Predicting healthcare utilization in youth with type 1 diabetes: The importance of family level variables

OBJECTIVE

Little is known about how family factors impacting treatment adherence in type 1 diabetes are directly associated with unplanned healthcare utilization (e.g., emergency room visits and hospital admissions). Given the substantial financial burden of diabetes, understanding predictors of healthcare utilization in particular is important to inform behavioral interventions aimed toward improving adherence.

RESEARCH DESIGN AND METHODS

The current study examined the relationship between family-level variables and healthcare utilization in a sample of 239 youth with type 1 diabetes and their parents. Healthcare utilization was determined via parent report and chart review. Parent- and youth-reports regarding levels of family conflict, youth autonomy, and parent support related to diabetes management were obtained via questionnaire, and negative reciprocity was obtained by coding observations of parent and youth interactions. Generalized Estimating Equations were used to examine the longitudinal association between healthcare utilization and family-level factors.

RESULTS

Higher levels of observed negative reciprocity were associated with more frequent hospital admissions, while higher levels of youth-reported parent involvement in diabetes management were associated with fewer hospital admissions and ED visits.

CONCLUSIONS

These findings highlight how family-level factors are directly related to healthcare utilization and point to the continued importance of integrating family-focused behavioral interventions in routine medical care for improving type 1 diabetes outcomes and reducing healthcare costs.

Featured Article: Comparison of Diabetes Management Trajectories in Hispanic versus White Non-Hispanic Youth with Type 1 Diabetes across Early Adolescence

OBJECTIVE

Ethnic minority youth with type 1 diabetes (T1D) often have poorer glycemic control and lower rates of adherence compared to White Non-Hispanic (WNH) youth. Variables such as family conflict, autonomy support, and youth regimen responsibility have been shown to change over adolescence and impact diabetes management. However, these factors have been investigated in predominantly White samples. Few studies have examined potential differences in these variables and their trajectories for Hispanic youth over early adolescence.

METHODS

Youth with T1D (178 WNH and 33 Hispanic youth participants), as well as their maternal caregivers (174 WNH and 32 Hispanic maternal caregivers), completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency at 4 timepoints over a 3-year period.

RESULTS

At baseline, Hispanic youth had significantly poorer glycemic control, more family conflict, and fewer blood glucose checks on average compared to WNH youth. Similar to WNH youth, Hispanic youth have increasing independence for regimen tasks and decreasing parent autonomy support during this developmental period. However, while Hispanic youth had worsening diabetes management during early adolescence (as did WNH youth), Hispanic parents reported a more gradual change in youth's diabetes management over early adolescence.

CONCLUSIONS

This study presents an important contribution to the existing literature on youth with T1D. Findings suggest potential strengths and targets for Hispanic youth navigating diabetes management during the adolescent period. It is important to continue to investigate the trajectories of ethnic minority youth with diabetes.

Society of Pediatric Psychology Workforce Survey: Factors Related to Compensation of Pediatric Psychologists

Objective

To summarize compensation results from the 2015 Society of Pediatric Psychology (SPP) Workforce Survey and identify factors related to compensation of pediatric psychologists.

Methods

All full members of SPP ( n  = 1,314) received the online Workforce Survey; 404 (32%) were returned with usable data. The survey assessed salary, benefits, and other income sources. The relationship between demographic and employment-related factors and overall compensation was explored.

Results

Academic rank, level of administrative responsibility, and cost of living index of employment location were associated with compensation. Compensation did not vary by gender; however, women were disproportionately represented at the assistant and associate professor level.

Conclusions

Compensation of pediatric psychologists is related to multiple factors. Longitudinal administration of the Workforce Survey is needed to determine changes in compensation and career advancement for this profession over time. Strategies to increase the response rate of future Workforce Surveys are discussed.

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.

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.

Identification and prediction of group-based glycemic control trajectories during the transition to adolescence

OBJECTIVE

To identify trajectories of glycemic control over a period of 3 years in a pediatric sample of youth diagnosed with Type 1 diabetes transitioning to adolescence. A second aim was to examine a set of modifiable individual and family level baseline predictors of glycemic control group membership.

METHODS

This multisite, prospective study included 239 children and adolescents (ages 9-11 years at baseline) diagnosed with Type 1 diabetes and their caregivers. Glycemic control was based on hemoglobin A1c (HbA1c) collected at 6-month intervals over a period of 3 years. Predictors of glycemic control membership included baseline global executive functioning, diabetes self-management, diabetes-specific family conflict, blood glucose monitoring frequency, and relevant individual and family level covariates.

RESULTS

Group-based trajectory analyses were used to describe patterns of glycemic control from baseline to 36 months and 3 trajectories were identified: low risk (42.9%), elevated risk (44.6%), and high risk (12.1%) subgroups. Baseline maternal-reported family conflict, blood glucose monitoring frequency, and gender were significant predictors of glycemic control group membership. Higher levels of baseline family conflict, lower frequency of blood glucose monitoring, and female gender were associated with elevated and high-risk group membership.

CONCLUSIONS

These findings underscore the importance of examining trajectories of HbA1c across time. These results suggest that problematic trajectories of glycemic control are evident during the transition to adolescence. Furthermore, there are modifiable individual and family level characteristics that predict group membership and hence could be targeted in interventions to ensure adequate glycemic control is maintained over time and that risks for diabetes-related complications are reduced.

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.

Mother-father informant discrepancies regarding diabetes management: associations with diabetes-specific family conflict and glycemic control

OBJECTIVE

To examine the relationship of mother-father informant discrepancies regarding diabetes management to diabetes-specific family conflict and glycemic control.

METHODS

One hundred thirty-six mothers and fathers of youth with Type 1 diabetes reported on the youth's diabetes management, diabetes-specific family conflict, and amount of paternal involvement in diabetes care. Glycosylated hemoglobin A1c (HbA1c) was used to measure glycemic control.

RESULTS

As hypothesized, mother-father discrepancies regarding diabetes management were positively associated with frequency of diabetes-specific family conflict. Contrary to hypotheses, mother-father discrepancies regarding diabetes management predicted poorer glycemic control for youth with less involved fathers only.

CONCLUSIONS

Results highlight the importance of caregivers being consistent about pediatric illness management and support the idea that informant discrepancies represent an important window into the functioning of the family system.

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.

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.

When Distraction Fails: Parental Anxiety and Children’s Responses to Distraction during Cancer Procedures

OBJECTIVE

To examine parental anxiety in the context of successful and unsuccessful distraction treatment of preschool aged children undergoing chemotherapy procedures.

METHODS

Twenty-nine children (M age = 42 months) experiencing intramuscular or portacatheter injections participated in the study. Parents and children were shown how to use a portable electronic toy as a distractor during chemotherapy injections. Parental anxiety was assessed at baseline and child distress was coded during each procedure.

RESULTS

Parents' baseline state anxiety accounted for 17% of the variance in changes in children's distress following distraction intervention. Parents of children who did not benefit from distraction reported significantly higher state anxiety at baseline than parents of the other participants.

CONCLUSIONS

Results highlight the importance of examining individual outcomes in intervention studies and suggest that parents' emotional states may moderate distraction treatment outcome in young children. Future research formally testing parent anxiety as a moderator is recommended.

Peer and family support in children and adolescents with type 1 diabetes

OBJECTIVE

To examine social support and peer and family involvement in relation to diabetes management within a developmental context.

METHODS

Sixty-eight youths ages 8 to 17 diagnosed with type 1 diabetes participated. This study represents the phase 1 data from a multisystemic, home-based intervention. Data included parent and youth report of disease management and conflict, youth-reported perceptions of support, peer participation in the intervention, and HbA1c.

RESULTS

Adolescents perceived greater diabetes-related peer support than did school-age children. Perceived peer and family support were not correlated with metabolic control. Peer participation in the intervention was correlated with metabolic control.

CONCLUSIONS

There is a developmental shift in perceptions of peer support. Increased perceptions of peer and family support overall may not result in improved metabolic control. Social support interventions should focus on the types of support that are most highly associated with positive health outcomes.

Distraction intervention for preschoolers undergoing intramuscular injections and subcutaneous port access

This study evaluated a distraction intervention designed to reduce the distress of preschool children undergoing repeated chemotherapy injections. Twenty-nine children aged 2-5 years were randomly assigned either to distraction by a developmentally appropriate electronic toy or to a wait-list control. Children who received the distraction intervention demonstrated lower overt behavioral distress and were rated by parents and nurses as less anxious than children in the control condition. The improvements were maintained over the 8-week intervention. The results suggest that a developmentally appropriate, multisensory, variable-distracting activity that requires active cognitive processing and active motor responses may be a viable cost-effective alternative to more time-intensive parent-training programs for preschool-age children.

A peer group intervention for adolescents with type 1 diabetes and their best friends

OBJECTIVE

To devise and implement a structured intervention for integrating peers into diabetes care in a healthy and adaptive manner.

METHODS

Adolescents with diabetes (n = 21) and their best friends (n = 21) participated in a group intervention aimed at increasing diabetes knowledge and social support of diabetes care. Measures of social support, knowledge about diabetes and support, diabetes functioning, and social functioning were obtained prior to and following intervention.

RESULTS

Following the intervention, adolescents and their friends demonstrated higher levels of knowledge about diabetes and support, as well as a higher ratio of peer to family support, and friends demonstrated improved self-perception. Parents reported decreased diabetes-related conflict.

CONCLUSIONS

Peer group intervention approaches may result in increased positive peer involvement in adolescents' diabetes care.

Body image and psychosocial adjustment in adolescent cancer survivors

Examined body image and social adjustment in 21 adolescents who had completed cancer treatment and a healthy comparison group. Subjects completed questionnaires assessing body image and social adjustment and were videotaped during an interview. Raters blind to health status independently rated subjects' attractiveness. Cancer survivors reported less than half as many social activities as the healthy controls. No group differences were found on social anxiety, loneliness, or composite body image scores. However, within the cancer group, adolescents who had been off treatment longer reported lower self-worth, more social anxiety, and more negative body image perceptions, but were not rated as less attractive by observers. Findings suggest body image concerns and social anxiety may not develop until several years after treatment termination.

Daughter and mother report of individual symptoms on the Children's Depression Inventory

PURPOSE

To examine differences between early adolescent girls' and their mothers' perceptions of girls' depressive symptoms.

METHODS

313 daughter-mother dyads completed the Children's Depression Inventory.

RESULTS

Low to modest agreement was found for most symptoms, although higher agreement was found for symptoms relating to school performance. The hypothesis that girls would report more ideational symptoms and mothers more behavioral symptoms of depression was tested; girls generally reported more ideational and behavioral symptoms when differences occurred. However, several specific ideational symptoms (feeling like crying; feeling sad; guilt; worrying) tended to be more frequently endorsed by girls and had particularly poor daughter-mother agreement. Examining third variables associated with daughter-mother agreement, girls scoring high on social desirability tended to have smaller daughter-minus-mother difference scores for ideational, but not for behavioral items; therefore, social desirability may be associated with girls underreporting ideational symptoms.

CONCLUSIONS

Mothers appear to be reliable raters of symptoms related to school functioning, but may be less aware of certain covert depressive symptoms in their early adolescent daughters.