Quality of life in children with Type 1 diabetes: a comparison of general and diabetes-specific measures and support for a unitary diabetes quality-of-life construct

Health-related quality of life in 4-to-6-year-old children with type 1 diabetes mellitus estimated by children and their mothers

Administration of pediatric Health Related Quality of Life (HRQoL) inventories frequently assesses both the child and parent perspectives in young children with type 1 diabetes mellitus (T1DM), but parent-proxy and child self-reports may differ, and little is known on these discrepancies. The aim is to evaluate HRQoL estimated by young children with T1DM and by their mothers, potential discrepancies in the children-maternal estimates and the factors influencing these discrepancies. Thirty-five 4-to-6-year-old children (19 boys) with T1DM admitted to the Pediatric Endocrinology Department were approached with the self-report KINDL questionnaire for children aged 4-6 years (Kiddy-KINDL for children). Their mothers were approached with the parental version (Kiddy-KINDL for parents). Both versions enable measuring child HRQoL in physical, emotional wellbeing, self-esteem, family, friends, everyday functioning, and the disease dimensions, as well as KINDL total on a 0-100 scale. Statistically significant differences were found between children's and maternal estimates on the KINDL total and "Disease" scales, in that the maternal proxy-reports produced lower values. A statistically significant difference between self- and proxy-reports was found for the KINDL "Emotional wellbeing" scale values, and the maternal proxy-reports yielded higher estimates compared with children's self-reports. These associations remained significant after adjustment for major potential confounders. Maternal education, maternal marital status, insulin regimen, and achievement of glycemic control modified the effect of child-maternal discrepancies.Conclusion: Attempts should be made to improve parental understanding of child problems related to his/her disease with due account to individual family social and demographic characteristics. What is Known: • HRQoL in children with T1DM has been advocated as an important complementary outcome to clinical and laboratory markers. • Self-and parental proxy-reports on HRQoL may differ, but little is known on these discrepancies and on the factors influencing them in young children with T1DM. What is New: • Mothers tend to underestimate general and disease-related components of HRQoL but likely to overestimate psychological wellbeing of their ill young children with T1DM. • Maternal education, marital status, insulin regimen, and achievement of glycemic control modify estimations of HRQoL and child-maternal discrepancies.

Social self-efficacy associated with HbA1c through physical activity and diabetes quality of life: A serial mediation study

OBJECTIVE

Type 1 diabetes (T1D) is one of the most common pediatric chronic illnesses and increasing worldwide in prevalence. Physical activity has been positively linked with better glycemic control in youth with T1D. Although not yet studied, children's social self-efficacy may be a parameter related to physical activity in youth with diabetes. The current study investigated associations among social self-efficacy, physical activity, diabetes quality of life, and hemoglobin A1c (HbA1c) among youth with T1D utilizing mediation and serial mediation models.

RESEARCH DESIGN AND METHODS

Participants were 144 youth (M age = 14.95) with T1D (53.5% girls) and their caregivers. Youth completed the PedsQL Diabetes Module, the Physical Activity Questionnaire for Older Children and Adolescents and the Self-Efficacy Questionnaire for Social Skills for Children. Youths' HbA1c values were also measured.

RESULTS

Physical activity significantly mediated the relationship between greater youth social self-efficacy and better diabetes quality of life. Diabetes quality of life mediated the relationship between greater physical activity and lower HbA1c. The serial mediation model demonstrated greater social self-efficacy is related to greater physical activity, which in turn is related to better diabetes quality of life and ultimately resulting in lower HbA1c.

CONCLUSIONS

Physical activity, social self-efficacy, and diabetes-related quality of life may be modifiable factors related to HbA1c for youth with T1D. Findings indicate a need for healthcare providers to consider youth physical activity, quality of life, and social self-efficacy when evaluating and intervening in youth diabetes treatment adherence.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

The Relationship between Glycated Hemoglobin Levels and the Quality of Life among Type 1 Diabetes Mellitus in Children

BACKGROUND: Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia that occurs due to impaired both in insulin secretion and insulin action. Children with type 1 diabetes mellitus should be targeted to achieve a glycated hemoglobin (HbA1C) level ≤7.0% to reduce the risk of complications and improve quality of life. The majority of children with type 1 diabetes mellitus exhibit poor self-care and Health-related Quality of life behavior. AIM: The objective of the study was to determine the relationship between HbA1C level and the quality of life among type 1 diabetes mellitus in children. METHODS: A cross-sectional study was conducted among 30 children with type 1 diabetes mellitus who attended at pediatric endocrine clinic Haji Adam Malik general hospital and Universitas Sumatera Utara hospital Medan. Sampling was carried out in April 2020–July 2020. HbA1C level and self-administered questionnaire were used to assess the quality of life. Spearman correlation test was conducted to assess the correlation between HbA1C levels and the quality of life. RESULTS: The mean of HbA1C level was 10.35 ± 2.68. No significant correlation between HbA1C level and the quality of life of children with type 1 diabetes mellitus (r = 0.264, p > 0.05) CONCLUSIONS: There was no significant correlation between HbA1C levels and the quality of life of children with type 1 diabetes mellitus.

Assessing Health-Related Quality of Life in Children and Adolescents with Diabetes: Development and Psychometrics of the Type 1 Diabetes and Life (T1DAL) Measures

OBJECTIVE

To develop and validate new measures of diabetes-specific health-related quality of life (HRQOL) for people with type 1 diabetes (T1D) that are brief, developmentally appropriate, and usable in clinical research and care. Here we report on the phases of developing and validating the self-report Type 1 Diabetes and Life (T1DAL) measures for children (age 8-11) and adolescents (age 12-17).

METHODS

Measure development included qualitative interviews with youth and parents (n = 16 dyads) followed by piloting draft measures and conducting cognitive debriefing with youth (n = 9) to refine the measures. To evaluate the psychometric properties, children (n = 194) and adolescents (n = 257) at three T1D Exchange Clinic Network sites completed the age-appropriate T1DAL measure and previously validated questionnaires measuring related constructs. Using psychometric data, the investigators reduced the length of each T1DAL measure to 21 and 23 items, respectively, and conducted a final round of cognitive debriefing with six children and adolescents.

RESULTS

The T1DAL measures for children and adolescents demonstrated good internal consistency (α = 0.84 and 0.89, respectively) and test-retest reliability (r = 0.78 and 0.80, respectively). Significant correlations between the T1DAL scores and measures of general quality of life, generic and diabetes-specific HRQOL, diabetes burden, and diabetes strengths demonstrated construct validity. Correlations with measures of self-management (child and adolescent) and glycemic control (adolescent only) demonstrated criterion validity. Factor analyses indicated four developmentally specific subscales per measure. Participants reported satisfaction with the measures.

CONCLUSIONS

The new T1DAL measures for children and adolescents with T1D are reliable, valid, and suitable for use in care settings and clinical research.

Health-related quality of life and metabolic control in immigrant and Italian children and adolescents with type 1 diabetes and in their parents

OBJECTIVE

To determine if the diabetes-specific health-related quality of life (D-HRQOL) of young people with type 1 diabetes (T1D) and their parents is influenced by migrant status.

SUBJECTS AND METHODS

One hundred and twenty-five patients (12.4 ± 3.55 years, males 53.6%) with T1D and their parents (102 mothers, 37 fathers) were enrolled and categorized into: group A (both foreign parents) and group B (both native Italian parents). The Pediatric Quality of Life Inventory™ 3.0 Diabetes Module (PedsQL™ 3.0 DM) was used to evaluate the D-HRQOL. Data on diabetic ketoacidosis (DKA) at T1D onset, insulin therapy, and glycosylate hemoglobin (HbA1c) were also collected.

RESULTS

Group A (n = 40), compared to group B (n = 85), had higher frequency of DKA at T1D onset (P < .001) and a lower use of sensor augmented insulin pump (P = .015). HbA1c values were higher in group A than in group B (P < .001). Patients' "Diabetes symptoms" (P = .004), "Treatment barriers" (P = .001), and "Worry" (P = .009) scales scores were lower in group A than in group B. Mothers of group A had lower scores in "Diabetes symptoms" (P = .030), "Treatment barriers" (P < .001), "Treatment adherence" (P = .018), "Communication" (P = .009) scales, and total score (P = .011) compared to the group B ones. High PedsQL™ 3.0 DM was significantly associated with being Italian, being prepubertal, and having lower HbA1c mean levels.

CONCLUSIONS

Being a migrant confers disadvantages in terms of D-HRQOL and metabolic control in children and adolescents with T1D. Specific educational interventions should be considered in the clinical care of patients with migration background, to improve D-HRQOL and health status.

Validation of the Healthcare Transition Outcomes Inventory for Young Adults With Type 1 Diabetes

OBJECTIVE

We recently developed and content validated the Healthcare Transition Outcomes Inventory (HCTOI), a stakeholder vetted, multidimensional measure of the outcomes of the transition from pediatric to adult healthcare for young adults (YA) with type 1 diabetes (T1D). In this study, we aimed to evaluate the psychometric properties of the HCTOI.

METHODS

We collected and analyzed cross-sectional data from 128 YA (18-25 years old) with T1D to evaluate the psychometric properties of the HCTOI. We conducted confirmatory factor analysis (CFA), item analysis, and examined reliability and validity in relation to measures of quality of life, diabetes distress, regimen adherence, and glycemic control.

RESULTS

CFA supported a five-factor solution: integration of T1D into emerging adult roles, balance of parental support with T1D autonomy, establishing and maintaining continuity of care, forming a collaborative patient-provider relationship, and ownership of T1D. We reduced the HCTOI from 54 to 34 items. The HCTOI demonstrated adequate internal consistency (α's = 0.62-0.87) and significant correlations demonstrated construct (quality of life, diabetes distress) and criterion validity (adherence, glycemic control).

CONCLUSIONS

The HCTOI demonstrated promising initial psychometric properties. As the first measure of the multiple dimensions of healthcare transition outcomes, the HCTOI provides a means to examine longitudinal relations between transition readiness and outcomes and to assess the efficacy or effectiveness of interventions and programs designed to improve the transition process for YA with T1D.

Impact of family-centered tailoring of pediatric diabetes self-management resources

BACKGROUND

The American Diabetes Association recommends a family-centered approach that addresses each family's specific type 1 diabetes self-management barriers.

OBJECTIVE

To assess an intervention that tailored delivery of self-management resources to families' specific self-management barriers.

SUBJECTS

At two sites, 214 children 8-16 years old with type 1 diabetes and their parent(s) were randomized to receive tailored self-management resources (intervention, n = 106) or usual care (n = 108).

METHODS

Our intervention (1) identified families' self-management barriers with a validated survey, (2) tailored self-management resources to identified barriers, and (3) delivered the resources as four group sessions coordinated with diabetes visits. Mixed effects models with repeated measures were fit to A1c as well as parent and child QOL during the intervention and 1 year thereafter.

RESULTS

Participants were 44% youth (8-12 years) and 56% teens (13-16 years). No intervention effect on A1c or QOL was shown, combining data from sites and age groups. Analyzing results by site and age group, post-intervention A1c for teens at one site declined by 0.06 more per month for intervention teens compared to usual care (P < 0.05). In this group, post-intervention A1c declined significantly when baseline A1c was >8.5 (-0.08, P < 0.05), with an even larger decline when baseline A1c was >10 (-0.19, P < 0.05). In addition, for these teens, the significant improvements in A1c resulted from addressing barriers related to motivation to self-manage. Also at this site, mean QOL increased by 0.61 points per month more during the intervention for parents of intervention youth than for usual care youth (P < 0.05).

CONCLUSIONS

Tailored self-management resources may improve outcomes among specific populations, suggesting the need to consider families' self-management barriers and patient characteristics before implementing self-management resources.

May gender influence the quality of life in children and adolescents with type 1 diabetes?

INTRODUCTION

Appropriate health-related quality of life (HRQOL) in children and adolescents with type 1 diabetes constitutes one of the most important factors that determine treatment effectiveness. There are numerous studies which tackle the issue of the relationship between HRQOL and various clinical and demographic factors, including gender. Therefore, the aim of the present study was to assess HRQOL and identify factors by which it may be affected, with particular emphasis on gender.

MATERIAL AND METHODS

The study group included 197 girls and boys (13.9±2.33 years old) with a history of type 1 diabetes (>1 year) treated with the use of insulin pumps. PedsQL Diabetes Module 3.0 questionnaire was used in the assessment of HRQOL. Multivariate linear regression with gender as a covariate was used to investigate the relationship between total PedsQL score and selected variables associated with patient characteristics, insulin dosage and the control of glycemia. Moreover, the presence of gender differences was verified in terms of variables which significantly affected HRQOL.

RESULTS

Significantly higher results were observed in boys as regards the total PedsQL score (70.8±11.91 vs 62.4±13.91; P<0.001) and individual subscales of the questionnaire (except "Worry"). Regression analysis demonstrated the presence of a significant negative relationship between HRQOL assessment and HbA1c concentrations, WHtR value and the frequency of hypoglycemic episodes. However, it was noted that better HRQOL was observed in boys than in girls, regardless of the quality of the metabolic control of diabetes, regular pattern of adipose tissue distribution and experiencing hyperglycemic episodes.

CONCLUSION

Female gender was an independent factor which adversely affected HRQOL. Other factors which negatively influenced HRQOL included poor metabolic control of diabetes, central distribution of adipose tissue and frequent episodes of hyperglycemia. It seems necessary to focus also on other factors that may potentially influence HRQOL of patients with type 1 diabetes.

Health-related quality of life of adolescents with type 1 diabetes in the context of resilience

BACKGROUND

Adolescents with type 1 diabetes (T1D) can be faced with deterioration in glycemic control (GC), reduced health-related quality of life (HRQoL), and other psychosocial problems. It is important to understand how the disease and its clinical conditions influence HRQoL and how adolescents are able to overcome the life adjustment difficulties.

OBJECTIVE

To assess HRQoL of adolescents with T1D from demographic, clinical, personal, and behavioral point of view.

SUBJECTS

A total of 229 adolescents with T1D (51.2% males) with a mean age of 15.35 (2.29) years old were recruited from three diabetes centers. The mean diabetes duration was 7.48 (3.87), the mean hemoglobin A1C (HbA1c) level was 10.3 (1.76) mmol/L.

METHODS

A multicenter quantitative correlational design study was applied to investigate the influence of sex, age, diabetes duration, GC expressed by HbA1c, intensive insulin regimen, physical activity (PA), resilience (RS), and socioeconomic background on HRQoL.

RESULTS

Presence of the diabetes symptoms and worry about the disease has negative impact on the patients' HRQoL. Stepwise multiple regression analyses indicated that insulin pump therapy, male sex, and higher level of RS were significantly related to an increase in HRQoL, whereas the higher level of PA, male sex, and better HRQoL was significantly related to positive change in RS. Patients treated with insulin pump therapy had significantly better HRQoL.

CONCLUSIONS

Significant association can be observed between HRQoL and RS. Supposedly, higher level of PA promotes higher level of RS that in turn helps increase HRQoL in adolescents with T1D. Treatment with insulin pump therapy also promotes better HRQoL.

PedsQL 3.2 Diabetes Module for Children, Adolescents, and Young Adults: Reliability and Validity in Type 1 Diabetes

OBJECTIVE

The objective of the study was to report on the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for children, adolescents, and young adults with type 1 diabetes.

RESEARCH DESIGN AND METHODS

The 33-item PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were completed in a 10-site national field test study by 656 families of patients ages 2-25 years with type 1 diabetes.

RESULTS

The 15-item Diabetes Symptoms Summary Score and 18-item Diabetes Management Summary Score were derived from the factor analysis of the items. The Diabetes Symptoms and Diabetes Management Summary Scores evidenced excellent reliability (patient self-report α = 0.88-0.90; parent proxy report α = 0.89-0.90). The Diabetes Symptoms and Diabetes Management Summary Scores demonstrated construct validity through medium to large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.43-0.67, P < 0.001). HbA_1c was significantly correlated with the Diabetes Symptoms and Diabetes Management Summary Scores (r = -0.21 to -0.29, P < 0.001). Minimal clinically important difference scores ranged from 5.05 to 5.55.

CONCLUSIONS

The PedsQL 3.2 Diabetes Module Diabetes Symptoms and Diabetes Management Summary Scores demonstrated excellent measurement properties and may be useful as standardized patient-reported outcomes of diabetes symptoms and diabetes management in clinical research, clinical trials, and practice in children, adolescents, and young adults with type 1 diabetes.

The Role of Authoritative Parenting in Adolescent Type 1 Diabetes Management

Objective

Adolescents with Type 1 diabetes are at risk for poorer adherence, lower quality of life (QOL), and poorer glycemic control (HbA1c). Authoritative parenting (AP) along with youth adherence and QOL was hypothesized to relate to better HbA1c.

Methods

Parent-youth dyads (N = 257) completed baseline measures of adherence and QOL. Youth completed an AP questionnaire, and HbA1c samples were evaluated. Structural equation modeling determined relations among AP, adherence, QOL, and glycemic control.

Results

AP indirectly linked to better HbA1c (β = -.15, p = .021) through both better adherence and higher QOL. AP also was associated directly with better adherence (β = .26, p = .001), which in turn was linked to better HbA1c (β = -.35, p = .021). In addition, adherence was associated directly with QOL (β = -.56, p = .001).

Conclusions

Together, better youth adherence and higher QOL are two mechanisms by which more AP indirectly relates to better glycemic control during the early adolescent years.

Executive Function in Adolescents With Type 1 Diabetes: Relationship to Adherence, Glycemic Control, and Psychosocial Outcomes

Objective

Impairments in executive function (EF) skills have been observed in youth with type 1 diabetes (T1D), and these skills are critical for following the complex treatment regimen. This study examines parent reports of EF in relation to measures of adherence, glycemic control (A1c), and psychosocial outcomes (depression and quality of life) in adolescents with T1D. A total of 120 adolescents (aged 13-17 years, 52.5% female, 87.5% White) with T1D and their parents completed questionnaires. Glucometers were downloaded and A1c was obtained during clinical visits at the time of enrollment. The prevalence of clinically significant elevated scores on specific EF skills ranged from 11 to 18.6%. In multivariate analyses, parent-reported EF deficits were associated with poorer adherence and lower quality of life, explaining 13 and 12% of the variance, respectively. Adolescents with T1D exhibit specific EF deficits that may negatively impact their quality of life and their ability to engage in self-management activities.

Factors Associated With Diabetes-Specific Health-Related Quality of Life in Youth With Type 1 Diabetes: The Global TEENs Study

OBJECTIVE

Our objective was to characterize diabetes-specific health-related quality of life (D-HRQOL) in a global sample of youth and young adults with type 1 diabetes (T1D) and to identify the main factors associated with quality of life.

RESEARCH DESIGN AND METHODS

The TEENs study was an international, cross-sectional study of youth, 8-25 years of age, with T1D. Participants (N = 5,887) were seen in clinical sites in 20 countries across 5 continents enrolled for 3 predetermined age groups: 8-12, 13-18, and 19-25 years of age. To assess D-HRQOL, participants completed the PedsQL Diabetes Module 3.0 and were interviewed about family-related factors. Specifics about treatment regimen and self-management behaviors were collected from medical records.

RESULTS

Across all age groups, females reported significantly lower D-HRQOL than did males. The 19-25-year age group reported the lowest D-HRQOL. Multivariate linear regression analyses revealed that D-HRQOL was significantly related to HbA_1c; the lower the HbA_1c, the better the D-HRQOL. Three diabetes-management behaviors were significantly related to better D-HRQOL: advanced methods used to measure food intake; more frequent daily blood glucose monitoring; and more days per week that youth had ≥30 min of physical activity.

CONCLUSIONS

In all three age groups, the lower the HbA_1c, the better the D-HRQOL, underscoring the strong association between better D-HRQOL and optimal glycemic control in a global sample of youth and young adults. Three diabetes-management behaviors were also related to optimal glycemic control, which represent potentially modifiable factors for clinical interventions to improve D-HRQOL as well as glycemic control.

Design and baseline data from a PCORI-funded randomized controlled trial of family-centered tailoring of diabetes self-management resources

This article describes the methodology, recruitment, participant characteristics, and sustained, intensive stakeholder engagement for Project ACE (Achieving control, Connecting resources, Empowering families). Project ACE is a randomized controlled trial of children and youth ages 8-16 with type 1 diabetes evaluating the impact of tailored self-management resources on hemoglobin A1c (A1c) and quality of life (QOL). Despite strong evidence that controlling A1c reduces long-term complications, <25% of US youth with type 1 diabetes meet A1c targets. Many interventions are efficacious in improving A1c and QOL for these youth, whose families often struggle with the substantial demands of the treatment regimen. However, most such interventions are ineffective in the real world due to lack of uptake by families and limited healthcare system resources. Project ACE is a multi-site trial designed to improve diabetes outcomes by tailoring existing, evidence-based interventions to meet families' needs and preferences. We hypothesize that this family-centered approach will result in better A1c and QOL than usual care. Project ACE has recruited and randomized 214 eligible 8-16year old youth and their parents. The 9-month intervention consisted of 4 group sessions tailored to families' self-management barriers as identified by a validated instrument. Outcomes including A1c and QOL for parents and youth will be assessed for 1year after the intervention. Stakeholder engagement was used to enhance this trial's recruitment, retention and integration into routine clinical care. Findings will inform implementation and dissemination of family-centered approaches to address self-management barriers.

TRIAL REGISTRATION NUMBER

NCT02024750 Trial Registrar: Clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT02024750.

Whose quality of life is it anyway? Discrepancies between youth and parent health-related quality of life ratings in type 1 and type 2 diabetes

PURPOSE

Health-related quality of life (HRQOL) is a critical diabetes outcome, yet differences between youth and parent-proxy ratings can make interpretation difficult. This study aims to explore potential differences between self- and parent-reports of Pediatric Quality of Life Inventory (PedsQL) scores from youth with type 1 (T1D) or type 2 diabetes (T2D) and to evaluate associations between discrepancies, PedsQL scores, and glycemic control (HbA1c).

METHODS

Youth and parents in the SEARCH for Diabetes in Youth Study (T1D: age 5-18, n = 3402; T2D: age 8-18, n = 353) completed the PedsQL Generic and Diabetes Modules, and youth provided a blood sample to assess HbA1c. Discrepancies (youth minus parent PedsQL ratings) were calculated and examined by age and diabetes type, and associations with youth PedsQL scores and HbA1c were evaluated.

RESULTS

Discrepancies existed between youth and parent-proxy reports of generic and diabetes PedsQL scores in T1D and T2D (all p values < 0.01). Higher (more favorable) ratings were reported by youth except for those 5-7-years old, where parents' scores were higher. When parent-proxy scores were higher, discrepancies were largest when the child reported low PedsQL scores. Higher HbA1c was associated with larger discrepancies (youth scores higher) for adolescents with T1D.

CONCLUSIONS

Discrepant PedsQL ratings suggest that parents may often underestimate youths' HRQOL except in the youngest children. Although examining both reports is optimal, the youth report should be prioritized, particularly for young children with T1D and for adolescents with either T1D or T2D.

Staying Positive: Positive Affect as a Predictor of Resilience in Adolescents With Type 1 Diabetes

BACKGROUND

Adolescents with Type 1 Diabetes (T1D) are at increased risk for diminished quality of life, deteriorating glycemic control, and psychological symptoms, yet some adolescents are able to adapt to the challenges associated with having diabetes exceptionally well. We sought to examine positive affect as a protective process predicting resilience over time in youth with T1D.

METHOD

Adolescents and their mothers completed questionnaire data, and HbA1c was obtained from adolescents' medical records at baseline and after 6 months. Adolescents were coded for observed positive mood during a videotaped interaction with their mothers.

RESULTS

Positive mood, including both self-report and observed mood, was associated with glycemic control, psychological symptoms, and quality of life. In addition, positive mood predicted improvements in glycemic control and externalizing problems over 6 months.

CONCLUSIONS

Positive affect emerged as a protective process for resilient outcomes in adolescents with T1D, suggesting novel targets for intervention in this high-risk population.

Coping and psychological distress in mothers of adolescents with type 1 diabetes

The purpose of this study was to describe coping in mothers of adolescents with type 1 diabetes and to examine the association among mothers' diabetes-related stress and coping strategies and maternal psychological distress (e.g., symptoms of anxiety and depression), adolescent adjustment (e.g., symptoms of depression, quality of life), diabetes-related family conflict, and glycemic control. One hundred and eighteen mother-adolescent dyads completed measures of diabetes-related stress, coping, symptoms of anxiety and depression, quality of life, and family conflict. Data on glycemic control were collected from adolescents' medical charts. Single/divorced mothers and mothers of color were significantly more likely to use disengagement coping strategies (e.g., avoidance) than White and married/partnered mothers. Mothers' use of primary control coping (e.g., problem solving) and secondary control coping (e.g., acceptance) strategies was related to fewer symptoms of anxiety (r = - .51, -.39) and depression (r = - .32, -.37) and less family conflict (r = - .22, -.30, all p < .05). Mothers' use of disengagement coping strategies was related to greater symptoms of anxiety (r = .30) and depression (r = .27, both p < .01). Further, secondary control coping was found to mediate the relationship between diabetes-related stress and maternal symptoms of anxiety and depression. Maternal coping was not significantly associated with adolescent outcomes. The ways in which mothers of adolescents with type 1 diabetes cope with diabetes-related stress are associated with psychological distress and family conflict. By identifying and improving mothers' coping through screening and targeted interventions, we may have the potential to improve both maternal and adolescent outcomes.

Effect of race and marital status on mothers' observed parenting and adolescent adjustment in youth with type 1 diabetes

OBJECTIVE

To examine demographic differences in parenting behaviors and adjustment in youth with type 1 diabetes. 

METHODS

Adolescents' psychosocial adjustment was assessed via self-reports and parent reports, and clinical data were obtained from adolescents' medical records. Mother-adolescent dyads (N = 93) engaged in a videotaped discussion task, which was coded for observed parenting behaviors.

RESULTS

Single and non-White mothers exhibited significantly more overinvolved and less collaborative parenting behaviors. Higher levels of overinvolved parenting and lower levels of collaborative parenting were associated with poorer adolescent adjustment (i.e., higher levels of externalizing problems). Observed parenting was not significantly associated with glycemic control. There was an indirect effect of marital status and race/ethnicity on externalizing behaviors through parenting.

CONCLUSIONS

The current study highlights parenting as a potential target for interventions, especially in single and minority mothers, to improve adjustment in this population.

Diabetes-related quality of life and the demands and burdens of diabetes care among emerging adults with type 1 diabetes in the year after high school graduation

The roles of glycemic control, diabetes management, diabetes care responsibility, living independently of parents, and time since high school graduation in predicting diabetes-related quality of life (DQOL) were examined in 184 emerging adults with type 1 diabetes. Data were collected at graduation and 1 year later. Analyses controlling for selected covariates were completed using generalized linear mixed models. Better diabetes management was associated with more positive responses on all four dimensions of DQOL. Impact and worry of DQOL were greater in the presence of depressive symptoms, and life satisfaction was lower. DQOL life satisfaction was lower in those living independently of parents. Young women reported poorer diabetes-related health status than did young men. Time since graduation was not linked to DQOL. Further research is needed on ways to improve DQOL in conjunction with diabetes management and on ways that families can support DQOL when youth live independently.

Italian translation, cultural adaptation and validation of the PedsQL™ 3.0 Diabetes Module questionnaire in children with type 1 diabetes and their parents

BACKGROUND

The PedsQL™3.0 Diabetes Module is a widely used instrument to measure the disease-specific health-related quality of life summary measures in children and adolescents with type 1 diabetes. After cultural adaptation, we confirmed reliability and validity of PedsQL™3.0 Diabetes Module in its Italian version.

METHODS

Participants were 169 Italian children and adolescents with type 1 diabetes aged 5-18 years and 100 parents. Reliability was determined by internal consistency using Cronbach's coefficient alpha, and test-retest reliability by intra-class correlation coefficient (ICC). Validity was assessed through factor validity examined by exploratory factor analysis, and discriminant validity examined through multitrait/multi-item scaling analysis. Discriminant validity with respect to dichotomous patients' characteristics at baseline was also examined through a multivariate analysis on the summary measures using the Wilks' Lambda test.

RESULTS

Data completeness was optimal. Item internal consistency was satisfied at 89% for the child self-report scales and at 100% for the parents' proxy-report scales. Most diabetes module scales was acceptable for group comparisons. Discriminant validity was satisfied for 71% of children and adolescents and for 82% of parents. A ≥70% Cronbach's α coefficient was found for the summary measures of both reports. For the test-retest reliability, the ICC coefficients ranged from 0.66 (i.e., the Worry scale) to 0.82 for the other scales of the child self-report. The ICC coefficients were ≥0.87 for all the parents' proxy-report scales. Factor analysis showed that the PedsQL™3.0 Diabetes Module for child self-report could be summarized in 10 components, which explained the 62% of the variance. For the parent proxy-report the statistical analysis selected 9 factors, which explained about 68% of variance. The external discriminant validity of the PedsQL™3.0 Diabetes Module summary measures were compared across gender, age, time since diagnosis and HbA1c mean cut off values. Significant differences in the "Treatment adherence" scale and in the "Communication" scale were observed across age, and by time since diagnosis.

CONCLUSIONS

The results show the reliability and validity of the Italian translation of the PedsQL™3.0 Diabetes Module, supporting therefore its use as an outcome measure for diabetes cross-national clinical trials and research.

Longitudinal trajectories of illness perceptions among adolescents with type 1 diabetes

OBJECTIVES

To examine development in illness perceptions of type 1 diabetes across adolescence and relationships with intelligence, diabetes responsibility, and diabetes outcomes.

METHODS

Illness perceptions were measured via the Illness Perceptions Questionnaire at 3 times, every 6 months in 213 adolescents (M age = 13.00; SD = 1.54) with type 1 diabetes. Intelligence and adolescents' perceived responsibility for diabetes were examined, and adolescents' report of adherence and quality of life (QOL), and glycosylated hemoglobin (HbA1c) from medical records addressed diabetes-related outcomes.

RESULTS

Linear growth models showed significant increases in perceptions of diabetes coherence, chronicity, consequences, personal and treatment control, and decreases in diabetes cyclicality and parental control across time. More favorable illness perceptions were generally associated with adolescent intelligence at baseline, more adolescent responsibility for management, better adherence and QOL, and lower HbA1c at each time point.

CONCLUSIONS

Results suggest that adolescents develop complex illness perceptions, which are associated with better diabetes management.

Development and validation of PRISM: a survey tool to identify diabetes self-management barriers

AIMS

Although most children with type 1 diabetes do not achieve optimal glycemic control, no systematic method exists to identify and address self-management barriers. This study develops and validates PRISM (Problem Recognition in Illness Self-Management), a survey-based tool for efficiently identifying self-management barriers experienced by children/adolescents with diabetes and their parents.

METHODS

Adolescents 13 years and older and parents of children 8 years and older visiting for routine diabetes management (n=425) were surveyed about self-management barriers. HbA1c was abstracted from the electronic health record. To develop PRISM, exploratory and confirmatory factor analyses were used. To assess validity, the association of PRISM scores with HbA1c was examined using linear regression.

RESULTS

Factor analyses of adolescent and parent data yielded well-fitting models of self-management barriers, reflecting the following domains: (1) Understanding and Organizing Care, (2) Regimen Pain and Bother, (3) Denial of Disease and Consequences, and (4) Healthcare Team, (5) Family, or (6) Peer Interactions. All models exhibited good fit, with χ(2) ratios<2.21, root mean square errors of approximation<0.09, Confirmatory Fit Indices and Tucker-Lewis Indices both >0.92, and weighted root mean square residuals<1.71. Greater PRISM barrier scores were significantly associated with higher HbA1cs.

CONCLUSIONS

Our findings suggest at least six different domains exist within self-management barriers, nearly all of which are significantly related to HbA1c. PRISM could be used in clinical practice to identify each child and family's unique self-management barriers, allowing existing self-management resources to be tailored to the family's barriers, ultimately improving effectiveness of such services.

Identification of minimal clinically important difference scores of the PedsQL in children, adolescents, and young adults with type 1 and type 2 diabetes

OBJECTIVE

To establish minimal clinically important difference (MCID) scores representing the smallest detectable change in quality of life (QOL), using the Pediatric Quality of Life Inventory (PedsQL) Generic Core and Diabetes Module among youth with diabetes and their parents, and to identify demographic and clinical correlates of QOL change over 1 year.

RESEARCH DESIGN AND METHODS

Participants in the SEARCH for Diabetes in Youth Study aged >5 years and parents of youth aged <18 years completed PedsQL surveys at their initial and 12-month study visits. MCIDs for each PedsQL module were calculated using one standard error of measurement. Demographic and clinical characteristics associated with QOL change were identified through multiple linear and logistic regression analyses.

RESULTS

The sample comprised 5,004 youth (mean age, 12.5 ± 4.7 years; mean diabetes duration, 3.4 ± 3.7 years). Of 100 possible points, PedsQL total score MCIDs for youth with type 1 and type 2 diabetes, respectively, were Generic Core, 4.88, 6.27 (parent) and 4.72, 5.41 (youth); Diabetes Module, 4.54, 6.06 (parent) and 5.27, 5.96 (youth). Among 1,402 youth with a follow-up visit, lower baseline QOL, male sex, private insurance, having type 1 diabetes, longer diabetes duration, and better glycemic control predicted improvements in youth- and parent-reported PedsQL total scores over 1 year. Clinically meaningful (≥1 MCID) improvements in total score for at least one PedsQL module were predicted by private insurance, lower BMI, and lower A1C at baseline.

CONCLUSIONS

These diabetes-specific reference points to interpret clinically meaningful change in PedsQL scores can be used in clinical care and research for youth with type 1 and type 2 diabetes.

How poorer quality of life in adolescence predicts subsequent type 1 diabetes management and control

OBJECTIVE

Detriments in quality of life (QOL) may contribute to the common, costly decline in adolescents' type 1 diabetes management and control, yet we know little about how this might happen.

METHODS

Participants were 150 adolescents (age 13-18) with type 1 diabetes and their parents. We constructed a latent QOL variable from a multi-informant, multi-domain assessment when participants entered the study. The QOL variable was examined in relation to prospective assessments of diabetes management (blood glucose monitoring frequency; BGM) and control (hemoglobin A1c). We used an indirect path model to test the links among these variables, using bias-corrected bootstrapping.

RESULTS

Poorer QOL at baseline was indirectly linked with higher A1c at 12 months via less frequent BGM obtained at 6 months (b = -0.01, 95% CI = -0.025, -0.004, p < 0.05). Older age (b = -0.32), longer diabetes duration (b = -0.07), and insulin delivery via injections versus the insulin pump (b = 0.67) were covariates of less frequent BGM, and unmarried caregiver status was associated with higher A1c (b = -0.76), all ps < 0.05.

CONCLUSIONS

In this study, poorer QOL acted as a barrier to effective diabetes management, subsequently altering diabetes control.

PRACTICE IMPLICATIONS

Efforts to monitor and enhance QOL may hold promise for improving adolescents' diabetes outcomes in the future.

Identification of minimal clinically important difference scores of the PedsQL in children, adolescents, and young adults with type 1 and type 2 diabetes

OBJECTIVE

To establish minimal clinically important difference (MCID) scores representing the smallest detectable change in quality of life (QOL), using the Pediatric Quality of Life Inventory (PedsQL) Generic Core and Diabetes Module among youth with diabetes and their parents, and to identify demographic and clinical correlates of QOL change over 1 year.

RESEARCH DESIGN AND METHODS

Participants in the SEARCH for Diabetes in Youth Study aged >5 years and parents of youth aged <18 years completed PedsQL surveys at their initial and 12-month study visits. MCIDs for each PedsQL module were calculated using one standard error of measurement. Demographic and clinical characteristics associated with QOL change were identified through multiple linear and logistic regression analyses.

RESULTS

The sample comprised 5,004 youth (mean age, 12.5 ± 4.7 years; mean diabetes duration, 3.4 ± 3.7 years). Of 100 possible points, PedsQL total score MCIDs for youth with type 1 and type 2 diabetes, respectively, were Generic Core, 4.88, 6.27 (parent) and 4.72, 5.41 (youth); Diabetes Module, 4.54, 6.06 (parent) and 5.27, 5.96 (youth). Among 1,402 youth with a follow-up visit, lower baseline QOL, male sex, private insurance, having type 1 diabetes, longer diabetes duration, and better glycemic control predicted improvements in youth- and parent-reported PedsQL total scores over 1 year. Clinically meaningful (≥1 MCID) improvements in total score for at least one PedsQL module were predicted by private insurance, lower BMI, and lower A1C at baseline.

CONCLUSIONS

These diabetes-specific reference points to interpret clinically meaningful change in PedsQL scores can be used in clinical care and research for youth with type 1 and type 2 diabetes.

Quality of life of children and adolescents with type 1 diabetes in Kuwait

OBJECTIVES

To evaluate the health-related quality of life (HRQoL) of children and adolescents with type 1 diabetes (T1DM) in Kuwait using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scale and PedsQL 3.0 Diabetes Module, and to identify the risk factors associated with unsatisfactory QoL and their effects on metabolic control.

SUBJECTS AND METHODS

A total of 436 patients (2-18 years) with T1DM (>6 months) and 389 healthy controls, with the parents of both groups, completed the Arabic Generic Core Scale. Those with T1DM also completed the Arabic Diabetes Module.

RESULTS

The mean total score of the PedsQL Diabetes Module was 70.2 ± 9.8 reported by children and 59.9 ± 11.1 reported by parents (higher scores indicate better QoL). Young age and long duration of diabetes were associated with poor QoL (p < 0.001). Boys had better total scores than girls in most age groups (70.3 ± 9.3 vs. 52.3 ± 7.2, p < 0.001); however, girls did better than boys regarding treatment barriers and adherence (71.3 ± 7.8 vs. 68.1 ± 6.2, p < 0.005). Higher HbA1c values were associated with lower QoL scores (31.1 ± 5.1 at HbA1c of 15% vs. 82.5 ± 6.1 at HbA1c of 6%, p < 0.0001).

CONCLUSION

HRQoL of children and adolescents with T1DM was consistently poorer than controls. Parents consistently reported poorer QoL scores than their children. We recommend that more support should be provided for the care of children with diabetes in Kuwait.

Content validity of the PedsQL™ 3.2 Diabetes Module in newly diagnosed patients with Type 1 diabetes mellitus ages 8-45

OBJECTIVES

The content validity of the 28-item PedsQL™ 3.0 Diabetes Module has not been established in research on pediatric and adult patients with newly diagnosed Type 1 diabetes across a broad age range. This study aimed to document the content validity of three age-specific versions (8-12 years, 13-18 years, and 18-45 years) of the PedsQL™ Diabetes Module in a population of newly diagnosed patients with Type 1 diabetes.

METHODS

The study included in-depth interviews with 31 newly diagnosed patients with Type 1 diabetes between the ages of 8 and 45 years, as well as 14 parents and/or caregivers of child and teenage patients between the ages of 8 and 18 years of age; grounded theory data collection and analysis methods; and review by clinical and measurement experts.

RESULTS

Following the initial round of interviews, revisions reflecting patient feedback were made to the Child and Teen versions of the Diabetes Module, and an Adult version of the Diabetes Module was drafted. Cognitive interviews of the modified versions of the Diabetes Module were conducted with an additional sample of 11 patients. The results of these interviews support the content validity of the modified 33-item PedsQL™ 3.2 Diabetes Module for pediatric and adult patients, including interpretability, comprehensiveness, and relevance suitable for all patients with Type 1 Diabetes.

CONCLUSIONS

Qualitative methods support the content validity of the modified PedsQL™ 3.2 Diabetes Module in pediatric and adult patients. It is recommended that the PedsQL™ 3.2 Diabetes Module replaces version 3.0 and is suitable for measuring patient-reported outcomes in all patients with newly diagnosed, stable, or long-standing diabetes in clinical research and practice.

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.

Demographic and clinical correlates of diabetes-related quality of life among youth with type 1 diabetes

OBJECTIVES

To evaluate the reliability and cluster structure of the Pediatric Quality of Life Inventory Type 1 Diabetes Module 3.0 (PedsQL-T1DM) and associated subscales and to explore the associations between PedsQL-T1DM total score and demographic and clinical characteristics and clinical indicators among a large racially/ethnically diverse cohort of youth with type 1 diabetes.

STUDY DESIGN

Principal components analysis was conducted on responses from the PedsQL-T1DM child self-report forms completed by SEARCH for Diabetes in Youth study participants aged ≥ 5 years. Multivariate linear regression models were fit to examine the associations among PedsQL-T1DM total score, demographic and clinical characteristics, and clinical indicators.

RESULTS

The sample comprised 2602 youth with a mean age of 13.6 ± 4.1 years and a mean T1DM duration of 62.1 ± 47.0 months. Principal components analysis did not support the 5 existing PedsQL-T1DM subscales. In multivariate analyses, the PedsQL-T1DM total score was negatively and significantly associated with younger age (5-7 years), female sex, receiving insulin by injection (vs pump), having parents without a college degree, Medicaid/Medicare insurance, and having a comorbid medical condition. Youth with poor glycemic control based on their age-specific hemoglobin A1c target values and those with depressive symptoms had significantly lower PedsQL-T1DM scores than their counterparts with good control and no or limited depressive symptoms.

CONCLUSION

This study has identified sociodemographic and clinical characteristics of youth with T1DM more likely to experience poor diabetes-specific quality of life. The association of lower PedsQL-T1DM scores with depressive symptoms and poor glycemic control is especially concerning and may be the focus of future interventions and studies.

Emotional processing and self-control in adolescents with type 1 diabetes

OBJECTIVE

This study examined whether emotional processing (understanding emotions), self-control (regulation of thoughts, emotions, and behavior), and their interaction predicted HbA1c for adolescents with type 1 diabetes over and above diabetes-specific constructs.

METHODS

Self-report measures of self-control, emotional processing, self-efficacy for diabetes management, diabetes-specific negative affect, and adherence, and HbA1c from medical records were obtained from 137 adolescents with type 1 diabetes (M age = 13.48 years).

RESULTS

Emotional processing interacted with self-control to predict HbA1c, such that when adolescents had both low emotional processing and low self-control, HbA1c was poorest. Also, both high emotional processing and self-control buffered negative effects of low capacity in the other in relation to HbA1c. The interaction of emotional processing × self-control predicted HbA1c over diabetes-specific self-efficacy, negative affect, and adherence.

CONCLUSIONS

These findings suggest the importance of emotional processing and self-control for health outcomes in adolescents with diabetes.

Psychological screening in adolescents with type 1 diabetes predicts outcomes one year later

AIMS

Adolescents with type 1 diabetes are at increased risk for depression and anxiety, which can adversely affect diabetes management, glycemic control, and quality of life (QOL). However, systematic psychological screening is rarely employed. We hypothesized that higher depression and anxiety screener scores would predict higher HbA1c, less frequent blood glucose monitoring (BGM), and poorer QOL one year later. Raw screener scores were expected to be more robust predictors than cutoff scores.

METHODS

150 adolescents age 13-18 with type 1 diabetes completed depression and anxiety screeners. One year later, blood glucose meters were downloaded to assess BGM frequency, HbA1c values were obtained, and caregivers rated the participants' QOL. Separate regressions were conducted for each outcome, including demographic and medical covariates.

RESULTS

Higher depression scores predicted less frequent BGM (b=-0.05, p<.05) and poorer QOL (b=-0.71, p<.01), and higher state anxiety scores predicted higher HbA1c (b=0.07, p<.05). Continuous screener scores identified risk for 12-month outcomes more robustly than clinical cut-off scores.

CONCLUSIONS

Psychological screeners predict diabetes outcomes one year later. Future clinical research studies should explore whether psychological screening and referral for appropriate intervention can prevent deteriorations in diabetes management and control commonly seen during adolescence.

Generic and diabetes-specific parent-child behaviors and quality of life among youth with type 1 diabetes

OBJECTIVE

To evaluate associations among parent-child behaviors and generic and diabetes-specific health-related quality of life (HRQOL) in a multi-site sample of youth with type 1 diabetes.

METHOD

One hundred and twenty-one youth and their primary caregivers completed measures of parent-child behaviors, child HRQOL, and participated in an observed family interaction task.

RESULTS

Diabetes-specific parent-child variables were associated significantly with both generic and diabetes-specific HRQOL above and beyond the contributions of demographic and generic parent-child variables, accounting for between 13% and 31% of the variance in HRQOL. Diabetes-specific family conflict and negative diabetes-specific family communication were associated with lower HRQOL. Collaborative parent involvement in diabetes care was associated with higher levels of HRQOL.

CONCLUSIONS

Interventions that target diabetes-specific family interactions will be beneficial to the quality of life of children with type 1 diabetes.

Predictors of study completion and withdrawal in a randomized clinical trial of a pediatric diabetes adherence intervention

PURPOSE

Loss of participants in randomized clinical trials threatens the validity of study findings. The purpose of this study was to determine pre-randomization predictors of study completion status throughout the course of a randomized clinical trial involving young children with type 1 diabetes and their primary caregivers.

METHODS

An intervention to improve adherence to the diabetes treatment regimen was delivered as part of the child's regular 3-month diabetes clinic visit. The study protocol involved 7 clinic visits across 18 months for the Immediate Treatment group and 9 clinic visits across 24 months for the Delayed Treatment group. Among those who completed the study and regardless of treatment group, participants were categorized into two groups: On-Time Completers (n=41) and Late Completers (n=39). Demographic, disease, and psychosocial characteristics of children and their primary caregivers measured prior to study randomization were tested for their association with the participants' completion status (i.e., On-Time Completers, Late Completers, or Withdrawals).

RESULTS

Of the 108 participants, 28 (25.9%) withdrew and 80 (74.1%) completed the study. On-Time Completers (i.e., study completed within 4 months of expected date) were more likely to have private insurance and primary caregivers with some college education. Late Completers (i.e., study completion took longer than 4 months) were more likely to be boys and to have primary caregivers who reported mild to moderate levels of depression. Children who subsequently withdrew from the study reported poorer diabetes-related quality of life and poorer school-related quality of life at study inception and were more likely to have primary caregivers who did not work outside the home.

CONCLUSIONS

Pre-randomization screening of participants on both demographic and psychological variables may help identify those at greatest risk for study withdrawal or poor study protocol adherence, permitting the investigators to develop retention strategies aimed at this high-risk group.

Collaborative involvement of primary and secondary caregivers: associations with youths' diabetes outcomes

OBJECTIVE

Collaboration between youths with type 1 diabetes (T1D) and their adult caregivers may be central to effective management of T1D. This article includes analysis of cross-sectional associations between T1D outcomes (adherence, glycemic control, quality of life, family conflict, depression, and self-efficacy) and scores on the Collaborative Parent Involvement (CPI) Scale obtained from 309 youths with T1D about their primary and secondary caregivers.

METHODS

MANCOVA, controlling for age, evaluated associations of diabetes outcomes with youths' CPI scores for each caregiver.

RESULTS

Diabetes outcomes were poor when both caregivers obtained CPI scores below the median. Diabetes outcomes were more strongly associated with CPI scores of primary, rather than secondary, caregivers. CPI scores at or above the median among primary caregivers were associated with more favorable status on multiple youth outcomes. When both caregivers obtained CPI scores at or above the median, children had significantly lower HbA1C and parents retained more responsibility for diabetes care.

CONCLUSIONS

Higher collaborative involvement, particularly among primary caregivers, was associated with favorable status along a variety of diabetes outcomes. Longitudinal studies could confirm if youth-parent collaboration is a justifiable intervention target.