Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: I. The influence of patient coping and adjustment

"I'll Just Forever Be That Person Who Stands in the Middle of the Dance Floor Drinking a Juice Box": Supporting the Transition to Adulthood With Type 1 Diabetes in a Post-Secondary University/College Setting

Background

The transition to adulthood is a challenging period for individuals with type 1 diabetes, especially those attending post-secondary education (PSE) at a university or college. In addition to balancing academic responsibilities and adapting to a novel environment, young adults (YAs) with type 1 diabetes must more independently manage the daily demands of diabetes care.

Objective

The aim of this study was to collect qualitative data from multiple stakeholders addressing the transition of students with type 1 diabetes into a PSE setting.

Methods

A total of 15 participants were interviewed, including three health care provider diabetes educators, four parents of YAs with type 1 diabetes, and eight YAs with type 1 diabetes. Reflexive thematic analysis of the qualitative interviews revealed four major themes and 11 subthemes.

Results

The four major themes revealed included 1) inappropriateness of services available to support students with type 1 diabetes in PSE settings, 2) individuals with type 1 diabetes having to compensate for inadequate systems, 3) variability of social support effectiveness, and 4) the need for a more holistic approach to improve diabetes education and social support systemically.

Conclusion

This study identified some key systemic barriers experienced by PSE students with type 1 diabetes. Future research needs to extend the sample populations to understand a wider range of PSE student experiences. The findings from this study provide initial recommendations to develop new PSE readiness interventions for YAs with type 1 diabetes.

Predicting optimal use of continuous glucose monitors in adolescents with type 1 diabetes: It's about benefit and burden

PURPOSE

Youth with type 1 diabetes (T1D) often use Continuous Glucose Monitoring (CGM) devices; however, many do not wear them consistently enough to obtain optimal glycemic benefit. This study aimed to identify demographic and psychosocial predictors of optimal CGM use in adolescents with T1D to inform nurse-led interventions to improve adherence.

DESIGN AND METHODS

Cross-sectional survey data from youth (12-19 years) using CGM were analyzed to determine whether perceived benefits/burdens of CGM, self-efficacy, and coping predicted being a "CGM Optimizer" (wearing CGM 6-7 days/week) or "CGM Sub-user."

RESULTS

Of 282 adolescents (54% female), 161 were CGM Optimizers and 121 were CGM Sub-Users. Optimizers were younger (15.91 ± 2.17 years vs. 16.79 ± 2.17, p = 0.001), more likely non-Hispanic White (91.9% vs 83.5%, p = 0.029), and more likely to have private insurance (82.0% vs. 69.4%, p = 0.009). Every 1-point increase on Benefits of CGM scale was associated with 2.8 times greater odds of being an Optimizer (OR = 2.82, 95% CI 1.548-5.132, p = 0.001), and every 1-point increase on the Burdens of CGM scale was associated with a 52% decrease in odds (OR = 0.48, 95% CI = 0.283-0.800, p = 0.005), with final logistic regression model (including only these two predictors) explaining 22.3% of variance.

CONCLUSION

CGM Optimizing adolescents were more likely to perceive higher benefit and lower burden of CGM.

PRACTICAL IMPLICATIONS

Nurse-led interventions to promote benefits of CGM and mitigate burden may help youth increase adherence with CGM to achieve glycemic benefit.

Diabetes distress in Indian children with type 1 diabetes mellitus and their mothers

BACKGROUND

Children and their mothers, who are usually the primary caregivers, are likely to be distressed due to type 1 diabetes (T1DM).

OBJECTIVES

(1) To assess diabetes-specific distress (DD) perceived by children and adolescents with T1DM and their mothers and association of distress between children and mothers. (2) To study the association of diabetes distress with glycemic control and disease duration.

SUBJECTS

Children and adolescents with T1DM over eight years and their mothers.

METHODS

Clinical data were recorded. DD was assessed by Problem Associated in Diabetes-Pediatric (PAID-Peds) (range 0-80) and Problem Associated in Diabetes-Parents Revised (PAID-PR) (range 0-72) questionnaires (higher scores indicate higher distress); administered to children and mothers, respectively. Sub-dimensions in questionnaires included diabetes-related emotional problems, and treatment-, food-, and social support-related problems. Correlation analysis (Spearman's) was performed, and a paired t-test was used to compare PAID-Peds and PAID-PR (SPSS 25).

RESULTS

Mean PAID-Peds and PAID-PR scores in 67 children and mothers were 24.4 ± 18.1 and 31.9 ± 21.5, respectively (p=0.009), and a significant correlation was noted between their scores (R=0.45, p=0.001). PAID-Peds score was positively associated with HbA1c (R=0.25, p=0.04). Diabetes-related emotional problems of mothers and children (R=0.38, p=0.003), treatment problems (R=0.5, p=0.001), and food problems (R=0.24, p=0.05) correlated positively. Subdimension scores were significantly different in children and mothers except in the social support domain.

CONCLUSION

DD was higher in mothers than children; higher distress in children was associated with poor metabolic control. Evaluation of DD needs to be performed in children with T1DM.

Use of Wise Device Technology to Measure Adherence to Hydroxyurea Therapy in Youth With Sickle Cell Disease

Despite broad support for hydroxyurea (HU) therapy, suboptimal adherence is reported for youth with sickle cell disease. Valid adherence measurement is crucial to understanding the relationship between medication behavior, disease response, and patient-centered health outcomes. The current pilot study examined the feasibility of the Wise electronic device for longitudinal HU adherence measurement in a sample of 36 youths prescribed HU. The study also explored the association between HU adherence, as measured by the Wise device, with other adherence measures (ie, family report, lab values, pill count, and medication possession ratio). A measure of family-reported acceptability was also completed. Overall, results supported the feasibility of the Wise device (rate of consent=82%, device use=75%, device failure=3%) for HU adherence measurement and most families rated their experience using their device positively (favorable responses ranged from 67% to 100%). Associations between HU adherence, as measured by the Wise device, and other adherence measures were not significant. Overall, the feasibility was supported. The Wise device allows longitudinal measurement of adherence with HU from initiation as a young child (ie, with liquid formulations) through adolescence and provides a novel means of adherence measurement for both clinical and research use.

Medication Adherence During Adjunct Therapy With Statins and ACE Inhibitors in Adolescents With Type 1 Diabetes

OBJECTIVE

Suboptimal adherence to insulin treatment is a main issue in adolescents with type 1 diabetes. However, to date, there are no available data on adherence to adjunct noninsulin medications in this population. Our aim was to assess adherence to ACE inhibitors and statins and explore potential determinants in adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

There were 443 adolescents with type 1 diabetes recruited into the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) and exposed to treatment with two oral drugs-an ACE inhibitor and a statin-as well as combinations of both or placebo for 2-4 years. Adherence was assessed every 3 months with the Medication Event Monitoring System (MEMS) and pill count.

RESULTS

Median adherence during the trial was 80.2% (interquartile range 63.6-91.8) based on MEMS and 85.7% (72.4-92.9) for pill count. Adherence based on MEMS and pill count dropped from 92.9% and 96.3%, respectively, at the first visit to 76.3% and 79.0% at the end of the trial. The percentage of study participants with adherence ≥75% declined from 84% to 53%. A good correlation was found between adherence based on MEMS and pill count (r = 0.82, P < 0.001). Factors associated with adherence were age, glycemic control, and country.

CONCLUSIONS

We report an overall good adherence to ACE inhibitors and statins during a clinical trial, although there was a clear decline in adherence over time. Older age and suboptimal glycemic control at baseline predicted lower adherence during the trial, and, predictably, reduced adherence was more prevalent in subjects who subsequently dropped out.

Validation of a risk screening tool for pediatric type 1 diabetes patients: a predictor of increased acute health care utilization

Background Both psychosocial and socioeconomic risk factors contribute to poor glycemic control (GC). Previous research has identified that diabetes care behaviors are generally 'set' by late childhood, further highlighting the importance of psychosocial screening and intervention in the early course of disease management. The purpose of the current study was to determine whether this brief risk assessment tool is associated with GC and acute health care (HC) utilization, and to evaluate the discriminatory utility of the tool for predicting poor outcomes. Methods This was a retrospective cohort design in which we compared risk assessment scores with health outcomes at 6, 12, and 18 months after new-onset type 1 diabetes diagnosis for 158 patients between 2015 and 2017. The two primary outcome variables were GC and acute HC utilization. Results Our data demonstrate that the greatest utility of the tool is for predicting increased acute HC utilization. It was most useful in differentiating between patients with vs. without any acute HC utilization, with excellent discriminatory ability (area under the receiver operator characteristic curve [AUC] = 0.93), sensitivity (90%), and specificity (97%). Conclusions Knowledge of the risk category in addition to identification of individual risk factors within each domain allows for not only clear treatment pathways but also individualized interventions. The risk assessment tool was less effective at differentiating patients with poor GC; however, the tool did have high specificity (83%) for predicting poor GC at 18 months which suggests that the tool may also be useful for predicting patients at risk for poor GC.

Foot care, 'spousal' support and type 2 diabetes: an exploratory qualitative study

OBJECTIVES

People with type 2 diabetes (T2DM) should check their feet and protect them against harm, but few do. Living with a spouse contributes to good foot care behaviour. This study explores awareness, perceived susceptibility of, and concern about, foot problems, and reported foot care behaviour, and ways in which a spouse may or may not contribute to foot care in T2DM.

METHODS

1:1 interviews were conducted with 6 individuals with T2DM. Half had a spouse half did not. There was one person at low, medium and high risk in each sample. Each spouse participated in a separate interview, and the dyads were interviewed together. Interviews were analysed using Applied Thematic Analysis.

RESULTS

All participants knew that diabetes was associated with foot problems. Not all people with T2DM thought that they were susceptible; spouses perceived greater susceptibility for the patient. This was unrelated to risk level. Most people with T2DM and all spouses engaged in behaviour to identify problems or protect feet, but rarely both. Spouses' attitude and behaviour did influence the patients' own behaviour. At times spouse support was perceived positively, and at times negatively.

CONCLUSION

Engaging spouses in foot care education may improve foot care behaviour.

Correlates of Medication Adherence in the TODAY Cohort of Youth With Type 2 Diabetes

OBJECTIVE

To identify factors that predict medication adherence and to examine relationships among adherence, glycemic control, and indices of insulin action in TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth).

RESEARCH DESIGN AND METHODS

A total of 699 youth 10-17 years old with recent-onset type 2 diabetes and ≥80% adherence to metformin therapy for ≥8 weeks during a run-in period were randomized to receive one of three treatments. Participants took two study pills twice daily. Adherence was calculated by pill count from blister packs returned at visits. High adherence was defined as taking ≥80% of medication; low adherence was defined as taking <80% of medication. Depressive symptoms, insulin sensitivity (1/fasting insulin), insulinogenic index, and oral disposition index (oDI) were measured. Survival analysis examined the relationship between medication adherence and loss of glycemic control. Generalized linear mixed models analyzed trends in adherence over time.

RESULTS

In this low socioeconomic cohort, high and low adherence did not differ by sex, age, family income, parental education, or treatment group. Adherence declined over time (72% high adherence at 2 months, 56% adherence at 48 months, P < 0.0001). A greater percentage of participants with low adherence had clinically significant depressive symptoms at baseline (18% vs. 12%, P = 0.0415). No adherence threshold predicted the loss of glycemic control. Longitudinally, participants with high adherence had significantly greater insulin sensitivity and oDI than those with low adherence.

CONCLUSIONS

In the cohort, the presence of baseline clinically significant depressive symptoms was associated with subsequent lower adherence. Medication adherence was positively associated with insulin sensitivity and oDI, but, because of disease progression, adherence did not predict long-term treatment success.

Quality of Life and Psychosocial Adaptation to Chronic Illness and Disability

This article describes and presents an initial analysis of a quality-of-life—based model of psychosocial adaptation to chronic illness and disability. This model, termed disability centrality, represents a conceptual and theoretical synthesis of several existing theories and models, drawn from the quality-of-life, rehabilitation counseling, and rehabilitation psychology literature. The model was analyzed in a cross-sectional analysis using survey-based research among 72 college students with disabilities. The results supported the relationships hypothesized in the proposed model. The implications for clinical practice and further research concerning the psychosocial adaptation process are presented.

Psychosocial Adaptation to Chronic Illness and Disability

This article reviews the fundamental components inherent in the process of psychosocial adaptation to chronic illness and disability (CID). It is proposed that investigation of the process of adaptation to CID should consider three distinct classes of interacting variables. First, antecedents or triggering events (causes and contextual variables) present during origination of condition are listed. Second, the dynamic process of adaptation itself (experienced reactions following the onset of CID), as anchored within the existing context of both internally and externally associated groups of variables, is discussed. Third, psychosocial outcome categories that reflect differing views of adaptation to CID are overviewed. Such outcomes correspond to specific or global indicators of quality of life and may be categorized according to their functional domains, content areas, technologies or methods of assessment, and sources of measurement data. This article concludes with discussion of the three-class model's potential implications to rehabilitation practitioners and researchers.

Predicting Medical Regimen Adherence: The Interactions of Health Locus of Control Beliefs

The present study examined the interactions between five dimensions of health locus of control beliefs and their relationships with medical regimen adherence in low-income individuals diagnosed with type 2 diabetes. One hundred and nine patients were administered an expanded Multidimensional Health Locus of Control (MHLC) scale. HbA1c was used as a biological indicator of medical regimen adherence. Multivariate regression analyses demonstrated that three interactions were significantly related to HbA1c. The present findings suggest that HLOC may be meaningfully related to medical outcomes. However, these relationships may not be captured through the examination of main effects and may be only found when interactions are considered.

The Young Person's Perspective on Living and Coping with Diabetes

Adolescence and young adulthood is a time of significant psychological and psychosocial development, and for young people with Type 1 diabetes mellitus it is a time when self-care and metabolic control of diabetes may become compromised. In order to enhance services’ efforts to meet the complex needs of young people with diabetes, a qualitative interview study with eight young people (aged 16–22 years) was carried out. Young people identified an inherent vulnerability associated with having diabetes and feared that diabetes would take control and overwhelm them. Through learning to live with diabetes, and learning to manage a relationship with diabetes, the young people had developed sophisticated, interrelated self-protective strategies to manage intrapersonal and interpersonal threats from diabetes.

Diabetes IN develOpment (DINO): the bio-psychosocial, family functioning and parental well-being of youth with type 1 diabetes: a longitudinal cohort study design

Background

Strict glycemic control during adolescence decreases the risk of developing complications later in life, even if this level of control is not maintained afterwards. However, the majority of adolescents with type 1 diabetes (T1D) are in poor control and so far medical or psychological interventions have shown limited success. Adolescence is characterized by major biological, psychosocial, cognitive and parent–child relationship changes and the complex interaction between these developmental trajectories, and its impact on health outcomes is still poorly understood. A specific topic of interest in this context is the timing of diagnosis. The longitudinal study DINO (Diabetes IN develOpment) aims to examine:

If and how the onset of T1D before vs. during puberty results in different outcomes of glycemic control, self-management, psychological functioning and diabetes-related quality of life.

The timing of onset of disturbed eating behavior, its risk factors and its prospective course in relation to glycemic and psychological consequences.

If and how the onset of T1D before vs. during puberty results in different family functioning and parental well-being.

If and how the cognitive development of youth with T1D relates to glycemic control and diabetes self-management.

Methods/design

DINO, a longitudinal multi-center cohort study is conducted in youth with T1D in the age range 8–15 years at baseline. Participants will be divided into two subgroups: pre-pubertal and pubertal. Both groups will be followed for 3 years with assessments based on a bio-psychosocial model of diabetes, scheduled at baseline, 12 months, 24 months and 36 months examining the biological, psychosocial -including disturbed eating behaviors- and cognitive development, family functioning and parental well-being.

Discussion

A better understanding of how the different trajectories affect one another will help to gain insight in the protective and risk factors for glycemic outcomes and in who needs which support at what moment in time. First results are expected in 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0400-1) contains supplementary material, which is available to authorized users.

Interpersonal engagement mediates the relation between maternal affect and externalising behaviour in young children with type 1 diabetes

Mother-child interactions around a shared activity have been shown to play a key role in the development of young children's capacity to interact cooperatively with others. This evidence is particularly germane to type 1 diabetes (T1D) management in younger children where cooperation with parental treatment efforts is crucial for treatment success and where maternal distress and child behavioural problems are risk factors for treatment management, biomedical and psychological outcomes. In 49 4-to-8 year old children with T1D, we investigated whether the association between maternal affect and child problematic behaviour is mediated by mother-child interactions in the context of a T1D-relevant collaborative problem-solving activity. Mothers completed standardised measures of maternal and child psychological adjustment and interacted with their children in the problem-solving activity, analysed for quality of interpersonal engagement based on evaluations of maternal (sensitivity and cognitive stimulation) and dyadic (joint attention and warmth) behaviours. Mediation analyses confirmed the hypothesis that interpersonal engagement mediates the relation between maternal affective state and child behavioural problems. Specifically, more negative maternal affect is associated with lower levels of interpersonal engagement; these less engaged interactions in turn are associated with more behavioural problems in children. These findings are consistent with research involving typically developing children. The implications of our findings are twofold. First, in the context of psychological adjustment to T1D, maternal affect and mother-child interactions are 2 potential targets for interventions which promote cooperative interactions. Second, understanding and caring for children at biological risk requires attention to developmental psychology theory and method; in particular, research addressing parent-child cooperation carries both conceptual and clinical relevance.

Patterns of self-management in pediatric type 1 diabetes predict level of glycemic control 2 years later

OBJECTIVE

To determine if 3 distinct self-management patterns (i.e., maladaptive, moderate/mixed, and adaptive) observed at baseline, 1 year, and 2 years in a sample of youth with type 1 diabetes and their caregivers predicted mean differences in adolescent's subsequent glycemic control.

METHODS

This study is a descriptive, multisite, prospective study that examined a sample of youth diagnosed with type 1 diabetes (ages 9-11 years at baseline). Youth and their maternal and paternal caregivers provided information about the youth's self-management patterns at baseline, 1 year, and 2 years using the Diabetes Self-Management Profile structured interview. Glycemic control (hemoglobin A1c: HbA1c) was examined at baseline and 6, 12, 18, and 24 months.

RESULTS

Three distinct self-management patterns were observed at 1 year and 2 years, which were conceptually consistent with previously reported baseline self-management patterns. Youth identified by their maternal caregivers as having adaptive self-management patterns at baseline had better glycemic control across 2 years compared with those in the maladaptive and mixed self-management groups. Similarly, maternal reports suggested that youth with less adaptive self-management patterns generally had worse glycemic control over time and HbA1c values above the American Diabetes Association recommendations. Youth and paternal caregiver reports yielded more variable findings.

CONCLUSIONS

Findings underscore the stability of self-management patterns in pediatric type 1 diabetes and the need for preventive interventions that are tailored to specific patterns of self-management associated with risk for problematic glycemic control.

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.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Re-examining a measure of diabetes-related burden in parents of young people with Type 1 diabetes: the Problem Areas in Diabetes Survey - Parent Revised version (PAID-PR)

AIMS

In a pediatric patients, the burden of diabetes lies within the family. In the current era of intensive insulin therapy, perceived parental burden may affect the family's efforts at effective diabetes management. The aims of this study were to re-examine and revise a measure of perceived parental burden associated with caring for a child with diabetes in the current era.

METHODS

A geographically diverse population of young people (N = 376) with Type 1 diabetes and their parents included participants in the Juvenile Diabetes Research Foundation continuous glucose monitoring study and patients from the Joslin Diabetes Center. Participants provided data on demographics, diabetes management, diabetes-specific family conflict, and quality of life at baseline and after 6 months of follow-up.

RESULTS

Young people were 12.9 ± 2.7 years old with diabetes duration of 6.3 ± 3.5 years. Mean HbA(1C) was 8.0 ± 1.2%(64 mmol/mol), 58% received insulin pump therapy, and young people monitored blood glucose 5.2 ± 2.3 times/day. Factor analysis yielded two factors, 'Immediate Burden' and 'Theoretical Burden'. The Problem Areas in Diabetes Survey - Parent Revised version (PAID-PR) demonstrated excellent internal consistency (Cronbach's α = 0.87; factor 1 α = 0.78; factor 2 α = 0.83). Greater parental burden was associated with more frequent blood glucose monitoring, higher HbA(1C) levels, greater diabetes-specific family conflict, and lower quality of life. Test-retest analysis was acceptable (r = 0.62).

CONCLUSIONS

The PAID-PR demonstrated excellent internal consistency, good test-retest reliability, and associations with diabetes-specific family conflict and quality of life. This brief measure may have both clinical and research utility in the management of young people with Type 1 diabetes.

Using mobile phones to measure adolescent diabetes adherence

OBJECTIVES

1) describe and determine the feasibility of using cell-phone-based ecological momentary assessment (EMA) to measure blood glucose monitoring and insulin administration in adolescent Type 1 diabetes, 2) relate EMA to traditional self-report and glycemic control, and 3) identify patterns of adherence by time of day and over time using EMA.

METHOD

Adolescents with Type 1 diabetes (n = 96) completed baseline measures of cell phone use and adherence. Glycemic control (measured by levels of HbA1c) was obtained from medical records. A subgroup of adolescents (n = 50) completed 10 days of EMA to assess blood glucose monitoring frequency, timing of glucose monitoring, insulin administration, and insulin dosing. One third of adolescents were not allowed to use their cell phones for diabetes at school. Parental restrictions on cell phone use at home were not prevalent.

RESULTS

The EMA response rate (59%) remained stable over the 10-day calling period. Morning time was associated with worse monitoring and insulin administration, accounting for 59-74% of missed self-care tasks. EMA-reported missed glucose checks and missed insulin doses were correlated to traditional self-report data, but not to HbA1c levels. Trajectory analyses identified two subgroups: one with consistently adequate adherence, and one with more variable, and worse, adherence. The latter adherence style showed worse glycemic control.

CONCLUSION

Mobile phones provide a feasible method to measure glucose monitoring and insulin administration in adolescents, given a limited assessment duration. The method provided novel insights regarding patterns of adherence and should be explored in clinical settings for targeting or tailoring interventions.

The infant and toddler with diabetes: Challenges of diagnosis and management

Infants and toddlers comprise a small minority of individuals with type 1 diabetes. However, epidemiological data provide evidence of a trend towards diagnosis at a younger age. These very young children pose significant challenges to both the health care professionals involved in their care as well as to their families. At diagnosis, younger children often do not present with classical symptoms of diabetes. Unless health professionals remain alert to the possibility of diabetes being the underlying cause of a child's illness, the diagnosis may be missed. Once the diabetes has been diagnosed, the major challenge is to set up a treatment regimen that is both reasonable and realistic; in the youngest children, the goal of very tight metabolic control may expose them to episodes of severe hypoglycemia which may lead to subtle cognitive impairments later in life. The therapeutic regimen must balance the naturally erratic eating and exercise patterns of very young children with the need to maintain adequate metabolic control. Setting a blood glucose target range of 6 to 12 mmol/L usually allows this to be accomplished. Diabetes during early childhood creates a psychosocial challenge to the families of these children. Successful management of infants and toddlers with diabetes depends on a well functioning and educated family, the availability of diabetes health care team experienced in the treatment of these youngsters, and the involvement of the extended family, child care personnel and others who play a role in their daily care.

Maternal communication style, problem-solving and dietary adherence in young children with type 1 diabetes

The incidence of type 1 diabetes (T1D) in young children is increasing markedly however young children have been overlooked in paediatric adherence research despite the unique challenges their care presents. We investigated the relation between maternal communication style and adherence to the dietary regimen in 40 children with T1D, aged 2-8 years, and their mothers. Mothers completed measures of children's sugar consumption, parent-child communication quality, and child psychological functioning. Mothers and children engaged in a videotaped problem-solving task related to the dietary regimen, with maternal utterances analysed for behavioural control style (e.g., commands versus suggestions) and cognitive complexity (e.g., provision of labels versus questions). Maternal communications which engaged children, behaviourally and cognitively, in the task were associated with better adherence, medical, communication quality, and child adjustment outcomes. We conclude that adherence and health (medical and psychological) are optimized when young children are given opportunities to participate in their care.

A conceptual model of childhood adaptation to type 1 diabetes

The Childhood Adaptation Model to Chronic Illness: Diabetes Mellitus was developed to identify factors that influence childhood adaptation to type 1 diabetes (T1D). Since this model was proposed, considerable research has been completed. The purpose of this article is to update the model on childhood adaptation to T1D using research conducted since the original model was proposed. The framework suggests that, in individuals and families, characteristics such as age and socioeconomic status as well as the individuals' and families' responses (self-management, coping, self-efficacy, family functioning, social competence) influence the level of adaptation; in children with T1D, characteristics such as treatment modality (pump vs injections) and psychosocial responses (depressive symptoms and anxiety) also influence the level of adaptation. Adaptation has both physiologic (metabolic control) and psychosocial (Quality of Life [QOL]) components. This revised model provides greater specificity to the factors that influence adaptation to chronic illness in children. Research and clinical implications are discussed.

The influence of diabetes upon adolescent and young adult development: A qualitative study

It is not clear how developmentally appropriate healthcare services for adolescents (11-15) and young adults (16-25) should be provided.

AIMS

First, to describe and understand the influence of diabetes upon psychosocial development and second, to highlight the implications for healthcare teams.

DESIGN

Given the heterogeneity of findings, lack of conceptual clarity and lack of quantitative measures, qualitative semi-structured interviews were used, to define more clearly the constructs significant to young people.

METHODS

People aged 16-25 registered with one secondary care diabetes service, across two districts in north-east England were contacted. Nineteen interviews were conducted and analysed using a Framework Approach.

RESULTS

Diabetes can impact upon personal identity and self-concept. Peer support can buffer from negative effects, especially if young people control the disclosure of their diabetes. In coming to rely more on peers, participants continue to value the safe base of their family, especially at times of change and challenge. A key challenge appears to be coming to terms with risk and mortality.

CONCLUSIONS

Health care services need to support young people with self-care but must also understand and respond to the social and personal complexities of growing-up with a long-term health condition. Psychologists may have a role in promoting and supporting such an approach.

A concept analysis: assuming responsibility for self-care among adolescents with type 1 diabetes

PURPOSE

This concept analysis clarifies "assuming responsibility for self-care" by adolescents with type 1 diabetes.

METHODS

Walker and Avant's (2005) methodology guided the analysis.

RESULTS

Assuming responsibility for self-care was defined as a process specific to diabetes within the context of development. It is daily, gradual, individualized to person, and unique to the task. The goal is ownership that involves autonomy in behaviors and decision-making.

PRACTICE IMPLICATIONS

Adolescents with type 1 diabetes need to be assessed for assuming responsibility for self-care. This achievement has implications for adolescents' diabetes management, short- and long-term health, and psychosocial quality of life.

Brief screening tool for disordered eating in diabetes: internal consistency and external validity in a contemporary sample of pediatric patients with type 1 diabetes

OBJECTIVE To update and validate a diabetes-specific screening tool for disordered eating (the Diabetes Eating Problem Survey [DEPS]) in contemporary youth with type 1 diabetes. RESEARCH DESIGN AND METHODS A total of 112 youth with type 1 diabetes, ages 13-19 years, completed the DEPS. Higher scores on the DEPS indicate more disordered eating behaviors. Youth and their parents also completed additional surveys to examine diabetes-specific family conflict, negative affect related to blood glucose monitoring, youth quality of life, and diabetes burden. Clinicians provided data on height, weight, A1C, and insulin dosing. The DEPS was revised into a shorter, updated measure and validated. RESULTS The revised 16-item DEPS (DEPS-R) displayed excellent internal consistency (Cronbach's alpha = 0.86). Construct validity was demonstrated by positive correlations with zBMI (P = 0.01), A1C (P = 0.001), diabetes-specific family conflict (P < 0.005), youth negative affect around blood glucose monitoring (P = 0.001), parental diabetes-specific burden (P = 0.0005), and negative correlations with frequency of blood glucose monitoring (P = 0.03) and quality of life (P < or = 0.002). External validity was confirmed against clinician report of insulin restriction. CONCLUSIONS The DEPS-R is a 16-item diabetes-specific self-report measure of disordered eating that can be completed in <10 min. It demonstrated excellent internal consistency, construct validity, and external validity in this contemporary sample of youth with type 1 diabetes. Future studies should focus on using the DEPS-R to identify high-risk populations for prevention of and early intervention for disordered eating behaviors.

Cognitive functions and glycemic control in children and adolescents with type 1 diabetes

BACKGROUND

The relationship between metabolic control and cognitive function in adolescents with type 1 diabetes (DM type 1) is not clear. We compared the quality of glycemic control (GC) and cognitive measures in adolescents with DM type 1 to find out if the quality of diabetes management is related to cognitive impairment.

METHOD

We assessed executive functions (EFs) and other neuropsychological and psychosocial variables in 70 adolescent patients with DM type 1 and 20 age-matched controls. Patients were divided into two groups according to their last hemoglobin A1c (HbA1c): acceptable (HbA1c 5.9-8.0%, mean 6.9%, 36 patients, mean age 14 years) and non-optimal (HbA1c 8.2-11.6%, mean 9.3%, 34 patients, mean age 15.6 years).

RESULTS

We found impaired EFs, mainly problems of concept formation (p=0.038), cognitive flexibility (p=0.011) and anticipation (p=0.000), in the patients with DM type 1. Both groups did not differ in intelligence, most assessed EFs and adjustment to chronic illness (Youth Self-Report; YSR). Younger patients (<15 years) were cognitively less flexible. GC was worse in older patients and in patients with longer duration of the disease. We also found significant differences between patients with diabetes and controls concerning somatic complaints, internalizing problems (Child Behavior Checklist; CBCL) and social activity (CBCL and YSR).

CONCLUSIONS

DM type 1 is associated with cognitive deficits in adolescents independent of the quality of metabolic control and the duration of the disease. These deficits are probably related to the disease, especially in patients with early-onset diabetes.

Brief report: normative data on a structured interview for diabetes adherence in childhood

OBJECTIVE

This study provides normative data, divided by age and gender, for the Diabetes Self-Management Profile (DSMP), an empirically supported structured interview that assesses adherence with the type 1 diabetes treatment regimen. Despite wide use, normative data on the DSMP have yet to be reported.

METHODS

The sample included 444 parents and 275 youth with type 1 diabetes. The DSMP was administered by a trained clinician.

RESULTS

For both child and parent ratings of adherence, means and standard deviations for the overall sample and subdivision by gender and three age groups are presented for normative comparisons. Subscale data (e.g., glucose monitoring, diet, exercise) are similarly presented. Lower adherence scores were reported among older adolescents relative to preadolescents.

CONCLUSIONS

The literature has lacked normative data on pediatric diabetes adherence. These data present means and standard deviations for parent and child ratings of regimen adherence from a relatively large sample of youth with diabetes that can be utilized for normative comparisons for clinical and research purposes.

Family experiences with pediatric antiretroviral therapy: responsibilities, barriers, and strategies for remembering medications

This study examines the relationship between adherence to pediatric HIV regimens and three family experience factors: (1) regimen responsibility; (2) barriers to adherence; and (3) strategies for remembering to give medications. Caregivers of 127 children ages 2-15 years in the PACTS-HOPE multisite study were interviewed. Seventy-six percent of caregivers reported that their children were adherent (taking > or = 90% of prescribed doses within the prior 6 months). Most caregivers reported taking primary responsibility for medication-related activities (72%-95% across activities); caregivers with primary responsibility for calling to obtain refills (95%) were more likely to have adherent children. More than half of caregivers reported experiencing one or more adherence barriers (59%). Caregivers who reported more barriers were also more likely to report having non-adherent children. Individual barriers associated with nonadherence included forgetting, changes in routine, being too busy, and child refusal. Most reported using one or more memory strategies (86%). Strategy use was not associated with adherence. Using more strategies was associated with a greater likelihood of reporting that forgetting was a barrier. For some families with adherence-related organizational or motivational difficulties, using numerous memory strategies may be insufficient for mastering adherence. More intensive interventions, such as home-based nurse-administered dosing, may be necessary.

Predictors of metabolic control among adolescents with diabetes: a 4-year longitudinal study

OBJECTIVE

To employ a risk and resistance framework to examine changes in metabolic control over early to middle adolescence.

METHODS

We interviewed 70 girls and 62 boys (mean age 12 years) annually for 4 years. Risk and resistance factors, including demographics, disease-related variables, self-care behavior, and psychosocial variables were assessed. Hemoglobin A1c was obtained from medical records.

RESULTS

Multilevel modeling showed metabolic control deteriorated with age. Self-care behavior interacted with age to predict the decline, such that self-care was more strongly related to poor metabolic control for older adolescents. Eating disturbances, depression, and peer relations were related to poor metabolic control, whereas good family relations were related to better metabolic control for girls.

CONCLUSIONS

Independent risk factors for poor metabolic control included poor self-care, disturbed eating behavior, depression, and peer relations; parental support was an independent resistance factor for girls. Future research should examine mechanisms by which these relations emerge.

Medical specialty camps for youth with diabetes

Camps for children with medical conditions have been in existence for decades. With the advent of new medical technology and research advances, children with medical illnesses are living long lives with chronic conditions. Camp provides an ideal setting to help these youth manage and cope with their disease. Using camps for children who have diabetes as a model, this article reviews the history of medical specialty camps and the psychosocial and medical aspects of the disease that are unique to this population and describes the intentional programming and special considerations within this camping environment. The article concludes with a review of research and recent studies conducted at camps for youth who have diabetes that investigate the benefits of these specialized camping programs.

Predictors of treatment adherence in young children with type 1 diabetes

AIM

This paper reports a study to investigate whether diabetes-specific, demographic and psychosocial variables predict adherence in young children with type 1 diabetes.

BACKGROUND

Paediatric diabetes rates are increasing worldwide; however, young children are neglected in treatment adherence research, despite the importance of adherence for health. Greater understanding of adherence in this group could enhance nurses' ability to provide care tailored to families' needs.

METHOD

A cross-sectional study was carried out between 2001 and 2003 with 65 children aged 2-8 years and their mothers in Britain. Mothers were interviewed about children's diabetes care, nutritional analyses were conducted and mothers completed assessments of diabetes knowledge, parenting stress, family functioning and child psychological adjustment. Demographic and medical information was collected from patient records.

FINDINGS

Consistent with older populations, blood glucose monitoring and dietary regimens showed greater adherence variability than injection frequency and injection time consistency. Better maternal diabetes knowledge correlated with less injection time variability, more frequent blood glucose monitoring, lower percentage energy intake from extrinsic sugars, lower glycosylated haemoglobin levels and fewer relationship difficulties. Longer diabetes duration, greater injection time variability and higher percentage energy intake from extrinsic sugars predicted less frequent blood glucose monitoring. More relationship difficulties and less frequent blood glucose monitoring predicted higher percentage energy intake from extrinsic sugars.

CONCLUSIONS

Nurses can facilitate treatment adherence through provision of educational, practical and socio-emotional support. Nursing interventions should target blood glucose monitoring and dietary regimens in particular, and nurses should be sensitive to the various caretaking challenges presented to parents by different components of the diabetes regimen.

Dietary adherence and associated glycemic control in families of young children with type 1 diabetes

OBJECTIVE

This study examined the dietary intake, dietary adherence, and associated daily glycemic control of young children (mean age 5.6+/-1.6 years) with type 1 diabetes in 33 families.

DESIGN

This was a one-sample cross-sectional study. Children's nutrient and energy intakes were measured using 3-day diet diaries. Children's mean daily blood glucose levels were assessed prospectively for 2 weeks using the FreeStyle (TheraSense, Inc, Alameda, CA) home blood glucose meter.

STATISTICAL ANALYSIS

Means, standard deviations, and frequencies described the sample. Associations between dietary adherence and glycemic control were examined by one-tailed Pearson correlations.

RESULTS

Mean nutrient intakes were less than the Dietary Reference Intake for children's intake of vitamin B-12 and calcium. Children's dietary deviations revealed better-than-predicted adherence to the number and timing of feedings per day and number of carbohydrate units consumed per meal. In contrast, children's daily carbohydrate intake was approximately 80%+/-21% of the recommended levels based on their weight and age. In addition, children's energy intake was only 78%+/-18% of the recommended levels based on age. Correlations revealed a positive association between poor dietary adherence and higher blood glucose levels.

CONCLUSIONS

Young children with type 1 diabetes are likely to have adequate dietary intake of most micronutrients. However, their adherence to specific carbohydrate and energy intake recommendations may be lower. Because the preschool years represent a period of rapid growth, diet plans for preschoolers with diabetes need to be revised often for optimal management of type 1 diabetes. Close adherence to dietary recommendations is one behavior that may improve blood glucose control in young children with diabetes.

Applying the Transactional Stress and Coping Model to Sickle Cell Disorder and Insulin-Dependent Diabetes Mellitus: Identifying Psychosocial Variables Related to Adjustment and Intervention

This review paper examines the literature on psychosocial factors associated with adjustment to sickle cell disease and insulin-dependent diabetes mellitus in children through the framework of the transactional stress and coping (TSC) model. The transactional stress and coping model views adaptation to a childhood chronic illness as mediated by several psychosocial factors. This review examines the utility of the model in explaining adjustment in two different childhood diseases, identifies needed research and intervention targets, as well as highlights potential changes to the model. The major conclusions of this review suggest that, in addition to child-specific factors, family functioning is an area that interventions should address in sickle cell disease and insulin-dependent diabetes mellitus.

Evaluating the Self-esteem of Myopic Children Over a Three-Year Period: The COMET Experience

PURPOSE

The purposes of this study were to evaluate self-esteem over 3 years in the 469 myopic children participating in the Correction of Myopia Evaluation Trial (COMET), and to examine its relationship with lens assignment (progressive addition lenses [PALs] vs. single-vision lenses [SVLs]), myopia progression, and several other ocular and demographic characteristics.

METHODS

Data collection included refractive error measurements, child-reported visual symptoms, attitude toward glasses, adherence, and self-esteem as measured by the Self-Perception Profile for Children (SPPC). A two-way analysis of variance (treatment group x time) was performed to examine whether PAL and SVL wearers differed in self-esteem over time. Multiple regression analyses were used to evaluate associations between self-esteem at follow-up and relevant factors identified by univariate analyses.

RESULTS

Regardless of lens assignment or myopia progression, COMET children reported moderate to high levels of self-esteem at follow-up in the areas of scholastic and athletic competence, physical appearance, social acceptance, behavioral conduct, and global self-worth. Mean scores ranged from 2.87 (+/- 0.68) on athletic competence to 3.40 (+/- 0.56) on global self-worth. Self-esteem changed significantly (p < 0.05) over 3 years in the domains of scholastic competence, social acceptance, and physical appearance. Self-esteem at follow-up was associated with visual symptoms, attitude toward glasses, age, gender, and ethnicity.

CONCLUSIONS

Lens assignment and myopia progression were not associated with self-esteem in the COMET cohort. These children had high levels of self-esteem, suggesting that having myopia does not negatively impact self-esteem. Follow-up reports will monitor self-esteem and related factors in this cohort of myopic children over the course of adolescence and early adulthood.

Childhood precursors of adolescent outcomes in type 1 diabetes mellitus

Contemporary outcome measures of chronic illnesses such as type 1 diabetes mellitus are broader than those clinical outcomes traditionally assessed in therapeutic encounters. A holistic approach emphasises quality of life and emotional well-being as well as the achievement of optimal disease management. This paper reviews current knowledge about growth, metabolic control, diabetes complications, neurocognitive and psychological outcomes as well as health-related quality of life in childhood diabetes mellitus. It is suggested that the antecedents of adverse diabetes and psychological outcomes in adolescence lie in the years prior to adolescence. The model of care in childhood diabetes mellitus must be focussed on earlier screening and intervention if adverse outcomes are to be reduced.

The Blood Glucose Monitoring Communication questionnaire: an instrument to measure affect specific to blood glucose monitoring

OBJECTIVE

The aim of this study was to present the psychometric properties of a new tool for evaluating affective response to blood glucose monitoring (BGM) in youths with type 1 diabetes and their parents.

RESEARCH DESIGN AND METHODS

Study participants included 153 youths with type 1 diabetes and their parents. Each youth and parent completed the Blood Glucose Monitoring Communication (BGMC) questionnaire, Diabetes Family Conflict Scale, and Pediatric Quality of Life Inventory. Statistical analyses evaluated the psychometric properties of the BGMC questionnaires and their association with glycemic outcomes.

RESULTS

Youth and parent BGMC questionnaires had acceptable internal consistency (youth, alpha = 0.77; parent, alpha = 0.82) and 1-year test-retest reliability (youth, r = 0.60; parent, r = 0.80). Higher BGMC questionnaire scores (indicating more negative affect) showed a strong association with higher levels of diabetes-specific family conflict (youth, r = 0.33; parent, r = 0.44) and poorer health-related psychosocial quality of life (youth, r = -0.50; parent, r = -0.42). Higher BGMC questionnaire scores were also associated with poorer glycemic control (youth, r = 0.28; parent, r = 0.20), even when the effects of diabetes-specific family conflict and psychosocial quality of life were controlled. Youths with BGMC questionnaire scores in the upper quartile had A1c values 1 percentage point higher (9.1%) than youths with scores in the lowest quartile (8.0%).

CONCLUSIONS

The BGMC questionnaires have strong psychometric properties and are convenient measures of affect specific to BGM. Further, BGM affect is associated with glycemic outcomes and may provide a unique contribution to factors associated with glycemic control in youths.

The impact of physiological, therapeutic and psychosocial variables on glycemic control in youth with type 1 diabetes mellitus

OBJECTIVE

Intensive management of type 1 diabetes mellitus (DM1) in youth is challenging. We evaluated the relative impact of variables related to DM1 among groups of pre/early pubertal, midpubertal and postpubertal youths with DM1.

METHODS

In this cross-sectional study of 153 youth with DM1, we ascertained Tanner stage, insulin dose and delivery modality (CSII vs MDI), daily blood glucose monitoring (BGM) frequency, and most recent hemoglobin A1c (HbA1c). We collected questionnaires from patients and their parents on diabetes-specific family conflict and family involvement in diabetes management tasks. We assessed predictors of glycemic control according to pubertal status.

RESULTS

Insulin doses increased between pre/ early puberty and midpuberty (p <0.0001); daily BGM frequency (p = 0.02) and family involvement for DM management (p <0.001) were lowest in the postpubertal group. HbA1c was similar among all three puberty groups (8.4+/-1.4). Lower levels of child-reported DM-specific family conflict, more frequent BGM, and CSII use were significantly associated with lower HbA1c (R2 = 0.20, p <0.001).

CONCLUSION

Although glycemic control was not significantly worse in midpubertal and post-pubertal patients, family involvement for DM management and adherence to BGM were lower in late adolescence. Interventions to optimize glycemic control may include minimizing DM-specific conflict, increasing BGM frequency, and implementing CSII use.

Depressive symptoms and inflammatory bowel disease in children and adolescents: a cross-sectional study

OBJECTIVES

This study assessed the rates of depressive symptoms in older children and adolescents with inflammatory bowel disease (IBD) and the associations between depressive symptoms and IBD disease characteristics.

METHODS

One hundred and two youths (aged 11-17 years) with IBD seen consecutively in a gastroenterology clinic were screened for depressive symptoms using the Children's Depression Inventory (CDI). Subjects with CDI scores > or = 12 were evaluated for current psychiatric diagnoses using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Disease characteristics examined included IBD type, duration, current severity, course, age at diagnosis and steroid treatment.

RESULTS

Of the total sample, 25 (24.5%) had a CDI score > or = 12, consistent with clinically significant depressive symptoms. Nineteen of 25 qualified subjects participated in the K-SADS-PL semi-structured interview and 16 of 19 met criteria for major or minor depressive disorder. Mean CDI scores positively correlated with age at IBD diagnosis but not with IBD type, duration or course. Youths with moderate/severe current IBD-related symptoms had significantly higher mean CDI scores than those with inactive disease activity. Anhedonia, fatigue and decreased appetite were selectively correlated with IBD disease severity. Subjects on steroids were more likely to have CDI scores > or = 12, and those with such scores were on higher doses of steroids than subjects without clinically significant depressive symptoms (both P values < 0.05).

CONCLUSIONS

These findings support the recommendation that adolescents with IBD in outpatient medical care settings, particularly older adolescents and those on steroids, should be screened for depression.

Adolescents' coping with surgery for scoliosis: effects on recovery outcomes over time

Surgery for adolescent idiopathic scoliosis is painful and stressful and has a long and demanding recovery. The purpose of this study was to examine pre- and postoperative avoidant/vigilant coping and long-term activity outcomes through 9 months postsurgery for adolescents (11-18 years, N = 113) undergoing scoliosis surgery. Generally, more vigilant copers (preoperatively and 1 month postoperatively) participated in more activities (usual, new, and social) and had higher academic performance during recovery. Several moderation effects indicated these relationships were stronger for older adolescents and those more internal in locus of control. Adolescents were more vigilant in the hospital, became more avoidant 1 month after surgery, and remained at these levels 6 months postsurgery. Understanding coping processes and individual factors is necessary to develop interventions to help adolescents cope successfully with recovery demands.

The coping styles of adolescents with type 1 diabetes are associated with degree of metabolic control

OBJECTIVE

To systematically study the various coping styles in a population-based sample of adolescents with type 1 diabetes, exploring the association of different coping styles with metabolic control and adolescent self-reported diabetes-related quality of life.

RESEARCH DESIGN AND METHODS

Of a total population of 116 adolescents with type 1 diabetes (age 13-18 years), 103 (89%) participated in the study, completing a questionnaire to obtain information on coping styles and perception of diabetes-specific quality of life. The mean age (+/-SD) was 14.9 +/- 1.6 years, diabetes duration 7.1 +/- 3.8 years, HbA(1c) 9.4 +/- 1.6%, and male-to-female ratio 52:51.

RESULTS

There was a significant correlation between higher HbA(1c) values and higher degree of mental (r = 0.25, P < 0.05) and behavioral (r = 0.33, P < 0.01) disengagement and aggressive coping (r = 0.33, P < 0.01). Stepwise multiple regression analyses indicated that greater use of aggressive coping (P < 0.05) and behavioral disengagement (P < 0.05) were significantly related to increase in HbA(1c). Greater use of active coping (P < 0.05) was significantly related to a decrease in HbA(1c). Partial correlation analysis showed that lower scores on diabetes-specific quality of life were significantly related to greater use of emotion-focused coping (r = -0.22 to -0.49). Stepwise multiple regression analyses showed that greater use of mental disengagement was significantly related to lower degree of perceived diabetes-related impact.

CONCLUSIONS

Poor metabolic control and lower degree of diabetes-related quality of life are associated with greater use of emotion-focused coping in adolescents with type 1 diabetes.