Parent-child relationships and the management of insulin-dependent diabetes mellitus

Trying to be like everybody else: A qualitative study revealing the importance of social contexts and illness representations among adolescents with type 1 diabetes and their parents

OBJECTIVE

Type 1 diabetes is one of the most common chronic conditions in young children and adolescents. During the period of adolescence, young people with diabetes often struggle with self-management and have compromised health-related quality of life. This often leads to familial conflicts affecting all family members negatively. The aim of this study is to provide qualitative insight into the everyday life of families with adolescents with type 1 diabetes.

METHODS

The data consisted of participatory family workshops conducted using interactive dialogue tools. The total number of participants was 33 (adolescents n = 13, parents n = 20). The adolescents were between 15 and 17 years. The data were analyzed using systematic text condensation.

RESULTS

The results showed two main themes. The first theme, Diabetes-friendly and unfriendly social contexts, highlighted how the (dis)comfortability of disclosing diabetes was a significant factor in achieving optimal metabolic control. For parents, it affected their perception of social support. The second theme, incongruent illness representations among family members, dealt with the extended family conflict during the period of adolescence.

DISCUSSION

Insights from our study could help healthcare professionals apply a family-centered approach minimizing family conflict and supporting metabolic control when consulting families with adolescents with type 1 diabetes.

Effects of Parental Involvement on Glycemic Control in Adolescents With Type 1 Diabetes Mellitus: A Scoping Review

Type 1 diabetes mellitus (T1DM) is typically diagnosed in pediatric patients. Transitioning from supported management in childhood to self-management in adolescence is an important step. Parental psychosocial influence is a possible factor in adolescents' disease control. This review summarized the effects of parental involvement on glycemic control in adolescents with T1DM by focusing on hemoglobin A1c (HgbAIc). A scoping review per the Guidance for Systematic Scoping Reviews was conducted with the following inclusion criteria: (a) studies in English, (b) focused on adolescents with T1DM, (c) outcomes included HgbAIc, and (d) focused on parental influence of children with T1DM. Of 476 articles, 14 were included. The study outcomes were classified based on direct or indirect influence. "Parental support for adherence" and "parental conflict" significantly affected HgbAIc control. This study provides current evidence on parental influence on glycemic control in adolescents.

Suubi4StrongerFamilies: A study protocol for a clustered randomized clinical trial addressing child behavioral health by strengthening financial stability and parenting among families in Uganda

Background

Children in Sub-Saharan Africa are burdened by significant unmet mental health needs. Across the region, high rates of poverty, HIV/AIDS, food insecurity, stigma, and an inadequate health safety net system exacerbate serious child behavioral health needs and impede an effective response. Disruptive behavioral disorders are particularly concerning as they persist through adolescence and adulthood. Hence, addressing the context-specific social influences on child behavioral health is critical given that children in the region comprise more than half of the total regional population. Against this backdrop, this study protocol describes a randomized clinical trial that will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial, and context-specific drivers affect the mental health of children in Uganda.

Methods

The study uses an experimental, longitudinal design across 30 cluster-randomized primary schools to compare single and combination intervention options; influences of economic empowerment and family strengthening on economic, perceptual, and functioning mediators; and context-specific moderators. The study will be conducted with 900 Ugandan children in mid-upper primary school (10-14 years). The three study conditions (n = 300 each) are: (1) economic empowerment only (EE only), (2) multiple family group-based family strengthening only (MFG-based FS only), and (3) combined EE + MFG-based FS. The interventions will be provided for 12 months; and assessments will occur at baseline, 12, 24, and 36 months.

Conclusion

Children in Sub-Saharan Africa are burdened by significant unmet mental health needs, including disruptive behavior disorders that persist through adolescence and adulthood if left untreated. The proposed study will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial and context-specific drivers affect the mental health of children in mid-upper primary schools in Uganda. Findings from this study can inform group, community, and population approaches that are needed for scalable solutions to address the social drivers negatively impacting child behavioral health in low-resource settings, including in Sub-Saharan Africa.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT053 68714].

Data Sharing While Using a Closed-Loop System: Qualitative Study of Adolescents' and Parents' Experiences and Views

Objective: To understand and explore data sharing practices among adolescents and their parents using a closed-loop system. Methods: Eighteen adolescents (aged 11-18 years) and 19 parents were interviewed after adolescents had ∼6 months experience of using a closed-loop system, which permitted them to share glucose and insulin data with parents/caregivers. Data were analyzed thematically. Results: There was considerable variability in how parent-child dyads perceived, valued, and undertook data sharing. Parents of early adolescents (11-13 years) reported making extensive use of "real time" data to remotely manage their child's diabetes and early adolescents described needing and wanting this input. Parents of middle adolescents (14-16 years) described making greater use of retrospective data. To avoid conflict and encourage and support their son/daughter's autonomy, these individuals reported practicing watchful waiting and only intervening after concerns about a pattern of problematic behavior or their child's safety arose. Middle adolescents indicated that data sharing had been done primarily for the benefit of their parents, although they also noted quality of life benefits for themselves. Among late adolescents (17+ years), parents were simply remote because their son/daughter had not permitted access to their data. Participants recommended clear ground rules be put in place about when, and how, data sharing should be used. Conclusions: To help parent-child dyads use data sharing in ways which minimize conflict and optimize constructive parental support, we recommend tailored input and support, which takes account of family dynamics, the young person's developmental maturity, and the different ways in which data are used across the adolescent age range.

Development and initial validation of the diabetes family conflict scale (revised)-short form in a racially and income diverse sample

OBJECTIVE

The purpose of the study was to develop a short form of the revised diabetes family conflict scale (DFCS) in a racially and income diverse sample while retaining strong psychometric properties.

METHODS

One seventy nine youth with type 1 diabetes (ages 12-18 years) and caregivers completed the DFCS-Revised as well as assessments of adherence, psychosocial functioning, and diabetes-related stress. Hemoglobin A1c was also obtained. The sample was split at random into a development sample and validation sample.

RESULTS

Confirmatory factor analyses in the validation sample supported the use of a six-item short form (DFCS-SF) either as a total score (6-items) or a direct (3-item) and indirect (3-item) score. Variations of the DFCS-SF (three items of the 6-item short form) also had acceptable model fit. The short-form questionnaires had acceptable internal consistency and convergent validity (6-item: Cronbach's a = 0.865, full scale DFCS r = 0.954; 3-item: Cronbach's a = 0.757, full scale DFCS r = 0.912). The DFCS-SF showed measurement invariance across both youth and caregiver respondents. Greater report of the DFCS-SF by both youth and caregivers was significantly associated with higher HbA1c, more diabetes-related stress, and more psychosocial concerns.

CONCLUSIONS

The DFCS-SF developed in the present study shows psychometric integrity in a diverse population of youth and can be utilized by providers to rapidly assess and potentially implement interventions to reduce diabetes family conflict, a psychosocial concern which is associated with elevated HbA1c, non-optimal adherence, diabetes-related stress, and psychological distress.

Family conflict in type 1 diabetes: Who is at risk?

BACKGROUND/OBJECTIVE

Diabetes-related conflict between caregiver and child has been associated with lower quality of life, reduced treatment adherence, and higher hemoglobin A1C. The objective of this project was to identify patient and family characteristics associated with higher levels of diabetes-specific family conflict.

METHODS

This was a cross-sectional study. Caregivers of children aged 4- to 18-years-old with type 1 diabetes were recruited from diabetes clinics across British Columbia. Data were collected through chart reviews and patient surveys, including the Diabetes Family Conflict Scale and the Adherence in Diabetes Questionnaire. All caregivers and children ≥8-years-old were invited to complete the survey. Potential predictors were explored using univariate and multivariable linear regression models.

RESULTS

In the unadjusted analysis, higher caregiver report of conflict (n = 196) was associated with: low family income, non-Caucasian ethnicity, missed school, older age at diagnosis, and insulin regimen (2-3 injections/day rather than multiple daily injections or pump). When all variables were adjusted for simultaneously, income, insulin regimen, one or more stay at home parent and recent hospitalization were significant. For the child report (n = 111), higher maternal education was associated with lower conflict in the unadjusted analysis and non-Caucasian ethnicity was associated with higher conflict in the adjusted analysis.

CONCLUSIONS

This exploratory study identified possible novel associations between patient and family characteristics and diabetes-related family conflict.

Decision-Making Involvement and Prediction of Adherence in Youth With Type 1 Diabetes: A Cohort Sequential Study

Objective

To assess developmental trajectories of decision-making involvement (DMI), defined as the ways in which parents and children engage each other in decision-making about illness management, in youth with type 1 diabetes (T1D) and examine the effects of DMI on levels of and changes in adherence with age.

Methods

Participants included 117 youth with T1D, enrolled at ages 8-16 years and assessed five times over 2 years. The cohort sequential design allowed for the approximation of the longitudinal curve from age 8 to 19 from overlapping cohort segments. Children and parents completed the Decision-Making Involvement Scale, which yields subscales for different aspects of DMI, and a self-report adherence questionnaire. Mixed-effects growth curve modeling was used for analysis, with longitudinal measures nested within participant and participants nested within cohort.

Results

Most aspects of DMI (Parent Express, Parent Seek, Child Express, and Joint) increased with child age; scores on some child report subscales (Parent Express, Child Seek, and Joint) decreased after age 12-14 years. After accounting for age, Child Seek, Child Express, and Joint were associated with overall higher levels of adherence in both child (estimates = 0.08-0.13, p < .001) and parent (estimates = 0.07- 0.13, p < .01) report models, but they did not predict changes in adherence with age.

Conclusion

These data suggest that helping children to be more proactive in T1D discussions, by encouraging them to express their opinions, share information, and solicit guidance from parents, is a potential target for interventions to enhance effective self-management.

Family Functioning and Medical Adherence Across Children and Adolescents With Chronic Health Conditions: A Meta-Analysis

Objectives

A meta-analysis examined family functioning and medical adherence in children and adolescents with chronic health conditions. Family functioning was evaluated at the level of the family unit, as well as parent-child interactions.

Methods

We conducted literature searches using PubMed, PsycINFO, SCOPUS, Web of Science, and Cochrane. After reviewing 764 articles, 62 studies met eligibility criteria. Pearson's r correlations were the effect size of interest. We conducted both omnibus and domain-specific (e.g., family conflict, cohesion) meta-analyses. Meta-regressions examined whether relevant covariates related to the magnitude of the effect.

Results

The omnibus meta-analysis showed that family functioning was significantly related to medical adherence across a variety of pediatric chronic health conditions. Lower family conflict, greater family cohesion, greater family flexibility, more positive communication, and better family problem-solving were each associated with better adherence. There were no significant differences in the magnitude of the omnibus effect based on child age, measurement features (subjective vs. objective or bioassay adherence; family unit vs. parent-child interactions), or study quality.

Conclusions

Consistent with social-ecological frameworks, findings supported links between family functioning and medical adherence. This study highlights several limitations of the extant research, including absence of a guiding theoretical framework and several methodological weaknesses. We offer clinical and research recommendations for enhancing scientific understanding and promotion of adherence within the family context.

Income Relates to Adherence in Youth with Type 1 Diabetes Through Parenting Constructs

OBJECTIVE

Informed by the family stress and family investment models, this study investigated whether income is indirectly related to adherence and glycemic control through parenting constructs among youth with type 1 diabetes (TID).

METHODS

Youth and their families (n = 390) from 4 geographically dispersed pediatric endocrinology clinics in the United States were participants in a multisite clinical trial from 2006 to 2009 examining the efficacy of a clinic-integrated behavioral intervention targeting family disease management for youth with TID. Baseline data were collected from youth aged 9 to 14 years and their parents. Parents reported family income and completed a semistructured interview assessing diabetes management adherence. Parents and children reported diabetes-specific parent-child conflict. Children completed measures of collaborative parent involvement and authoritative parenting. Hemoglobin A1c (HbA1c), a biomarker of glycemic control, was analyzed centrally at a reference laboratory. The relations of income, parenting variables, regimen, adherence, and HbA1c were examined using structural equation modeling.

RESULTS

Lower family income was associated with greater parent-child conflict and a less authoritative parenting style. Authoritative parenting was associated with more collaborative parent involvement and less parent-child conflict, both of which were associated with greater adherence, which was associated with more optimal glycemic control (p < 0.05 all associations). Indirect effects of family income on adherence and glycemic control through parenting constructs were significant (p < 0.001).

CONCLUSION

Findings lend support for the family stress and family investment models, suggesting that lower family income may negatively impact parent-child constructs, with adverse effects on diabetes management.

The Role of Cognitive and Psychosocial Maturity in Type 1 Diabetes Management

PURPOSE

The purpose of the article was to explore the longitudinal relationship between treatment responsibility and type 1 diabetes management (i.e., adherence and glycemic control) in adolescence and to examine whether indicators of cognitive and psychosocial maturity moderate the link between youth responsibility and diabetes outcomes.

METHODS

Participants included 117 youth with type 1 diabetes and their parents. Youth (aged 8-16 years) and parents were assessed five times over 2 years. Using a cohort sequential design, we estimated the growth trajectory of adherence and glycemic control (i.e., hemoglobin A1c [HbA1c]) from age 8 to 18 years. Treatment responsibility, verbal ability, and impulse control were used as predictors of within-person variability and between-person differences in the growth parameters (i.e., intercept and slope).

RESULTS

Adherence and HbA1c declined linearly from ages 8 to 18 years. Significant within-person interactions between impulse control and responsibility revealed that on occasions when youth experienced increases in both responsibility and impulse control, adherence and HbA1c were higher than would be predicted by the age-related trajectory. For adherence only, when youth acquired more responsibility, without experiencing contemporaneous gains in impulse control, adherence worsened. For glycemic control only, a significant within-person interaction indicated that time-specific increases in both youth responsibility and verbal capacity were associated with a concurrent decline in HbA1c.

CONCLUSIONS

The present findings underscore that the associations between treatment responsibility and diabetes management depend on youths' maturational context. Intervention efforts to enhance impulse control skills in youth with diabetes may prevent the decline in diabetes management that tends to occur as youth acquire more responsibility for diabetes-related tasks.

Codesigned Shared Decision-Making Diabetes Management Plan Tool for Adolescents With Type 1 Diabetes Mellitus and Their Parents: Prototype Development and Pilot Test

Background

Adolescents with type 1 diabetes mellitus have difficulty achieving optimal glycemic control, partly due to competing priorities that interfere with diabetes self-care. Often, significant diabetes-related family conflict occurs, and adolescents’ thoughts and feelings about diabetes management may be disregarded. Patient-centered diabetes outcomes may be better when adolescents feel engaged in the decision-making process.

Objective

The objective of our study was to codesign a clinic intervention using shared decision making for addressing diabetes self-care with an adolescent patient and parent advisory board.

Methods

The patient and parent advisory board consisted of 6 adolescents (teens) between the ages 12 and 18 years with type 1 diabetes mellitus and their parents recruited through our institution’s Pediatric Diabetes Program. Teens and parents provided informed consent and participated in 1 or both of 2 patient and parent advisory board sessions, lasting 3 to 4 hours each. Session 1 topics were (1) patient-centered outcomes related to quality of life, parent-teen shared diabetes management, and shared family experiences; and (2) implementation and acceptability of a patient-centered diabetes care plan intervention where shared decision making was used. We analyzed audio recordings, notes, and other materials to identify and extract ideas relevant to the development of a patient-centered diabetes management plan. These data were visually coded into similar themes. We used the information to develop a prototype for a diabetes management plan tool that we pilot tested during session 2.

Results

Session 1 identified 6 principal patient-centered quality-of-life measurement domains: stress, fear and worry, mealtime struggles, assumptions and judgments, feeling abnormal, and conflict. We determined 2 objectives to be principally important for a diabetes management plan intervention: (1) focusing the intervention on diabetes distress and conflict resolution strategies, and (2) working toward a verbalized common goal. In session 2, we created the diabetes management plan tool according to these findings and will use it in a clinical trial with the aim of assisting with patient-centered goal setting.

Conclusions

Patients with type 1 diabetes mellitus can be effectively engaged and involved in patient-centered research design. Teens with type 1 diabetes mellitus prioritize reducing family conflict and fitting into their social milieu over health outcomes at this time in their lives. It is important to acknowledge this when designing interventions to improve health outcomes in teens with type 1 diabetes mellitus.

The Impact of Frequency and Tone of Parent-Youth Communication on Type 1 Diabetes Management

BACKGROUND

The purpose of this study is to assess the impact of frequency and tone of parent-youth communication on glycemic control as measured by the Family Communication Inventory (FCI). Adolescence provides a unique set of diabetes management challenges, including suboptimal glycemic control. Continued parental involvement in diabetes management is associated with improved HbA1c outcomes; however, diabetes-related conflict within the family can have adverse effects. Although it is clear that communication plays an important role in diabetes outcomes, the specific impact of frequency and tone of such communication is largely understudied.

METHODS

A total of 110 youths with type 1 diabetes and their parents completed questionnaires assessing diabetes-related adherence, family conflict, and family communication (i.e., frequency and tone) during a routine clinic visit. Routine testing of HbA1c was performed.

RESULTS

Youth- and parent-reported frequency of communication were unrelated to HbA1c. Instead, greater discrepancies between parents and children on reported frequency of communication (most commonly parents reporting frequent and youth reporting less frequent communication) corresponded with poorer glycemic control and increased family conflict. More positive tone of communication as rated by youth was associated with lower HbA1c.

CONCLUSIONS

Diabetes-related communication is more complex than conveyed simply by how often children and their parents communicate. Tone of communication and discrepancies in a family's perception of the frequency of communication were better than frequency as predictors of glycemic control. The FCI appears to capture the frequency and tone of diabetes-related communication, though larger-scale studies are warranted to inform future use of this scale.

Psychological and psychosocial implications for parenting a child with phenylketonuria: a systematic review

INTRODUCTION

Since phenylketonuria (PKU) appears to have specificities that might challenge the parents' adaptation and well-being, the present review aimed to evaluate the impact of parenting a child with PKU on parents' psychological and psychosocial functioning.

EVIDENCE ACQUISITION

A systematic electronic search was conducted using PubMED, Scopus, Embase, PsychInfo, Google Scholar and Cochrane Database to identify studies exploring psychological and psychosocial issues of parents of PKU children. The search retrieved 427 articles to review against inclusion criteria; a total of 17 studies were included in the review. Results were summarized qualitatively.

EVIDENCE SYNTHESIS

Findings revealed a complex pattern of interrelated factors both on parental psychological wellbeing and psychosocial functioning. In particular, crucial for parents' adjustment to child PKU are the diagnosis resolution and the perceived social support; parents showed good coping strategies and quality of life; while, with regard to mental health, the studies reviewed showed inconsistent results, thus pointed out a moderate level of distress. The review examines patterns of results across studies and discusses methodological heterogeneities and problems related to different or inconsistent findings.

CONCLUSIONS

Parenting a child with PKU had direct implications on the diagnosis resolution, the parents mental health and the disease management. Findings could help healthcare professionals to identify situations at risk for psychological maladjustments both in parents and in children, as the unresolved diagnosis or a tendency toward the social isolation. Results highlighted the necessity of a multidisciplinary caring approach for the family, with a particular focus on critical moments such diagnosis or developmental transitions.

Positive parenting for healthy living (Triple P) for parents of children with type 1 diabetes: protocol of a randomised controlled trial

Background

Type 1 diabetes is a serious, life-long condition which causes major health, social and economic burden for children, their families and the community. Diabetes management involves strict adherence to a complex regimen, and poor management and non-adherence are a persistent problem among children. Parent-child interactions and parenting have been identified as crucial points of intervention to support children’s health and emotional well-being, yet few parenting interventions have been developed or evaluated for parents of young children. This paper describes a randomised controlled trial of a brief, group-based parenting intervention for parents of young children (2-10 years) with type 1 diabetes compared against care as usual (CAU).

Methods/design

Families will be randomised to either Positive Parenting for Healthy Living Triple P or CAU. Positive Parenting for Healthy Living Triple P involves 2 × 2 h group sessions. Outcomes will be assessed via parent and child questionnaire, home observations and blood glucose monitoring at baseline, 1-month and 6-months post-intervention. Primary outcomes will be parent- and child-reported parenting behaviour, parent-reported child behaviour and adjustment, and parent-reported child quality-of-life. Secondary outcomes will include parental self-efficacy with diabetes management, illness-specific and general parenting stress, parent-reported child illness behaviour, family quality-of-life, observed parenting and child behaviour, and child’s illness control.

Discussion

The theoretical background, study hypotheses, methods and planned analyses are discussed.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12613001281785. Registered 20 November, 2013.

Behavioral Assessment and Intervention in Pediatric Diabetes

This article reviews the empirical research literature on behavioral assessment and intervention methods in the context of diabetes mellitus in children and adolescents. The review summarizes the pathophysiology, medical management, and monitoring of pediatric type 1 and type 2 diabetes. Next, the article describes common behavioral barriers to acceptable diabetes management and adequate metabolic control and the role of behavior change agents in evaluation and intervention for these problems. Validated approaches to the assessment of diabetes-specific behavioral problems are described for the measurement of treatment adherence, diabetes-related fears and avoidance behaviors, diabetes-specific social skills, and disease-related stressors. Behavioral interventions that have empirical support are discussed, including treatments that target treatment adherence, social skills, coping skills, family communication and problem solving, anxiety and stress management, and weight control. The article concludes with clinical practice recommendations for behavior change specialists who have the opportunity to work with this population.

Depression in Mexican Americans with diagnosed and undiagnosed diabetes

BACKGROUND

Depression and diabetes commonly co-occur; however, the strength of the physiological effects of diabetes as mediating factors towards depression is uncertain.

METHOD

We analyzed extensive clinical, epidemiological and laboratory data from n = 2081 Mexican Americans aged 35-64 years, recruited from the community as part of the Cameron County Hispanic Cohort (CCHC) divided into three groups: Diagnosed (self-reported) diabetes (DD, n = 335), Undiagnosed diabetes (UD, n = 227) and No diabetes (ND, n = 1519). UD participants denied being diagnosed with diabetes, but on testing met the 2010 American Diabetes Association and World Health Organization definitions of diabetes. Depression was measured using the Center for Epidemiological Studies - Depression (CES-D) scale. Weighted data were analyzed using dimensional and categorical outcomes using univariate and multivariate models.

RESULTS

The DD group had significantly higher CES-D scores than both the ND and UD (p ⩽ 0.001) groups, whereas the ND and UD groups did not significantly differ from each other. The DD subjects were more likely to meet the CES-D cut-off score for depression compared to both the ND and UD groups (p = 0.001), respectively. The UD group was also less likely to meet the cut-off score for depression than the ND group (p = 0.003). Our main findings remained significant in models that controlled for socio-demographic and clinical confounders.

CONCLUSIONS

Meeting clinical criteria for diabetes was not sufficient for increased depressive symptoms. Our findings suggest that the 'knowing that one is ill' is associated with depressive symptoms in diabetic subjects.

Facilitators and barriers to antiretroviral therapy adherence among adolescents in Ghana

INTRODUCTION

Adherence to antiretroviral therapy (ART) is known to be challenging among adolescents living with HIV/AIDS, notwithstanding the life-saving importance of this therapy. Of the global total number of adolescents living with HIV in 2013, 83% reside in sub-Saharan Africa. The study aimed to identify facilitators of and barriers to antiretroviral treatment adherence among adolescents in Ghana.

METHODS

A cross-sectional qualitative study using semi-structured interviews for data collection was carried out among adolescents (aged 12-19 years) at the adolescents HIV clinic at the Korle-Bu Teaching Hospital in Ghana. Predominantly open-ended questions relating to ART were used. Interviews were done until saturation. In total, 19 interviews were conducted. Analysis was done manually to maintain proximity with the text.

FINDINGS

The main facilitators were support from health care providers, parental support, patient's knowledge of disease and self-motivation, patient's perceived positive outcomes, and dispensed formulation. The identified barriers were patient's forgetfulness to take medicines, perceived stigmatization due to disclosure, financial barriers, and adverse effects of ART. Support from health care workers was the most frequently mentioned facilitator, and patient's forgetfulness and perceived stigmatization after disclosure were the most frequently mentioned barriers. Self-motivation (knowledge induced) to adhere to treatment was a specific facilitator among older adolescents.

CONCLUSION

Continuous information provision in addition to unflinching support from health care workers and parents or guardians may improve adherence among adolescents. Also, interventions to reduce patient forgetfulness may be beneficial. A multi-sectorial approach would be needed to address adolescent disclosure of HIV/AIDS status.

Identifying Differences in Risk Factors for Depression and Anxiety in Pediatric Chronic Disease: A Matched Cross-Sectional Study of Youth with Lupus/Mixed Connective Tissue Disease and Their Peers with Diabetes

OBJECTIVE

To investigate differences in risk factors for depression and anxiety, such as central nervous system involvement in systemic lupus erythematosus (SLE)/mixed connective tissue disease (MCTD), by comparing youth with SLE/MCTD to peers with type 1 diabetes mellitus (T1D).

STUDY DESIGN

We conducted a cross-sectional study of 50 outpatient pairs, ages 8 years and above, matching subjects with SLE/MCTD and T1D by sex and age group. We screened for depression, suicidal ideation, and anxiety using the Patient Health Questionnaire-9 and the Screen for Childhood Anxiety Related Emotional Disorders, respectively. We collected parent-reported mental health treatment data. We compared prevalence and treatment rates between subjects with SLE/MCTD and T1D, and identified disease-specific risk factors using logistic regression.

RESULTS

Depression symptoms were present in 23%, suicidal ideation in 15%, and anxiety in 27% of participants. Compared with subjects with T1D, subjects with SLE/MCTD had lower adjusted rates of depression and suicidal ideation, yet poorer rates of mental health treatment (24% vs 53%). Non-White race/ethnicity and longer disease duration were independent risk factors for depression and suicidal ideation. Depression was associated with poor disease control in both groups, and anxiety with insulin pump use in subjects with T1D.

CONCLUSION

Depression and anxiety are high and undertreated in youth with SLE/MCTD and T1D. Focusing on risk factors such as race/ethnicity and disease duration may improve their mental health care. Further study of central nervous system and other disease-related factors may identify targets for intervention.

A systematic review of parenting interventions for parents of children with type 1 diabetes

OBJECTIVE

To summarize the parenting intervention literature for parents of children aged 2-10 years (mean age <10 years) with type 1 diabetes and to evaluate intervention efficacy in improving a range of parent, family and child outcomes. The present review de-emphasizes the traditional medical approach to illness management summarized in previous reviews and focuses on parenting factors identified in the literature as important to diabetes management. This review article is important as it outlines the present state of parenting intervention literature for this population.

METHODS

Electronic searches were conducted for seven databases (Cumulative index to nursing and allied health literature, MEDLINE, PsycINFO, PubMed, Scopus, The Cochrane library and Web of Science) from their start dates until April 2014. Reference lists of all included papers were also searched for potentially relevant articles.

RESULTS

Seven papers, representing six studies, met the inclusion criteria. Three studies primarily focused on improving parenting practices. The intervention programmes described in the remaining studies comprised multiple components; thus, it is difficult to establish the contribution of the parenting components to improving outcomes.

CONCLUSIONS

Parenting interventions may help to improve responsibility sharing and cooperation in diabetes management, child behaviour difficulties, parental behaviour, parents' psychological distress and child health outcomes. This review suggests the need for further well-designed trials of parenting interventions to determine their specific contribution to improving outcomes for this population.

COMMUNICATION IN THE CONTEXT OF FAMILY CAREGIVING: AN EXPLORATORY STUDY OF UGANDAN CHILDREN ON ANTIRETROVIRAL THERAPY

It is important to consider the complexities of family dynamics when deciding when and how to communicate with HIV-infected children about their illness and treatment. Previous research has focused on providers' and caregivers' perspectives on whether, when and how to disclose HIV/AIDS diagnosis and treatment to HIV-infected children. From the perspective of HIV-infected children, communication does not mean just giving information about illness and treatment, but also encompasses emotional and material care. This paper places communication within the broader framework of caregiving in family situations. This exploratory study was conducted in Jinja district, Uganda, between November 2011 and December 2012. Through participant observation and in-depth interviews, communication by, and with, HIV-infected children in the context of family situations was explored from the perspectives of 29 HIV-infected children aged 8-17 years on antiretroviral therapy (ART) using content thematic analysis. Children's communication with caregivers about their illness and treatment varied depending on whom they were living with and the nature of caregiving. Although a mother's care was considered best, children described others who cared 'like a mother'. For some, caregiving was distributed among several relatives and non-relatives, while others felt they had hardly anyone to care for them. Caregiving from the children's perspective involved emotional support, expressed verbally and explicitly in messages of concern, encouragement conveyed in reminders to take medicines, attention when sick and confidential conversations about the challenges of having HIV and taking ART. Caregiving was also communicated implicitly in acts of provision of food/drinks to take with medicines, counting pills to confirm they had taken the medicines and accompanying children to treatment centres. Children's communication about their health and medicines and the care they received was to a large extent shaped by the nature of their relatedness to their caregivers, the extent to which caregiving was dispersed among several people and who else in the household was infected with HIV and on medication.

Seeing Is Believing: Using Skype to Improve Diabetes Outcomes in Youth

OBJECTIVE

The objective of this study was to compare the relative effectiveness of two modes of delivering Behavioral Family Systems Therapy for Diabetes (BFST-D) to improve adherence and glycemic control among adolescents with type 1 diabetes with suboptimal glycemic control (HbA(1c) ≥9.0% [≥74.9 mmol/mol]): face to face in clinic (Clinic) and Internet videoconferencing (Skype) conditions.

RESEARCH DESIGN AND METHODS

Adolescents aged 12 to 18 years and at least one adult caregiver were randomized to receive BFST-D via the Clinic or Skype condition. Participants completed up to 10 therapy sessions within a 12-week period. Changes in youth- and parent-reported adherence and glycemic control were compared before and after the intervention and at follow-up assessment.

RESULTS

Using an intent-to-treat analytic approach, no significant between-group differences were identified between the before, after, and follow-up assessments. Groups were collapsed to examine the overall effects of BFST-D on adherence and glycemic control. Results identified that statistically significant improvements in adherence and glycemic control occurred from before to after the intervention; improvements were maintained at 3-month follow-up.

CONCLUSIONS

Delivery of BFST-D via Internet-based videoconferencing is viable for addressing nonadherence and suboptimal glycemic control in adolescents with type 1 diabetes, potentially reducing important barriers to care for youth and families.

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.

Recognizing the psychosocial aspects of type 1 diabetes in adolescents

OBJECTIVE

Considering the ever increasing population of diabetic adolescents and the association of the disease with psychosocial problems throughout its course, depression and/or anxiety and social support from parents are issues of special concern in these patients. The study aimed to identify the depression and anxiety state of diabetic adolescents and its impact on the management of diabetes mellitus (DM).

METHODS

295 adolescents with type 1 DM and their parents attended our study. Psychological distress was assessed using the Children's Depression Inventory and the State-Trait Anxiety Inventory (STAI I-II) for Children, Perceived Social Support from Family (PSS-Fa) scale, Beck Depression Inventory for adults, STAI I-II for adults and the Multidimensional Scale of Perceived Social Support (MSPSS). Records of glycemic measurements, insulin dosage and hemoglobin A1c levels were used as glycemic control parameters.

RESULTS

Depression rate was 12.9%. State (p<0.001) and trait anxiety (p<0.001) levels were high; PSS-Fa (p<0.001) and MSPSS (p<0.006) scores were low in the depressive patients. Positive correlations were noted between depression, PSS-Fa, STAI-I and STAI-II.

CONCLUSION

Therapeutic strategies of DM should include co-existing psychiatric conditions throughout the course of the disease. In diabetic adolescents, PSS-Fa, STAI-I and STAI-II appear to be effective tools in the evaluation of depression.

From controlling to letting go: what are the psychosocial needs of parents of adolescents with a chronic illness?

While one of the main objectives of adolescence is to achieve autonomy, for the specific population of adolescents with a chronic illness (CI), the struggle for autonomy is accentuated by the limits implied by their illness. However, little is known concerning the way their parents manage and cope with their children's autonomy acquisition. Our aim was to identify the needs and preoccupations of parents of adolescents with CI in coping with their children's autonomy acquisition and to determine whether mothers and fathers coped differently. Using a qualitative approach, 30 parents of adolescents with CI participated in five focus groups. Recruitment took place in five specialized pediatric clinics from our university hospital. Thematic analysis was conducted. Transcript analyses suggested four major categories of preoccupations, those regarding autonomy acquisition, giving or taking on autonomy, shared management of treatment and child's future. Some aspects implied differences between mothers' and fathers' viewpoints and ways of experiencing this period of life. Letting go can be hard for the father, mother, adolescent or all three. Helping one or the other can in turn improve family functioning as a whole. Reported findings may help health professionals better assist parents in managing their child's acquisition of autonomy.

Primary care of female adolescents with type 1 diabetes mellitus and disordered eating

AIM

To identify the role of the nurse practitioner in caring for female adolescents with type 1 diabetes mellitus at risk for disordered eating behaviour and to formulate clinical recommendations for nurse practitioners in the primary care setting.

BACKGROUND

Transition into adulthood can be difficult for female adolescents with type 1 diabetes mellitus. Challenges associated with management of this illness may place adolescent females at an increased risk for disordered eating.

DESIGN

Discussion paper.

DATA SOURCES

Sourced literature from 1991-2013, located through CINAHL, Health Source, Proquest, PubMed, PsychInfo, Web of Science and Medline databases.

IMPLICATIONS FOR NURSING

Nurses involved in the primary care of female adolescents with type 1 diabetes mellitus need to be aware of the increased risk for disordered eating behaviours and develop the competencies to care for both the adolescent and her family to reduce the serious consequences of these behaviours.

CONCLUSION

Awareness and acquisition of the skills required to intervene will enable nurse practitioners to recognize clients at risk for disordered eating, gain appreciation of the motivation of female adolescents with type 1 diabetes mellitus towards disordered eating behaviours and give optimal opportunity for education, counselling and recovery. Future direction for research includes exploration of the experiences of adolescents with type 1 diabetes mellitus; early interventions in the primary care setting; effective educational, preventative or supportive services for adolescents with this illness and their families; and outcomes to emerging technologies for insulin therapy on disordered eating occurrence.

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.

Brief report: Maternal posttraumatic stress symptoms are related to adherence to their child’s diabetes treatment regimen

Although research suggests that posttraumatic stress disorder symptoms in relation to physical health diagnoses may be related to poor adherence to treatment regimens, so far, whether parental posttraumatic stress disorder symptoms have an impact on their child’s adherence to insulin-dependent diabetes mellitus treatment has not been investigated. Using self-report questionnaires, the present study found that children of mothers who have posttraumatic stress disorder symptoms in relation to their child’s diagnosis of type I diabetes showed poorer adherence to treatment than the children of mothers without posttraumatic stress disorder. However, this was only the case for younger children (aged 0–8 years) where mothers played a more active role in their child’s treatment.

Longitudinal testing of a dietary self-care motivational model in adolescents with diabetes

OBJECTIVE

Based on self-determination theory, this study tests a model positing that perceived autonomy support from parents and health care providers positively predicts self-efficacy and autonomous self-regulation in dietary self-care. In turn, self-efficacy and autonomous self-regulation predict better dietary self-care over time.

METHOD

Longitudinal data were collected in a consecutive series of 289 adolescent patients with type I diabetes at two time points separated by a two-year interval.

RESULTS

Structural equation modeling analysis revealed that perceived autonomy support from health care providers at Time 1 (T1) positively predicted self-efficacy and autonomous self-regulation at Time 2 (T2), T1 self-efficacy and autonomous self-regulation positively predicted T2 dietary self-care, and T1 dietary self-care positively predicted T2 autonomous self-regulation.

CONCLUSION

Autonomy support from health care providers appears to help adolescents develop motivational factors for dietary self-care and adhere to dietary recommendations.

Longitudinal trajectories of parental involvement in Type 1 diabetes and adolescents' adherence

OBJECTIVE

The purpose of this study was to examine longitudinal trajectories of parental involvement and adolescent adherence to the Type 1 diabetes regimen, to determine whether changes in multiple facets of parental involvement over time predicted subsequent changes in adolescents' adherence, and to examine whether adolescent self-efficacy mediated the effect of parental involvement on adherence.

METHOD

Two hundred fifty-two adolescents (M age = 12.49 years, SD = 1.53; 53.6% females) diagnosed with Type 1 diabetes mellitus, their mothers, and 188 fathers were enrolled in a 2.5-year longitudinal study. Across 5 time points, up to 252 adolescents and their parents completed measures of adherence, parental involvement (diabetes monitoring, behavioral involvement in diabetes management, and acceptance), and adolescent diabetes self-efficacy.

RESULTS

Using multilevel modeling, analyses indicated significant average declines over time in adherence and most indicators of parental involvement. Lagged multilevel models indicated that declines in mothers' and fathers' acceptance and diabetes monitoring predicted subsequent declines in adolescents' adherence. Additional analyses revealed that longitudinal associations between both maternal acceptance and diabetes monitoring and subsequent adolescent adherence were mediated by adolescents' self-efficacy.

CONCLUSIONS

Results of this study, which were largely consistent across reporters, highlight the importance of maintaining parental involvement in diabetes across adolescence and suggest that parental involvement is beneficial for adolescents' adherence, in part, because it contributes to higher self-efficacy for diabetes management among adolescents.

The psychosocial impact of diabetes in adolescents: a review

Type 1 Diabetes mellitus is known to have a major psychological impact on adolescents. Different types of therapies have been developed to support the patient as well as their families to deal with this impact. These include Behavioral Family Systems Therapy and Cognitive Behavioral Therapy. However, studies conducted recently, though few in numbers have shown a direct relationship between general psychological functioning and metabolic control. Self-management of diabetes and its complication therefore, is an integral part of these program. This review looks into the various studies carried out that decide the best approach towards addressing the psychological aspect of type 1 Diabetes Mellitus.

Behavioral health care for adolescents with poorly controlled diabetes via Skype: does working alliance remain intact?

BACKGROUND

Increasingly various technologies are being tested to deliver behavioral health care. Delivering services via videoconferencing shows promise. Given that the patient-provider relationship is a strong predictor of patient adherence to medical regimens, addressing relationship quality when services are not delivered face-to-face is critical. To that end, we compared the therapeutic alliance when behavioral health care was delivered to youth with poorly controlled type 1 diabetes mellitus (T1DM) and their caregivers in-clinic with the same services delivered via Internet-based videoconferencing (i.e., Skype™).

METHODS

Seventy-one adolescents with poorly controlled T1DM (hemoglobin A1c ≥9%) and one of their caregivers received up to 10 sessions of a family-based behavioral health intervention previously shown to improve adherence to diabetes regimens and family functioning; 32 were randomized to the Skype condition. Youth and caregivers completed the working alliance inventory (WAI), a 36-item measure of therapeutic alliance, at the end of treatment. Additionally, the number of behavioral health sessions completed was tracked.

RESULTS

No significant differences in WAI scores were found for those receiving behavioral health care via Skype versus in-clinic. Youth WAI goal and total scores were significantly associated with the number of sessions completed for those in the clinic group.

CONCLUSION

Behavioral health can be delivered to youth with T1DM via Internet-based videoconferencing without significantly impacting the therapeutic relationship. Thus, for those adolescents with T1DM who require specialized behavioral health care that targets T1DM management, Internet-based teleconferencing represents a viable alternative to clinic-based care.

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

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

Impact of blood glucose monitoring affect on family conflict and glycemic control in adolescents with type 1 diabetes

BACKGROUND

This longitudinal study examined whether diabetes-specific family conflict and glycemic control were impacted/explained by negative affective responses to blood glucose checks (Negative BGM Affect).

METHOD

Adolescents (N=150, ages 13-18 years) with type 1 diabetes, and their caregivers, completed measures of Negative BGM Affect, diabetes-specific family conflict, and glycemic control (i.e., hemoglobin A1c) at baseline, 6-, and 12-months.

RESULTS

Caregiver Negative BGM Affect predicted higher A1c values at 12 months. Diabetes-specific family conflict mediated and explained 39% of the Negative BGM Affect-A1c relationship. Conflict around direct management tasks mediated the caregiver Negative BGM Affect-A1c relationship for adolescents (30.6% of variance). The impact of Negative BGM Affect on diabetes-specific family conflict is more pervasive for caregivers (direct and indirect diabetes management tasks) than adolescents (direct diabetes management tasks only).

CONCLUSIONS

Caregiver Negative BGM Affect is an important contributor to A1c via diabetes-specific family conflict. Identifying and intervening with families who endorse high levels of Negative BGM Affect may prevent diabetes-specific family conflict, thereby minimizing the impact of family conflict on glycemic control. Brief clinic-based interventions to address Negative BGM Affect can be incorporated into clinical practice to prevent long-term negative impact on glycemic control.

Finding straight answers: identifying the needs of parents and service providers of adolescents with type 1 diabetes to aid in the creation of an online support intervention

AIMS AND OBJECTIVES

To explore the needs and preferences of parents and service providers of adolescents with type 1 diabetes in an online support intervention.

BACKGROUND

Parents experience stress during this time of transition as adolescent conflict is common and the consequences of risk-taking behaviour in combination with type 1 diabetes can be severe. Parents are in need of social support and desired an online intervention. Online support interventions have not been previously designed from the perspective of the users of these interventions.

METHODS

Participatory, qualitative design. Fourteen group interviews across Canada (n=60).

RESULTS

Participants identified four main themes (Finding straight answers, Making transitions, Struggling with parenting and Connecting with others) within the context of accessibility. Parents described their needs for credible Canadian information, support from other parents, fostering positive family dynamics while shifting parenting roles during adolescence. Connecting with others included finding a social support system and venue to share stories and resources.

DISCUSSION

These findings are innovative as these experienced participants desired a blend of professional information and peer informal knowledge and support in an accessible, online format.

CONCLUSION

The results of this study will form the foundation of an online support intervention while providing unique insight into the experiences of parents of adolescents with type 1 diabetes.

RELEVANCE TO CLINICAL PRACTICE

Parents and service providers indicate the need for information that is trusted, accurate and on a wide range of topics, within a preferred online environment. Supporting parents during this difficult time includes directing them to appropriate and accessible resources, facilitating a positive, healthy process of transition to interdependence, in their parenting of adolescents with type 1 diabetes.

Socioeconomic status and health: mediating and moderating factors

Health disparities (differences in health by socioeconomic groups) are a pressing issue in our society. This article provides an overview of a multilevel approach that seeks to understand the mechanisms underlying health disparities by considering factors at the individual, family, and neighborhood levels. In addition, we describe an approach to connecting these factors to various levels of biological processes (systemic inflammation, cellular processes, and genomic pathways) that drive disease pathophysiology. In the second half of the article, we address the question of why some low-socioeconomic-status (low-SES) individuals manage to maintain good physical health. We identify naturally occurring psychosocial factors that help buffer these individuals from adverse physiological responses and pathogenic processes leading to chronic disease. What is protective for low-SES individuals is not the same as what is protective for high-SES individuals, and this needs to be taken into account in interventions aimed at reducing health disparities.

Quality of life and technology: impact on children and families with diabetes

Ensuring quality of life (QOL) while maintaining glycemic control within targets is an important challenge in type 1 and type 2 diabetes treatment. For children with diabetes, QOL includes enjoying meals, feeling safe in school, and perceiving positive, supportive relationships with parents, siblings, and friends. Yet many treatment-related and psychosocial barriers can interfere with a child's QOL and their ability to manage diabetes effectively. Diabetes management also imposes considerable lifestyle demands that are difficult and often frustrating for children to negotiate at a young age. Recent advances in diabetes medications and technologies have improved glycemic control in children with diabetes. Two widely used technologies are the insulin pump and continuous glucose monitoring (CGM) system. These technologies provide patients with more flexibility in their daily life and information about glucose fluctuations. Several studies report improvements in glycemic control in children with type 1 diabetes using the insulin pump or sensor-augmented pump therapy. Importantly, these technologies may impact QOL for children and families with diabetes, although they are rarely used or studied in the treatment of children with type 2 diabetes. Further, emerging closed loop and web- and phone-based technologies have great potential for supporting diabetes self-management and perhaps QOL. A deeper understanding and appreciation of the impact of diabetes technology on children's and parents' QOL is critical for both the medical and psychological care of diabetes. Thus, the purpose of this review is to discuss the impact of new diabetes technologies on QOL in children, adolescents and families with type 1 diabetes.

Psychometric evaluation of the adherence in diabetes questionnaire

OBJECTIVE

To assess the psychometric properties of a short, new, self-administered questionnaire (17-19 items) for evaluating the adherence behavior of children and adolescents with type 1 diabetes and their caregivers. This instrument has separate versions depending on the means of insulin administration, i.e., continuous subcutaneous insulin infusion (Adherence in Diabetes Questionnaire [ADQ]-I), or conventional insulin injection (ADQ-C).

RESEARCH DESIGN AND METHODS

A total of 1,028 caregivers and 766 children and adolescents 2-17 years of age were recruited through the Danish Registry of Childhood Diabetes and completed the national web survey, including the ADQ and psychosocial measures of self-efficacy, parental support, family conflict, and aspects of diabetes-related quality of life. Blood samples were obtained for central HbA(1c) analysis. The psychometric properties of the ADQ were evaluated, and the association with glycemic control was assessed.

RESULTS

There was good internal consistency for both the youth and caregiver reports and strong agreement between the caregiver and youth reports. Higher ADQ scores, indicating better adherence, were associated with better self-efficacy, more parental support, less diabetes-related conflict, and less experience with treatment barriers. Factor analysis supported maintaining the one-factor structure of the ADQ. Higher ADQ scores were associated with lower HbA(1c) levels.

CONCLUSIONS

The ADQ showed good psychometric properties. Although the test-retest reliability and sensitivity to change of the instrument still need to be established, the ADQ appears to be a valuable tool for assessing adherence in families with children and adolescents with type 1 diabetes in both clinical and research settings.

An examination of how adolescent-caregiver dyad illness representations relate to adolescents' reported diabetes self-management

BACKGROUND

Adolescence is a period associated with poor glycaemic control. The key developmental concerns of young people are in conflict with the requirements of diabetes self-management. This study explores the relative influence of adolescents' and caregivers' illness representations and how any difference/similarity in their representations may be related to adolescents' diabetes self-management.

METHODS

Fifty-five adolescents between 12 and 16 years of age were asked to complete the Diabetes Illness Representation Questionnaire and Summary of Diabetes Self-Care Activities Questionnaire. Their primary caregivers were asked to complete a caregivers' version of the Diabetes Illness Representation Questionnaire.

RESULTS

Caregivers believed diabetes to be more chronic, to have a more negative impact, pose more of a threat to adolescents' health and believed more strongly in the effectiveness of treatment than did adolescents. Caregivers' representations about the impact of diabetes and the ability of treatment to prevent future complications were related to adolescents' dietary self-management.

CONCLUSIONS

This study emphasizes the important role of significant others illness representations in adolescent self-management of diabetes.

Couple and family interventions in health problems

Intervention research for couples and families managing chronic health problems is in an early developmental stage. We reviewed randomized clinical trials of family interventions for common neurological diseases, cardiovascular diseases, cancer, and diabetes, which is similar to the content of previous reviews discussed later. One overriding theme of these studies is that patients with chronic illnesses and their families face a variety of challenges to which researchers have responded with an array of treatment modalities. Very few of the interventions reviewed, with the exception of treatment for adolescents with diabetes, tested family psychotherapy models. Most interventions were time-limited therapeutic interventions that trained families to improve their communication and problem-solving skills, individual and family coping skills, and medical management. Researchers more clearly described mechanisms of change in intervention studies with cancer and diabetes than with other diseases, and not surprisingly, they found greater empirical support for their interventions. Family interventions show promise to help patients and family members manage chronic illnesses. To develop an empirical base for family approaches to managing chronic illnesses, interventions must be based on theories that delineate mechanisms of change in family processes and skills in medical management necessary to maintain patients' and family members' health.

Needle with a novel attachment versus conventional screw-thread needles: a preference and ease-of-use test among children and adolescents with diabetes

BACKGROUND

This usability test investigated the overall preference and usability of the novel NovoTwist® insulin pen needle versus conventional screw-thread needles, when used with Next Generation FlexPen®, in children and adolescents with diabetes.

METHODS

This was an open-label, randomized, crossover usability test in children and adolescents with type 1 diabetes who administered insulin with an insulin pen. Test needles were NovoTwist and the participant's current screw-thread needle (or NovoFine® needle). Following instruction, participants attached the needle to Next Generation FlexPen, made an injection into a foam cushion, and detached the needle. This procedure was conducted three times with both needles in a random order. Responses to 13 questions on user experience with each needle (including overall preference, ease of attachment/detachment of needle/cap, handling, learning, confidence in attachment, and convenience of use) were subsequently recorded on a six-point rating scale (1 = very difficult; 6 = very easy).

RESULTS

Fifteen children aged ≥ 6 to ≤ 12 years and 15 adolescents aged ≥ 13 to ≤ 17 years participated in the test. A significantly higher proportion of children and adolescents (77%) indicated that they would prefer to use NovoTwist compared with screw-thread needles (p = .005). NovoTwist was preferred by most children and adolescents for overall ease of use (77%; p = .005), for ease of attachment (87%; p < .001) and detachment (83%; p < .001), and as the most appropriate needle to handle for daily injections (73%; p = .016). The mean rating for confidence in correct needle attachment was not significantly different between the two needle types. Seven out of eight parents of children who required assistance for their daily insulin injections stated that they would be "very likely" to allow their child to attach NovoTwist.

CONCLUSIONS

These factors may promote confidence in this needle, and thus in self-injecting, among younger patients and their parents.

A systematic review of adherence-enhancing interventions in adolescents taking long-term medicines

PURPOSE

To assess the effectiveness of adherence-enhancing interventions (AEIs) aimed at adolescents (10-19-year-olds).

METHODS

An extensive search of seven bibliographic databases was conducted at the end of 2009 to identify comparative studies evaluating AEIs targeting adolescents. Data describing study characteristics and intervention effects on adherence to medicines or health outcomes were extracted and summarized using qualitative and quantitative methods.

RESULTS

A total of 17 AEIs were identified: 12 studies (70%) were conducted in the United States, 10 (59%) included adolescents with type 1 diabetes mellitus, and 14 (82%) considered the developmental tasks of adolescence. In all, 12 AEIs successfully improved outcome measures. Features of successful interventions included targeting AEIs to a narrow age range, including family in type 1 diabetes mellitus management, and improving access to care. Poor quality and underpowered studies limit the inferences drawn from this review.

CONCLUSIONS

More diverse and robust studies are needed to identify strategies to help adolescents manage medicines.

Blood glucose monitoring and glycemic control in adolescents with type 1 diabetes: meter downloads versus self-report

BACKGROUND

Reported frequencies of blood glucose monitoring (BGM) by both adolescents and their caregivers serve as adherence proxies when meter downloads are not available. Yet, correlates of reported BGM frequencies and their predictive utility are understudied.

OBJECTIVE

To identify sociodemographic, psychological, and disease-specific correlates of reported BGM frequencies in adolescents with type 1 diabetes and to explore the predictive utility of BGM indices on glycemic control.

SUBJECTS

Study participants included caregivers and adolescents with type 1 diabetes (N=143, 13-18 yr) receiving diabetes treatment at a tertiary care setting.

METHODS

At the initial visit, adolescents and caregivers reported on daily BGM frequencies. A sub-sample provided meter downloads. Adolescents also completed a depression inventory. Three months later, adolescents provided blood sampling for A1c assessment.

RESULTS

Multivariate general linear modeling identified that older adolescent age and more depressive symptoms were associated with reports of less frequent BGM. Two stepwise multivariate regression models examined the predictive utility of BGM indices (i.e., adolescent-reported BGM, caregiver-reported BGM, meter download) on glycemic control. Caregiver-reported BGM frequency predicted glycemic control in the absence of meter download data (p<0.001). However, when clinical and contextual variables were included, meter download data were the most robust predictor of glycemic control (p<0.0001).

CONCLUSIONS

Meter downloads have the most robust association with glycemic control when contextual variables are considered. Caregiver-reported BGM frequencies can serve as reliable substitutes in the absence of meter download, but they may not be as reliable in adolescents with depressive symptoms.