) (0.7%) and reported significant improvements in quality of life from baseline to follow-up (p = .001). No significant changes were found for adolescents in standard medical care. However, while dose of primary intervention session delivered was acceptable, dose of follow-up sessions used for skills practice was low.

Conclusions

Results provide preliminary support for RFC's acceptability and effectiveness to improve health status and quality of life when used in community settings serving high-risk, low-income families. Additional testing in a full-scale effectiveness trial appears warranted.

Physical Activity as a Predictor of Changes in Systolic Blood Pressure for African-American Adolescents Seeking Treatment for Obesity

PURPOSE

The aim of the study was to examine changes in systolic blood pressure (SBP) and whether physical activity and obesity status predicted SBP change for African-American adolescents (n = 181) participating in a behavioral weight control trial.

METHODS

Data were collected at baseline, 7 months (end-of-treatment), and 9 months (2-month follow-up).

RESULTS

Nearly half of adolescents achieved clinically significant SBP reductions at 7 and 9 months. Significantly, fewer adolescents had elevated SBP at 7 and 9 months compared with baseline (both p < .001). Changes in percent overweight and moderate-to-vigorous activity predicted changes in SBP over time.

CONCLUSIONS

Obesity reduction and increases in moderate-to-vigorous physical activity may predict short-term, clinically meaningful reductions in SBP for African American adolescents with obesity.

African-American Adolescents' Weight Loss Skills Utilization: Effects on Weight Change in a Sequential Multiple Assignment Randomized Trial

OBJECTIVE

Successful weight loss interventions for African-Americans adolescents are lacking. Cognitive-behavioral interventions seek to develop weight loss skills (e.g., counting calories, goal setting, managing one's environment). Little is known about how well adolescents implement such skills in their daily lives. Study aims were to (1) examine weight loss skills utilization at midpoint and end of a 6-month cognitive-behavioral/motivational interviewing weight loss sequential multiple assignment randomized trial (SMART), and (2) determine if greater skill utilization predicted weight loss at treatment end and 3 months post-treatment.

METHOD

One hundred and eighty six African-Americans adolescents with obesity and their caregiver were first randomly assigned to complete 3 months of cognitive-behavioral and motivational interviewing family-based weight loss treatment in their home or in the research office (Phase 1). Nonresponders (i.e., those who lost < 3% of initial weight, n = 161) were rerandomized to 3 months of continued skills training (n = 83) or contingency management (n = 78) for Phase 2; responders were allocated to 3 months of relapse prevention (n = 20). Adolescents' frequency of weight loss skills utilization was assessed via questionnaire at treatment midpoint and end.

RESULTS

Higher treatment attendance was associated with better skill utilization. Higher skill utilization was associated with more weight loss at treatment end, whereas higher baseline confidence was associated with more weight loss at follow-up.

CONCLUSIONS

This study indicates the importance of attending weight loss intervention sessions to develop and strengthen weight loss skills in African-American adolescents with obesity, and strengthening confidence to use such skills for continued weight loss.

Efficacy of mindfulness-based stress reduction in emerging adults with poorly controlled, type 1 diabetes: A pilot randomized controlled trial

BACKGROUND/OBJECTIVE

The negative effects of stress on persons with type 1 diabetes (T1D) are well-established, but effective interventions to reduce stress among emerging adults with T1D are limited. The study objective was to conduct a pilot randomized controlled trial (RCT) to obtain preliminary data on the efficacy of mindfulness-based stress reduction (MBSR) to reduce stress and improve diabetes health outcomes in a population of high-risk, urban emerging adults with poorly controlled diabetes.

METHODS

Forty-eight participants aged 16 to 20 years of age with T1D (mean duration = 8 years) were randomly assigned to one of three conditions: MSBR, cognitive-behavioral stress management (CBSM), or a diabetes support group. Data were collected at baseline, end of treatment, and 3 months after treatment completion. Measures of self-reported stress and depressive symptoms, diabetes management, and glycemic control were obtained.

RESULTS

MBSR was found to reduce self-reported stress at end of treatment (P = 0.03, d = -0.49) and 3-month follow-up (P = 0.01, d = -0.67), but no effects on diabetes management or glycemic control were found. Diabetes support group participants had improved glycemic control at the end of treatment (P = 0.01, d = -0.62) as well as reduced depressive symptoms at 3-month follow-up (P = 0.01, d = -0.71).

CONCLUSIONS

Results provide preliminary support for the efficacy of MBSR to improve psychosocial adjustment in emerging adults with poorly controlled T1D but require replication in adequately powered studies. Findings also support the value of peer support in improving health outcomes in this age group.

Improving Diabetes-Related Parent-Adolescent Communication With Individualized Feedback

Objective

To pilot a brief individualized feedback intervention to improve the communication skills of parents with an adolescent with type 1 diabetes.

Methods

Parent-adolescent dyads (N = 79) discussed a diabetes-related problem, while an interventionist rated the parent's communication skills to give feedback to the parents. Parents were then randomized to a brief feedback session to target person-centered communication skills or an educational session. Dyads discussed another diabetes care problem to assess for change in communication skills. Independent raters coded parent communication skills from video recordings to rate behaviors in the service of examining possible changes in communication skills. Dyads completed ratings of perceived closeness and empathy after each conversation.

Results

Controlling for overall positive communication at baseline, parents who received feedback showed more improvement in specific person-centered communication skills than parents in the control group. Adolescents in the feedback group reported greater increases in parental empathy and intimacy from pre- to postmanipulation than the control.

Conclusions

The feedback intervention showed preliminary efficacy for increasing person-centered communication skills and perceived empathy and intimacy.

Feasibility of Mindfulness-Based Stress Reduction for Older Adolescents and Young Adults with Poorly Controlled Type 1 Diabetes

Objective

The purpose of the study was to assess the acceptability and feasibility of Mindfulness-Based Stress Reduction (MBSR), a group-delivered intervention, to reduce stress and improve illness management among urban, older adolescents, and young adults with poorly controlled type 1 diabetes (T1D).

Method

Ten older adolescents and young adults (9 females, 1 male) were recruited to participate in an MBSR group. Acceptability and feasibility were assessed based on recruitment and retention, treatment satisfaction, and changes in stress, diabetes management, and health status using a mixed-methods approach.

Results

Satisfaction with MBSR was high based on both quantitative and qualitative data. Preliminary evidence was found to suggest that MBSR reduced stress and improved blood glucose levels.

Conclusions

Findings from a small feasibility study suggest that MBSR could be delivered to urban older adolescents and young adults with T1D with high rates of satisfaction. Additional testing in adequately powered controlled clinical trials appears warranted.

Evaluation of an Evidence-Based Weight Loss Trial for Urban African American Adolescents and Caregivers

Rates of obesity are among the highest for African American adolescents in the US. However, African American adolescents benefit the least from evidence-based weight loss interventions, often experiencing poor treatment retention and low motivation. Participant evaluations provide key information for future development of family-based weight loss interventions able to address these barriers. The purpose of this study was to examine the experiences of African American adolescent and caregivers participating in the FIT Families trial for program satisfaction and content palatability. Content analysis was used to analyze semi-structured exit interviews from 136 African American adolescents [median age 14 years, 69% female] and caregiver pairs [primarily mothers] participating in a family-based 6-month behavioral weight loss intervention that was delivered either in the home or in an office setting. Participants reported most program practices [location, parent involvement, interpersonal relationship with weight loss counselors] and intervention content [cognitive behavioral skills training, motivational interviewing, contingency management] were helpful. Many adolescents [49%] and their caregivers [47%] reported that the program was acceptable overall, however noted that areas for refinement did exist. Participants reported that managing the logistics of weekly sessions was hard. Families expressed a desire for more engaging skills-based learning and the inclusion of exercise sessions and additional tailoring to needs and interests. Individualization, active learning, and support around parenting continues to be beneficial when designing interventions.

Biopsychosocial pathways linking subjective socioeconomic disadvantage to glycemic control in youths with type I diabetes

Older adolescent and young adults (OAYA) with type 1 diabetes (T1D) living in contexts of socio-economic disadvantage (SED) suffer disproportionately from poor glycemic control and related health complications. Although SED may convey a variety of risks, it may exacerbate diabetes-related stress levels, which in turn may account for observed disparities in health outcomes. The primary goal of the present study was to investigate the relationship between subjective SED, diabetes-related perceived stress, and diurnal cortisol secretion in urban OAYA with T1D. A secondary goal was to determine if cortisol was related to measures of blood glucose (HbA1c and mean blood glucose). Analyses were conducted among OAYA ages 17-20 years (n=61) affected by T1D, who provided daily saliva samples for four days, measures of glycemic control (i.e., HbA1c and mean blood glucose assessed via Continuous Glucose Monitor), and completed psychosocial questionnaires. We found that subjective SED was associated with a flatter diurnal cortisol rhythm via diabetes-related stress. Flattened cortisol rhythm was, in turn, associated with higher levels of HbA1c, but not with mean blood glucose assessed via Continuous Glucose Monitor. These results represent some of the first empirical evidence on how distal social factors (i.e., subjective SED) and proximal psychological processes (diabetes-related perceived stress) are connected to condition-relevant biological mechanisms (i.e., elevated HbA1c), via broad biological pathways implicated in health (i.e., flatter cortisol slope).

Brief Computer-Delivered Intervention to Increase Parental Monitoring in Families of African American Adolescents with Type 1 Diabetes: A Randomized Controlled Trial

BACKGROUND

African American adolescents with type 1 diabetes (T1D) are at elevated risk for poor diabetes management and metabolic control. Parental supervision and monitoring of adolescent diabetes management have been shown to promote better diabetes management among adolescents, but parents typically decrease their oversight during the transition to independent diabetes care.

INTRODUCTION

The purpose of the study was to conduct a randomized clinical trial to test the feasibility and efficacy of a three-session, computer-delivered motivational intervention (The 3Ms) to promote increased parental monitoring among primary caregivers of young African American adolescents with T1D. The intervention was brief and optimized for delivery during routine diabetes clinic visits.

MATERIALS AND METHODS

Sixty-seven adolescents with T1D aged 11-14 and their primary caregiver were randomly assigned to one of three arms: adolescent and parent motivational intervention (Arm 1), adolescent control and parent motivational intervention (Arm 2), or adolescent and parent control (Arm 3). Intervention effects were assessed 1 month after intervention completion.

RESULTS

Parents in Arm 1 and Arm 2 had significant increases in knowledge of the importance of monitoring adolescents' diabetes care. Parents in Arm 2 also had trend to significant increases in direct observation and monitoring of adolescent diabetes care, and adolescents in Arm 2 had significant improvements in glycemic control.

DISCUSSION AND CONCLUSIONS

Findings from the present study provide preliminary support for the efficacy of a brief, computer-delivered parenting intervention for improving family management practices and adolescent health outcomes among African American adolescents with T1D and their caregivers.

Multisystemic Therapy Improves the Patient-Provider Relationship in Families of Adolescents with Poorly Controlled Insulin Dependent Diabetes

The purpose of this study was to determine if multisystemic therapy (MST), an intensive, home and community-based family treatment, significantly improved patient-provider relationships in families where youth had chronic poor glycemic control. One hundred forty-six adolescents with type 1 or 2 diabetes in chronic poor glycemic control (HbA1c ≥8 %) and their primary caregivers were randomly assigned to MST or a telephone support condition. Caregiver perceptions of their relationship with the diabetes multidisciplinary medical team were assessed at baseline and treatment termination with the Measure of Process of Care-20. At treatment termination, MST families reported significant improvement on the Coordinated and Comprehensive Care scale and marginally significant improvement on the Respectful and Supportive Care scale. Improvements on the Enabling and Partnership and Providing Specific Information scales were not significant. Results suggest MST improves the ability of the families and the diabetes treatment providers to work together.

Effects of socio-demographic factors on parental monitoring, and regimen adherence among adolescents with type 1 diabetes: A moderation analysis

Parental monitoring of adolescent diabetes care is an important predictor of adolescent regimen adherence. To date, no studies have investigated whether socio-demographic factors are associated with low levels of parental monitoring or differences in parental monitoring styles, and their moderating effects in families of adolescents with type 1 diabetes. The purpose of this cross-sectional study was to determine whether youth and family socio-demographic factors moderated the relationship between monitoring and youth regimen adherence (i.e., mean frequency of blood glucose testing [BGT]). Data were collected from 267 adolescents with type 1 diabetes and their parents. Hierarchical multiple regression analyses were employed. Socio-demographic factors accounted for 17.1% of the variance in adherence. After parental monitoring scales were entered, R2 in all eight equations increased and R2 change score in six of eight equations were significant. All models were significant after the interaction terms were entered. In the adolescent report models, parent age and family structure were both independently associated with adherence and also moderated the association between adolescent-report parental monitoring and adherence to diabetes care, in particular, adolescent report of parental direct observation/presence during diabetes care. In the parent report models, income was moderated the association between parent-report youth disclosure and adherence. Research should focus on identifying additional modifiable factors that place families at risk for low levels of parental monitoring of diabetes care. Future clinical research is needed to help identify risk factors for low levels of parental monitoring and develop interventions to promote optimal parenting skills that can support youth diabetes care.

Contingency management adapted for African-American adolescents with obesity enhances youth weight loss with caregiver participation: a multiple baseline pilot study

BACKGROUND

Contingency management (CM) interventions, which use operant conditioning principles to encourage completion of target behavioral goals, may be useful for improving adherence to behavioral skills training (BST). Research-to-date has yet to explore CM for weight loss in minority adolescents.

OBJECTIVE

To examine the effects of CM in improving adolescent weight loss when added to BST.

DESIGN

The study utilized an innovative experimental design that builds upon multiple baseline approaches as recommended by the National Institutes of Health.

PARTICIPANTS/SETTING

Six obese African-American youth and their primary caregivers living in Detroit, Michigan, USA.

INTERVENTION

Adolescents received between 4 and 12 weeks of BST during a baseline period and subsequently received CM targeting weight loss.

MAIN OUTCOME MEASURES

Youth weight.

STATISTICAL ANALYSIS PERFORMED

Linear mixed effects modeling was used in the analysis.

RESULTS

CM did not directly affect adolescent weight loss above that of BST (p=0.053). However, when caregivers were involved in CM session treatment, contingency management had a positive effect on adolescent weight loss. The estimated weight loss due to CM when caregivers also attended was 0.66 kg/week (p<0.001, [95% CI; -1.96, -0.97]) relative to the baseline trajectory.

CONCLUSION

This study demonstrates application of a novel experimental approach to intervention development and demonstrated the importance of parent involvement when delivering contingency management for minority youth weight loss. Lessons learned from contingency management program implementation are also discussed in order to inform practice.

Mediators of Treatment Effects in a Randomized Clinical Trial of Multisystemic Therapy-Health Care in Adolescents With Poorly Controlled Asthma: Disease Knowledge and Device Use Skills

OBJECTIVE

Determine whether Multisystemic Therapy-Health Care (MST-HC) improved asthma knowledge and controller device use skills among African-American youth with poorly controlled asthma and whether any improvements mediated changes in illness management.

METHODS

A randomized controlled trial was conducted with 170 adolescents with moderate to severe asthma. Families were randomized to MST-HC or attention control. Data were collected at baseline and 6 and 12 months after intervention completion.

RESULTS

In linear mixed models, adolescents in the MST-HC group had increases in asthma knowledge; asthma knowledge was unchanged for attention control. Controller device use skills increased for adolescents in the MST-HC group, while skills declined for attention control. Both knowledge and skills mediated the relationship between intervention condition and changes in illness management.

CONCLUSIONS

Tailored, home-based interventions that include knowledge and skills building components are one means by which illness management in African-American youth with poorly controlled asthma can be improved.

Recruitment strategies and the retention of obese urban racial/ethnic minority adolescents in clinical trials: the FIT families project, Michigan, 2010-2014

Introduction

The successful recruitment and retention of participants is integral to the translation of research findings. We examined the recruitment and retention rates of racial/ethnic minority adolescents at a center involved in the National Institutes of Health Obesity Research for Behavioral Intervention Trials (ORBIT) initiative by the 3 recruitment strategies used: clinic, informatics, and community.

Methods

During the 9-month study, 186 family dyads, each composed of an obese African American adolescent and a caregiver, enrolled in a 6-month weight-loss intervention, a sequential multiple assignment randomized trial. We compared recruitment and retention rates by recruitment strategy and examined whether recruitment strategy was related to dyad baseline characteristics.

Results

Of the 186 enrolled families, 110 (59.1%) were recruited through clinics, 53 (28.5%) through informatics, and 23 (12.4%) through community. Of those recruited through community, 40.4% enrolled in the study, compared with 32.7% through clinics and 8.2% through informatics. Active refusal rate was 3%. Of the 1,036 families identified for the study, 402 passively refused to participate: 290 (45.1%) identified through informatics, 17 (29.8%) through community, and 95 (28.3%) through clinics. Recruitment strategy was not related to the age of the adolescent, adolescent comorbidities, body mass index of the adolescent or caregiver, income or education of the caregiver, or retention rates at 3 months, 7 months, or 9 months. Study retention rate was 87.8%.

Conclusion

Using multiple recruitment strategies is beneficial when working with racial/ethnic minority adolescents, and each strategy can yield good retention. Research affiliated with health care systems would benefit from the continued specification, refinement, and dissemination of these strategies.

Sequential Multiple Assignment Randomized Trial (SMART) to Construct Weight Loss Interventions for African American Adolescents

The purpose of this study was to develop an adaptive behavioral treatment for African American adolescents with obesity. In a sequential multiple assignment randomized trial, 181 youth ages 12-16 years with primary obesity and their caregiver were first randomized to 3 months of home-based versus office-based delivery of motivational interviewing plus skills building. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based skills or contingency management. Primary outcome was percent overweight and hypothesized moderators were adolescent executive functioning and depression. There were no significant differences in primary outcome between home-based or office-based delivery or between continued home-based skills or contingency management for nonresponders to first-phase treatment. However, families receiving home-based treatment initially attended significantly more sessions in both phases of the trial, and families receiving contingency management attended more sessions in the second phase. Overall, participants demonstrated decreases in percent overweight over the course of the trial (3%), and adolescent executive functioning moderated this effect such that those with higher functioning lost more weight. More potent behavioral treatments to address the obesity epidemic are necessary, targeting new areas such as executive functioning. Delivering treatment in the home with contingency management may increase session attendance for this population.

Effects of family treatment on parenting beliefs among caregivers of youth with poorly controlled asthma

OBJECTIVE

Caregiver involvement is critical in ensuring optimal adolescent asthma management. The study investigated whether multisystemic therapy (MST), an intensive home-based family therapy, was superior to family support for changing beliefs regarding asthma-related positive parenting among caregivers of African-American youth with poorly controlled asthma. The relationship between parenting beliefs and asthma management at the conclusion of the intervention was also assessed.

METHODS

A randomized controlled trial was conducted with 167 adolescents with moderate-to-severe, persistent, poorly controlled asthma and their primary caregivers. Families were randomly assigned to MST or family support (FS), a home-based family support condition. Data were collected at baseline and 7-month posttest. Changes in caregiver ratings of importance and confidence for engaging in asthma-related positive parenting were assessed through questionnaire. Illness management was assessed by the Family Asthma Management System Scale.

RESULTS

Participation in MST was associated with more change in caregiver beliefs as compared with FS for both importance (t = 2.39, p = .02) and confidence (t = 2.04, p = .04). Caregiver beliefs were also significantly related to youth controller medication adherence at the conclusion of treatment (importance: r = .21, p = .01; confidence: r = .23, p = .004).

CONCLUSION

Results support the effectiveness of MST for increasing parental beliefs in the value of asthma-related positive parenting behaviors and parental self-efficacy for these behaviors among families of minority adolescents with poorly controlled asthma.

Enhancing parental motivation to monitor african american adolescents' diabetes care: development and Beta test of a brief computer-delivered intervention

Background

African American youth are at increased risk for poor diabetes management. Parenting behaviors such as parental monitoring are significant predictors of youth diabetes management and metabolic control, but no intervention has targeted parental monitoring of daily diabetes care.

Objective

The purpose of the present study was to develop and pilot test a three-session computer-delivered intervention to enhance parental motivation to monitor African American pre-adolescents’ diabetes management.

Methods

The 3 Ms (Medication, Meter, and Meals) intervention was based on the Information-Motivation-Behavioral Skills (IMB) model of health behavior change and Motivational Interviewing approaches. Five caregivers of African American youth aged 10-13 years diagnosed with type 1 diabetes for a minimum of one year (ie, the target population) reviewed the intervention and provided feedback via semi-structured interviews. Interviews were transcribed and analyzed using thematic analysis.

Results

Caregivers’ responses to interview questions suggest that The 3 Ms was helpful (minimum rating was 8 out of 10) and they would recommend the program to another parent of a child with diabetes (minimum rating was 9 out of 10). Three of five reported that The 3 Ms program increased the likelihood that they would talk to their child about diabetes. Thematic analysis suggested two primary themes: caregivers found the intervention to be a useful reminder of the importance of supervising their child’s diabetes care and that it evoked a feeling of shared experience with other parents.

Conclusions

The 3 Ms computer-delivered intervention for increasing parental monitoring of African-American youth with type 1 diabetes was well-received and highly rated by a small sample of representative caregivers.

Trial Registration

ClinicalTrials.gov NCT01515930; http://clinicaltrials.gov/ct2/show/NCT01515930 (Archived by WebCite at http://www.webcitation.org/6Rm0vq9pn).

Adherence to asthma medication regimens in urban African American adolescents: application of self-determination theory

OBJECTIVE

Asthma medication adherence is low, particularly among African American adolescents, a high-risk group with respect to asthma prevalence, morbidity, and mortality. This study tested the utility of self-determination theory (SDT), a theory of motivation, to explain adherence to asthma medication regimens in African American adolescents.

METHOD

We used baseline data from 168 urban African American adolescents (Mage = 13.94 years; 61% male) with poorly controlled asthma who were part of a trial testing the efficacy of interventions to improve adherence. Participants and their caregivers were interviewed using the Family Asthma Management System Scale; this study used the Asthma Medication Adherence subscale. Adolescents completed four asthma-specific scales representing the SDT constructs of autonomous motivation (one importance scale), competence (one confidence scale), and relatedness (two scales--family routines and parental support). Using multiple linear regression, we tested the hypothesis that SDT variables would predict adherence.

RESULTS

Adherence was significantly correlated with three SDT variables--importance, confidence, and family routines. In multivariate analysis, family routines was the only significant predictor of asthma adherence (p < .001). Asthma management behaviors integrated into and shared among family members was associated with better adherence. Greater confidence was marginally associated with increased adherence (p = .07).

CONCLUSION

Though several variables representing SDT constructs were correlated with adherence, results demonstrate that family routines may be more relevant for African American adolescents' adherence than other SDT constructs. Thus, helping families to share and better integrate asthma care into daily schedules may be an important intervention strategy to improve medication adherence among high-risk African American adolescents.

Multisystemic therapy for poorly adherent youth with HIV: results from a pilot randomized controlled trial

Adherence to antiretroviral medication for the treatment of HIV is a significant predictor of virologic suppression and is associated with dramatic reductions in mortality and morbidity and other improved clinical outcomes for pediatric patient populations. Effective strategies for addressing adherence problems in youth infected with HIV are needed and require significant attention to the complex interplay of multiple, interacting causal risk factors that lead to poor self-care. Within the context of a pilot randomized trial, we evaluated the feasibility and initial efficacy of a multisystemic therapy (MST) intervention adapted to address HIV medication adherence problems against a usual care condition that was bolstered with a single session of motivational interviewing (MI). For 34 participating youth, health outcomes (viral load [VL] and CD4 count) were obtained from approximately 10 months pre-baseline through approximately 6 months post-baseline and self-reported medication adherence outcomes were obtained quarterly from baseline through 9 months post-baseline. Using mixed-effects regression models we examined within- and between-groups differences in the slopes of these outcomes. Feasibility was supported, with a 77% recruitment rate and near-maximal treatment and research retention and completion rates. Initial efficacy also was supported, with the MST condition but not the MI condition demonstrating statistically and clinically significant VL reductions following the start of treatment. There was also some support for improved CD4 count and self-reported medication adherence for the MST but not the MI condition. MST was successfully adapted to improve the health outcomes of youth poorly adherent to antiretroviral medications. Replication trials and studies designed to identify the mechanisms of action are important next steps.

Linking caregiver strain to diabetes illness management and health outcomes in a sample of adolescents in chronically poor metabolic control

OBJECTIVE

This study examined a multivariate model of the relationship between caregiver strain and adolescent diabetes illness outcomes in a sample of caregivers of adolescents in chronically poor metabolic control (hemoglobin A1c ≥8.0% at enrollment and for previous 12 mo). Caregiver mental health symptoms were hypothesized to mediate the relationship between caregiver strain and adolescent illness management behavior and metabolic control. Caregivers' perceptions of social support and their level of responsibility for diabetes care tasks were hypothesized to be directly related to caregiver strain and indirectly to caregiver mental health symptoms.

METHODS

One hundred forty-six caregiver-adolescent dyads completed baseline measures of caregiver strain, responsibility for diabetes care, social support, mental health symptoms, and illness management behavior. Adolescent metabolic control was also assessed.

RESULTS

Findings from structural equation modeling suggested that caregiver strain was directly and positively associated with caregiver mental health symptoms which mediated the relationship to adolescent diabetes management behavior and metabolic control. Caregivers' responsibility for diabetes care tasks was directly related to caregiver strain and indirectly to caregiver mental health, but caregivers' perception of social support was not.

CONCLUSIONS

These findings suggest that caregiver strain is an important dimension of the caregiving context of diabetes. Clinicians and researchers should consider how caregiving strain, responsibility for illness management, and mental health symptoms might be impacting children's diabetes care behavior and diabetes health when working with and designing interventions for adolescents with diabetes.

Psychometric properties of the revised Parental Monitoring of Diabetes Care questionnaire in adolescents with type 1 diabetes

PURPOSE

We evaluated the psychometric properties of a revised version of the Parental Monitoring of Diabetes Care questionnaire (PMDC-R) designed to evaluate parental supervision and monitoring of adolescent diabetes care behaviors. The revised measure was intended to capture a broad range of ways used by parents to gather information about youth adherence to diabetes care.

METHODS

Two hundred sixty-seven caregivers of 12-18-year-old adolescents with type 1 diabetes completed the PMDC-R. Measures of parental knowledge of youth illness management, illness management behavior, and metabolic control were also obtained.

RESULTS

The PMDC-R demonstrated good internal consistency (alpha coefficient = .91) and test-retest reliability (r = .79, p < .001). Supporting the instrument's construct validity, a bifactor model with one primary factor and three secondary factors had an acceptable fit to the data (comparative fit index = .92, root mean square error of approximation = .06). Concurrent validity was also supported. In structural equation models, parental monitoring, as assessed by the PMDC-R, had a significant direct effect on parental knowledge of adolescent diabetes management and, through knowledge, an indirect effect on adolescent diabetes management and metabolic control.

CONCLUSIONS

The PMDC-R displayed strong psychometric properties and represents an important next step in refining the measurement of parental monitoring for youth with chronic illnesses.

Adolescent and parent motivation for change affects psychotherapy outcomes among youth with poorly controlled diabetes

OBJECTIVES

Investigate effect of baseline motivation for change on treatment fidelity, therapeutic alliance, treatment dose, and treatment outcome in a randomized controlled trial of family therapy for youth with poorly controlled diabetes.

METHODS

Seventy-four adolescents and caregivers completed measures of motivation for change. Measures of fidelity, alliance, dose, and youth health status were collected. Structural equation modeling was used to test the direct and indirect effects of motivation on treatment outcomes.

RESULTS

Parent motivation was significantly related to alliance and fidelity. Only alliance was significantly related to posttreatment metabolic control. In adolescent models, only motivation was significantly related to alliance. In both models, motivation had a significant indirect effect on metabolic control through alliance.

CONCLUSIONS

Findings demonstrate the importance of parent and youth initial motivational status and treatment alliance to treatment outcome among youth with poorly controlled diabetes. Additional research on treatment techniques that promote motivation for change is needed.

Case study: multisystemic therapy for adolescents who engage in HIV transmission risk behaviors

OBJECTIVE

To present a case study using multisystemic therapy (MST), an intensive family focused psychotherapy. For the clinical trial from which this case was drawn, MST was adapted to address multiple human immunodeficiency virus (HIV) transmission risk behaviors in HIV-infected youth. Targeted behaviors included medication nonadherence, risky sexual behaviors, and substance use.

METHOD

One young woman's transmission risk behaviors are described, followed by a description of the MST procedures used to identify and treat the primary drivers of these risk behaviors. Outcome measures were self-report, urine screens, and blood draws.

RESULTS

At discharge, the young woman showed significant improvements in medication adherence and related health status (e.g., reduced HIV viral load), healthier sexual behaviors, and reduced substance use. Importantly, neither her boyfriend nor her newborn tested positive for HIV.

CONCLUSIONS

Findings from this case study suggest that MST has the potential to reduce transmission risk behaviors among teens with HIV.

The effects of parental depression and parenting practices on depressive symptoms and metabolic control in urban youth with insulin dependent diabetes

OBJECTIVE

Examine relationships between parental depressive symptoms, affective and instrumental parenting practices, youth depressive symptoms and glycemic control in a diverse, urban sample of adolescents with diabetes.

METHODS

Sixty-one parents and youth aged 10-17 completed self-report questionnaires. HbA1c assays were obtained to assess metabolic control. Path analysis was used to test a model where parenting variables mediated the relationship between parental and youth depressive symptoms and had effects on metabolic control.

RESULTS

Parental depressive symptoms had a significant indirect effect on youth depressive symptoms through parental involvement. Youth depressive symptoms were significantly related to metabolic control. While instrumental aspects of parenting such as monitoring or discipline were unrelated to youth depressive symptoms, parental depression had a significant indirect effect on metabolic control through parental monitoring.

CONCLUSIONS

The presence of parental depressive symptoms influences both youth depression and poor metabolic control through problematic parenting practices such as low involvement and monitoring.

Toward conceptual clarity in a critical parenting construct: parental monitoring in youth with chronic illness

Parental monitoring has been defined as "a set of correlated parenting behaviors involving attention to and tracking of the child's whereabouts, activities, and adaptations." This construct is of significant interest due to its relatedness to a broad range of youth risk behaviors, including risky sexual behavior, substance abuse, and poor adherence. However, to date, measures of parental monitoring are largely absent from the chronic illness literature. The present article focuses upon two key problems in the operationalization of the monitoring construct to date: (a) poor conceptual specificity in parenting constructs such as monitoring, overprotection, and over-involvement when used to date among youth with chronic conditions and (b) the confounding of existing measures of parental monitoring with items evaluating parental knowledge of youth activities, which has resulted in a lack of data regarding the mechanisms by which parents obtain their information. Recommendations for the future development of monitoring measures are discussed.

The parental monitoring of diabetes care scale: development, reliability and validity of a scale to evaluate parental supervision of adolescent illness management

PURPOSE

Monitoring of adolescents' behavior and whereabouts has been repeatedly identified as an important predictor of adolescent behavioral outcomes. However, to date, measures of parental supervision and monitoring are lacking in the chronic illness literature. The present study describes development and initial evaluation of a measure of parental monitoring of the illness management of adolescents with diabetes: the Parental Monitoring of Diabetes Care scale (PMDC).

METHODS

Ninety-nine parents of 12-18-year-old children with type 1 diabetes completed the PMDC. Measures of illness management and metabolic control were also obtained.

RESULTS

The PMDC demonstrated good internal consistency (alpha coefficient = .81) and test-rest reliability (ICC = .80). Supporting the instrument's construct validity, confirmatory factor analysis indicated that a five subdomain structure had an acceptable fit to the data, [chi(2) (181.65)/df (126) = 1.44, Bollen-Stine chi(2) = 165.03, p = .32, comparative fit index (CFI) = .91, and root-mean-square error of approximation = .07]. In structural equation models, parental monitoring as assessed by the PMDC had a significant direct effect on adolescent diabetes management, accounting for 38% of the variance. Parental monitoring also had a significant indirect effect on metabolic control.

CONCLUSIONS

The PMDC represents an important first step in the development of measures of parental monitoring for use with adolescents with chronic medical conditions.

Improving health outcomes among youth with poorly controlled type I diabetes: the role of treatment fidelity in a randomized clinical trial of multisystemic therapy

The purpose of the study was to assess whether therapist treatment fidelity was a predictor of treatment outcome in a randomized clinical trial of multisystemic therapy with 10- to 16-year-old youths with chronically poorly controlled Type I diabetes (N = 40). Treatment fidelity was assessed by objective ratings of therapy sessions and questionnaires completed by caregivers and by therapists. Relationships between fidelity measures were assessed. Structural equation modeling (SEM) was used to test whether high fidelity would lead to improved regimen adherence and to improved metabolic control outcomes via regimen adherence. Objective ratings of treatment fidelity were significantly related to therapist-reported but not to caregiver-reported treatment fidelity. SEM results supported a completely mediated pathway between treatment fidelity and metabolic control, with regimen adherence mediating the relationship. Results suggest that conducting complex behavioral interventions with a high degree of fidelity can improve treatment outcomes among youths with chronic illnesses.

The effects of weight status on treatment outcomes in a randomized clinical trial of multisystemic therapy for adolescents with type 1 diabetes and chronically poor metabolic control

OBJECTIVE

The purpose of the study was to determine if being overweight attenuated the effect of multisystemic therapy (MST), an intensive, home-based psychotherapy, on metabolic outcomes among adolescents with type 1 diabetes and chronically poor metabolic control. As overweight is a marker of insulin resistance, it was hypothesized that weight status would limit the impact of behavioral changes in traditional aspects of adherence to the type 1 diabetes regimen on metabolic control.

METHODS

A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and hemoglobin A1c (HbA1c) > or = 8% for the past year. Participants were randomly assigned to MST plus standard care (SC) or SC alone. Data were collected at baseline and 7 months post-test (i.e., treatment termination). Overweight was defined as body mass index > 85%.

RESULTS

Forty-one percent of the sample was overweight. Intent-to-treat analysis showed that adolescents in the MST group had a significant increase in frequency of blood glucose testing (BGT) [F(1,113) = 15.43, p = 0.0001] and a trend to significant improvement in HbA1c [F(1,123) = 2.99, p = 0.086] irrespective of weight. However, HbA1c decreased 0.91% (p = 0.002) for normal weight adolescents in the MST group compared with 0.20% (p = 0.570) for overweight adolescents in the MST group.

DISCUSSION

Despite improvements in adherence to BGT, overweight adolescents receiving an intensive behavioral intervention did not have a significant improvement in metabolic control compared with their normal weight peers. Overweight, an accepted marker of insulin resistance and a major public health issue, warrants increased consideration in intervention trials to improve the metabolic control of adolescents with type 1 diabetes.

Atmospheric chemistry of 4:2 fluorotelomer alcohol (n-C4F9CH2CH2OH): products and mechanism of Cl atom initiated oxidation in the presence of NOx

Smog chamber/FTIR techniques were used to study the Cl atom initiated oxidation of 4:2 fluorotelomer alcohol (C(4)F(9)CH(2)CH(2)OH, 4:2 FTOH) in the presence of NO(x) in 700 Torr of N(2)/O(2) diluent at 296 K. Chemical activation effects play an important role in the atmospheric chemistry of the peroxy, and possibly the alkoxy, radicals derived from 4:2 FTOH. Cl atoms react with C(4)F(9)CH(2)CH(2)OH to give C(4)F(9)CH(2)C(*)HOH radicals which add O(2) to give chemically activated alpha-hydroxyperoxy radicals, [C(4)F(9)CH(2)C(OO(*))HOH]*. In 700 Torr of N(2)/O(2) at 296 K, approximately 50% of the [C(4)F(9)CH(2)C(OO(*))HOH]* radicals decompose "promptly" to give HO(2) radicals and C(4)F(9)CH(2)CHO, the remaining [C(4)F(9)CH(2)C(OO(*))HOH]* radicals undergo collisional deactivation to give thermalized peroxy radicals, C(4)F(9)CH(2)C(OO(*))HOH. Decomposition to HO(2) and C(4)F(9)CH(2)CHO is the dominant atmospheric fate of the thermalized peroxy radicals. In the presence of excess NO, the thermalized peroxy radicals react to give C(4)F(9)CH(2)C(O(*))HOH radicals which then decompose at a rate >2.5 x 10(6) s(-1) to give HC(O)OH and the alkyl radical C(4)F(9)CH(2)(*). The primary products of 4:2 FTOH oxidation in the presence of excess NO(x) are C(4)F(9)CH(2)CHO, C(4)F(9)CHO, and HCOOH. Secondary products include C(4)F(9)CH(2)C(O)O(2)NO(2), C(4)F(9)C(O)O(2)NO(2), and COF(2). In contrast to experiments conducted in the absence of NO(x), there was no evidence (<2% yield) for the formation of the perfluorinated acid C(4)F(9)C(O)OH. The results are discussed with regard to the atmospheric chemistry of fluorotelomer alcohols.

The Role of Parental Monitoring in Adolescent Health Outcomes: Impact on Regimen Adherence in Youth with Type 1 Diabetes

OBJECTIVE

To determine if parental monitoring of adolescent behavior was related to regimen adherence and metabolic control among adolescents with type 1 diabetes. An additional objective was to compare the relative importance of instrumental parenting behaviors such as monitoring to affective behaviors such as parental support as predictors of regimen adherence.

METHOD

Ninety-nine adolescents aged 12-18 years and their primary caregiver completed self-report questionnaires. Path analysis was used to test a model where diabetes-specific parental monitoring and support were predicted to have direct effects on regimen adherence and indirect effects on metabolic control via regimen adherence and an alternative model where parental support moderated the effects of monitoring on adherence.

RESULTS

Diabetes-specific, but not general, monitoring was found to be associated with regimen adherence based on both parent and youth report. Monitoring had an indirect effect on metabolic control through regimen adherence. Although adolescent-reported parental support was significantly associated with regimen adherence in bivariate analyses, multivariate analyses indicated that parental support was not a significant independent predictor of health outcomes when parental monitoring was considered simultaneously. Modest support was also found for parental support as a moderator of the relationship between monitoring and adherence.

CONCLUSIONS

Close parental monitoring of care completion can contribute to better adherence in adolescents with diabetes. General warmth and support in the absence of careful parental supervision may be insufficient to help youth achieve adequate levels of adherence.

Multisystemic therapy for adolescents with poorly controlled type I diabetes: Stability of treatment effects in a randomized controlled trial

The primary purpose of the present study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, improved regimen adherence, metabolic control, and rates of hospitalization for diabetic ketoacidosis (DKA) among adolescents with chronically poorly controlled Type 1 diabetes 6 months after the completion of treatment. A randomized controlled trial was conducted with 127 adolescents and their families. Mean participant age was 13.2 years. Sixty-three percent of participants were African American, and 51% were female. Data were collected at baseline, treatment termination, and 6-month follow-up. Changes in glycated hemoglobin (HbA1c), frequency of blood glucose testing (BGT), and rate of DKA admissions were assessed. In intent-to-treat analyses, a main effect of MST on DKA admissions was found at both treatment termination and follow-up. Improvements in BGT were moderated by family composition; only 2-parent MST families maintained improvements at follow-up. Improvements in HbA1c for the MST group at treatment termination were lost at follow-up. Results show that intensive, home-based psychotherapy created stable reductions in serious lapses in adherence, as indexed by episodes of DKA, among youth with poorly controlled diabetes.

Atmospheric Chemistry of n-CxF2x+1CHO (x = 1, 2, 3, 4): Fate of n-CxF2x+1C(O) Radicals

Smog chamber/FTIR techniques were used to study the atmospheric fate of n-C(x)F(2)(x)(+1)C(O) (x = 1, 2, 3, 4) radicals in 700 Torr O(2)/N(2) diluent at 298 +/- 3 K. A competition is observed between reaction with O(2) to form n-C(x)()F(2)(x)()(+1)C(O)O(2) radicals and decomposition to form n-C(x)F(2)(x)(+1) radicals and CO. In 700 Torr O(2)/N(2) diluent at 298 +/- 3 K, the rate constant ratio, k(n-C(x)F(2)(x)(+1)C(O) + O(2) --> n-C(x)F(2)(x)(+1)C(O)O(2))/k(n-C(x)F(2)(x)(+1)C(O) --> n-C(x)F(2)(x)(+1) + CO) = (1.30 +/- 0.05) x 10(-17), (1.90 +/- 0.17) x 10(-19), (5.04 +/- 0.40) x 10(-20), and (2.67 +/- 0.42) x 10(-20) cm(3) molecule(-1) for x = 1, 2, 3, 4, respectively. In one atmosphere of air at 298 K, reaction with O(2) accounts for 99%, 50%, 21%, and 12% of the loss of n-C(x)F(2)(x)(+1)C(O) radicals for x = 1, 2, 3, 4, respectively. Results are discussed with respect to the atmospheric chemistry of n-C(x)F(2)(x)(+1)C(O) radicals and their possible role in contributing to the formation of perfluorocarboxylic acids in the environment.