Adolescents' behavioral autonomy related to diabetes management and adolescent activities/rules

Supporting Parents of Children With Type 1 Diabetes: Experiment Comparing Message and Delivery Types

BACKGROUND

Type 1 diabetes (T1D) is a chronic condition that typically affects young age group people and is estimated to afflict approximately 154,000 people younger than 20 years in the United States. Since T1D typically impacts children, parents must play an active role in helping their child manage the condition. This creates a substantial burden and responsibility for the parents.

OBJECTIVE

This pilot study sought to find ways to help parents with children with T1D in coping with stresses related to managing and monitoring their child's disease by providing informational support, either about parenting a child with T1D or general parenting messages through different channels.

METHODS

Parents (N=120) of children with T1D were recruited through an email listserv through local T1D Facebook groups. A total of 102 participants were included in the analysis. We conducted a 2×2 experimental study over an 8-week period to test 2 types of messages (diabetes specific vs general parenting) and the medium in which the messages were delivered (Facebook vs SMS text message). Diabetes behavior, informational support, emotional support, and quality of life were the main outcomes of interest.

RESULTS

The results suggested that the participants in the diabetes message groups showed improvement in diabetes behaviors (F_1,99=3.69; P=.05) and were more satisfied with the intervention (F_3,98=4.59; P=.005). There were no differences between message and medium groups on informational support, emotional support, or quality of life.

CONCLUSIONS

The results of this study demonstrate that the medium-Facebook or SMS text messaging-does not matter for parents' perceptions of social support or quality of life. The diabetes message group reported higher levels of disease management. Finally, the groups with the diabetes support messages were more satisfied than those who received general parenting messages. The findings provide starting guidance for the development of social support interventions for this population.

More hypoglycemia not associated with increasing estimated adiposity in youth with type 1 diabetes

BACKGROUND

Despite the widespread clinical perception that hypoglycemia may drive weight gain in youth with type 1 diabetes (T1D), there is an absence of published evidence supporting this hypothesis.

METHODS

We estimated the body fat percentage (eBFP) of 211 youth (HbA1c 8.0-13.0%, age 13-16) at baseline, 6, and 18 months of the Flexible Lifestyles Empowering Change trial using validated equations. Group-based trajectory modeling assigned adolescents to sex-specific eBFP groups. Using baseline 7-day blinded continuous glucose monitoring data, "more" vs. "less" percent time spent in hypoglycemia was defined by cut-points using sample median split and clinical guidelines. Adjusted logistic regression estimated the odds of membership in an increasing eBFP group comparing youth with more vs. less baseline hypoglycemia.

RESULTS

More time spent in clinical hypoglycemia (defined by median split) was associated with 0.29 the odds of increasing eBFP in females (95% CI: 0.12, 0.69; p = 0.005), and 0.33 the odds of stable/increasing eBFP in males (95% CI: 0.14, 0.78; p = 0.01).

CONCLUSIONS

Hypoglycemia may not be a major driver of weight gain in US youth with T1D and HbA1c ≥8.0. Further studies in different sub-groups are needed to clarify for whom hypoglycemia may drive weight gain and focus future etiological studies and interventions.

IMPACT

We contribute epidemiological evidence that hypoglycemia may not be a major driver of weight gain in US youth with type 1 diabetes and HbA1c ≥8.0% and highlight the need for studies to prospectively test this hypothesis rooted in clinical perception. Future research should examine the relationship between hypoglycemia and adiposity together with psychosocial, behavioral, and other clinical factors among sub-groups of youth with type 1 diabetes (i.e., who meet glycemic targets or experience a frequency/severity of hypoglycemia above a threshold) to further clarify for whom hypoglycemia may drive weight gain and progress etiological understanding of and interventions for healthy weight maintenance.

Responsibility sharing for adolescents with type 1 diabetes: A scoping review

BACKGROUND

The term 'Responsibility Sharing', albeit poorly defined, has emerged from the diabetes literature, to describe a distinct mechanism for comprehensively managing the characteristic shift in responsibility that underpins the transition to self-management for adolescents.

METHODS

A scoping review, following the PRISMA-ScR guidelines, distilled the literature from seven databases to answer the questions: What is responsibility sharing? Who are the key stakeholders? What factors affect responsibility transaction? What are its recognized outcomes? How is responsibility shared?

RESULTS

Responsibility sharing is a transactional arrangement between youth and their caregiver/s that functions to repeatedly and flexibly apply ownership to the management of diabetes care tasks, across the course of adolescence. In the main, responsibility sharing was associated with better metabolic and/or psychosocial outcomes. Effective responsibility sharing was seen as being responsive to adolescent capacity and driven by autonomy supportive, sustained communication patterns that enable mutually agreeable responsibility assumption by all stakeholders.

CONCLUSION

Different perspectives on responsibility sharing for adolescents with Type 1 diabetes, and the lack of a universal definition, have led to discordance within the literature about its operationalization and measurement. This paper proposes a definition of responsibility sharing for future researchers to apply.

Clinical Utility of Psychoeducational Interventions for Youth with Type 1 Diabetes: A Scoping Review

Adolescence is a challenging time for the medical management of type 1 diabetes. Thus, a range of psychoeducational interventions have been developed to improve diabetes management among youth. Systematic reviews of this literature have emphasized the effectiveness of interventions for improving patient outcomes. However, knowledge beyond what works is required for interventions to be adopted into routine clinical practice. The objective of this scoping review was to map the clinical utility of the literature based on a variety of indicators, including the problem base, context placement, information gain, transparency, pragmatism, and patient-centeredness of the research. This lens for reviewing research is consistent with the biopsychosocial model and an increasing focus on reducing disability, including activity limitation and participation restriction. PsycINFO, MEDLINE, and CINHAL databases were searched for evaluative psychoeducational intervention studies published between January 2005 and October 2020. Two cited reference searches and one reference list search were also performed. Fifty studies describing 46 different interventions were identified. The clinical utility of the interventions was highly variable. A detailed overview of the clinical utility of the literature is provided with an emphasis on current gaps and shortcomings to be addressed in future research. This work helps advance the translation of clinical knowledge into practice in schools, homes, and communities; and, ultimately, improve the health and well-being of adolescents with T1D.

Parent strategies to support young people experiencing mental health problems in Australia: What is most helpful?

Parents are a critical resource in supporting young people who live with mental health problems. Qualitative research has identified that parents use a wide range of strategies to provide support. However, parents report being unsure which strategies are likely to be helpful, so often struggle in this role. Presently, little empirical evidence exists to assist parents to decide which strategies are likely to be most helpful. This study aimed to explore the parent-perceived helpfulness of parental strategies to support young people living with mental health problems. Data were collected from February to July of 2018, using a cross-sectional, online, anonymous, self-report survey of participants who identified as parenting a young person (15-24 years) diagnosed with a mental health problem (n = 70). Overall, the strategies perceived as most helpful were practical assistance and personal interactions aimed at promoting positive thoughts and feelings and obtaining appropriate treatment. Least helpful strategies tended to be control-type strategies, aimed at behaviour change. Overall, there was good alignment between strategies' helpfulness and frequency of use, however, there were exceptions. These exceptions are likely reflections of the specific context of particular situations as well as parental uncertainty regarding alternative strategies. Generally, perceptions of strategies' helpfulness were unrelated to parent or child characteristics. However, helpfulness of strategies was associated with parents' satisfaction with their relationship with the young person. Parents' collective experience-based perceptions about the helpfulness of strategies used to support young people experiencing mental health problems can be harnessed to inform mental health practitioners' advice to parents and contribute to better mental health outcomes for young people.

Adolescent Perspectives on the Use of Social Media to Support Type 1 Diabetes Management: Focus Group Study

Background

A majority of adolescents report the use of some form of social media, and many prefer to communicate via social networking sites. Social media may offer new opportunities in diabetes management, particularly in terms of how health care teams provide tailored support and treatment to adolescents with diabetes.

Objective

The aim of this study was to explore the experiences and perspectives of adolescents with type 1 diabetes on the feasibility of social media use as a tool to collaboratively manage their diabetes with their diabetes care team.

Methods

Focus groups of adolescents with type 1 diabetes were conducted in the Seattle metropolitan area in Washington State. Semistructured questions were used to elicit views around the preferred means of communication with the adolescents’ diabetes care team, how to best support diabetes self-management, and how social media could be used outside of the clinic setting by the diabetes care team to engage with adolescents with type 1 diabetes. Focus groups were audio recorded and transcribed verbatim. Qualitative content analysis was carried out, and emergent themes were subsequently mapped onto 4 domains of feasibility, which included acceptability, demand, implementation, and practicality.

Results

Participants included 45 adolescents with type 1 diabetes (mean age 15.9, SD 1.7 years; 58% male; diabetes duration mean 6.2, SD 3.6 years; 76% on insulin pumps; 49% wore continuous glucose monitors; 93% reported use of social media; 84% used smartphones as the primary means for social media access). A total of 7 major topics were identified and mapped onto areas consistent with our focus on feasibility. For acceptability and demand, participants expressed how communication over social media could help facilitate (1) improved communication outside of clinic visits to optimize diabetes management, (2) independence in diabetes self-management, (3) connection to other youth with diabetes for additional diabetes support, and (4) delivery of more timely and personalized care. Addressing implementation and practicality, participants shared the need to (1) ensure patient privacy, (2) maintain professional nature of provider-patient relationship, and (3) recognize that social media is not currently used for medical care by youth with diabetes.

Conclusions

Adolescents with type 1 diabetes expressed interest in the use of social media as a tool to support diabetes management and increase engagement with their diabetes care team. Specific implementation measures around privacy and professionalism should be considered when developing a social media intervention to facilitate communication between adolescents and care teams.

Diabetes-related events in adolescents and young adults: opportunities for psychosocial interventions

This study was conducted to evaluate predictive factors of diabetes-related emergency room (ER) visits and hospitalizations among adolescents and young adults (AYA) with type 1 diabetes (T1D). Baseline demographic, medical, and psychosocial variables were collected for 177 AYA with T1D. Medical records were reviewed to identify ER visits and hospitalizations related to diabetes. Those with diabetes-related events had significantly higher hemoglobin A1c (A1c) values at baseline (p = 0.0001) and during an average 3.36 years of follow-up (p < 0.0001). Participants with events were more likely to have Medicaid or no insurance vs. private insurance (p = 0.0006) and were more likely to be on multiple daily injections vs. insulin pumps (p = 0.0159). Participants with events reported greater diabetes impact on their lives and their parents reported less autonomy in AYA with events (p = 0.0435). These results suggest that when participants were transferring from pediatric to adult care services, factors such as A1c, insurance status and diabetes treatment are associated with diabetes-related events. Further research is needed to elucidate a causative relationship and develop focused interventions to reduce diabetes-related events during this high-risk time. Autonomy should be further explored to determine its role in diabetes-related events during this transition period.

Using an mHealth App to Transition Care of Type 1 Diabetes from Parents to Teens: Protocol for a Pilot Study

BACKGROUND

Type 1 diabetes mellitus (T1DM) afflicts approximately 154,000 people under the age of 20 in the United States. Most people with T1DM are diagnosed at a young age, and parents have to take on the responsibility of T1DM management. Eventually, the child must begin to transition to self-management. Adolescents often struggle to take on responsibility for all the necessary tasks to successfully self-manage their T1DM. In fact, approximately three-quarters of adolescents are not achieving American Diabetes Association-recommended glycated hemoglobin (HbA_1c) targets. This lack of adherence can lead to negative health outcomes.

OBJECTIVE

The goals of this interdisciplinary proposal are as follows: (1) to develop a unique and theory-driven technology using a mobile phone app to promote self-management behaviors for adolescents aged 10-15 years with T1DM and their parents and (2) to explore the feasibility and impact of the self-management mobile app.

METHODS

This study has two phases: app development and pilot testing. In the app development phase, the app will be conceptualized and a prototype will be tested. In Phase 2, the mobile app will undergo pilot testing to determine its feasibility and impact on diabetes self-management.

RESULTS

The pilot test was launched in September 2017. Data collection for the final pilot test is underway, and results are forthcoming.

CONCLUSIONS

Adolescents with T1DM and their parents can have a difficult time managing the transition of diabetes care. It is hoped that this app can help. The focus groups and prototype testing have indicated promising outcomes of app use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03436628; https://clinicaltrials.gov/ct2/show/NCT03436628 (Archived by WebCite at http://www.webcitation.org/72tHXTE2Z).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/10803.

Close relationships and diabetes management across the lifespan: The good, the bad, and autonomy

Relationships are linked with positive and negative self-management and illness outcomes for individuals with type 1 diabetes. Explanations for these mixed associations have remained separated in psychosocial research in type 1 diabetes by relationship type (e.g. parent vs spouse) and individual's age (e.g. adolescence vs older adulthood). In this conceptual review, we present a novel perspective that close relationships across the lifespan may be beneficial for illness self-management when they support individuals' sense of autonomy, defined from a Basic Psychological Needs perspective. Processes of autonomy support are crucial for promoting illness management across all ages and relationship types.

Maturity in Adolescents with Type 1 Diabetes Mellitus: A Concept Analysis

THEORETICAL PRINCIPLES

The transition from adolescence to adulthood can be a particularly challenging time for teenagers with type 1 diabetes mellitus (T1DM). Adolescents with T1DM must manage a treatment regimen which requires a high level of responsibility and self-care. Often the responsibilities of self-care are given to these teens without a clear assessment of their maturity, resulting in poor health outcomes. In order to accurately assess a youth's ability to assume self-management of T1DM, a clear understanding of the concept of maturity is needed.

PHENOMENA ADDRESSED

The purpose of this paper is to provide a theoretical definition of the concept of maturity in the context of adolescents with T1DM and support this definition based on a literature review. This discussion was developed utilizing the Walker and Avant approach to concept analysis.

RESEARCH LINKAGES

This concept analysis defined maturity in adolescents with T1DM as a multi-dimensional state of development that encompasses the physical, cognitive, psychological, and social dimensions of being. Maturity requires that an individual is capable of functioning with behavioral, cognitive, and emotional autonomy in self-care activities related to TIDM on a consistent basis. This explanation also emphasizes that the process of achieving maturity is gradual and dynamic in nature. Caregivers must understand that physical age alone does not indicate that an adolescent is adequately prepared to assume independent diabetes management. Nurses are in the unique position to assist youth with the transition from dependent diabetes care to independent self-management of the disease; thus, increasing the likelihood of positive outcomes.

Realist-informed review of motivational interviewing for adolescent health behaviors

BACKGROUND

Clinical research investigating effective intervention strategies for adolescents to improve health behaviors has shifted to the application of motivational interviewing (MI). Evidence indicates that MI is an effective intervention for improving health behaviors as related to diet, exercise, and diabetes among adolescents. However, there is a lack of understanding about the mechanisms through which MI works and the contextual factors impacting MI effectiveness. The purpose of this review was to understand how, for whom, and under what circumstances MI works for adolescent health behavior change, which will inform future implementation of this intervention. To provide this in-depth understanding, a realist-informed systematic review was conducted in order to synthesize the evidence on the use of MI for health behaviors. Self-determination theory (SDT) was chosen as the candidate theory for testing in the present review.

METHODS

Databases including PsycINFO, Healthstar, Cochrane, and PubMed were searched for articles published until March 2017. The search strategy included studies that examined or reviewed the effectiveness or efficacy of MI to change health behaviors among adolescent populations. The search identified 185 abstracts, of which 28 were included in the review. The literature was synthesized qualitatively (immersion/crystallization) and tested SDT as the candidate theory.

RESULTS

Based on SDT, three mechanisms were found within reviewed studies, including competence, relatedness, and autonomy. The following contexts were found to impact mechanisms: school setting, clinician MI proficiency, parental involvement, and peer involvement.

CONCLUSIONS

This realist-informed systematic review provides advances in understanding the mechanisms involved in MI for adolescent health behavior change. Additionally, it provides important practical information as to which contexts create the conditions for these mechanisms to occur, leading to health behavior change. The results can inform future MI interventions for adolescent health behavior change. Future research should continue to test this realist theory and also examine mechanism variables not extensively documented in order to improve our understanding of MI in this population.

The design and development of MyT1DHero: A mobile app for adolescents with type 1 diabetes and their parents

INTRODUCTION

Type 1 diabetes impacts approximately 1.25 m Americans, many of them young children. As a child grows, there is a transition towards independence and they must learn to manage their diabetes independently. The objective of this study was to design, develop and conduct a prototype test to assess the satisfaction and feasibility of a mobile app for adolescents with type 1 diabetes and their parents to aid in this transition.

METHODS

Ten parent/adolescent groups used MyT1DHero for four weeks. They were given a pre-test/post-test survey regarding family conflict with three tasks of diabetes management and the general tone of family communication. At post-test they were asked questions regarding their satisfaction and perception of ease of use of the app. They also participated in short interviews regarding the app. Additionally, we used server data to examine actual app usage.

RESULTS

The parents' perceptions of conflict around the results of the blood sugar tests increased ( t(9) = 2.71, p = .02) as did perceptions of conflict around logging the blood sugar results ( t(9) = 3.67, p = .005). The adolescents perceived increased conflict surrounding the results around logging the blood sugars results ( t(9) = 3.09, p = .01).There was no change in the tone of general family communication. During the prototype testing, we discovered that the app crashed repeatedly and several of the functions were not working properly. In the interview data, three main themes emerged, app-crashing issues, problems with notifications and positive feedback.

DISCUSSION

Through this process, all of the reported issues were corrected and new features were planned for subsequent versions. A smartphone application has the potential to be a novel intervention for engaging adolescents and their parents in positive communication to support type 1 diabetes management.

The effectiveness of cognitive-function stress management training in glycemic control in children and in mental health of mother caring for child with type 1 diabetes mellitus

AIM

The study was aimed to evaluate the effectiveness of a training course of cognitive-behavioral stress management in glycaemia regulation in children with type 1 diabetes mellitus as well as in mental health status of their mothers.

MATERIALS AND METHODS

Fifty children with type 1 diabetes mellitus and their mothers were selected and randomly assigned into two groups. A group of mothers (n=25; as experimental one besides their children) passed a course, eight 2-h sessions, on the cognitive-behavioral and stress management, and the control group received the usual care. To evaluate the effectiveness of the intervention, before and after holding the course, glycosylated hemoglobin (HbA1C) test was done on both groups of children, and also some information was collected from the mothers through interview and the DASS (depression, anxiety, stress scale) and PSI (parenting stress index) questionnaires.

RESULTS

After the intervention, HbA1c level decreased in the experimental group. Feeling of depression, anxiety and stress was significantly lower than the control group. Furthermore, training for parenting stress management positively affected on the sense of demanding, reinforcement, and adaptability in child domain and also on attachment, competence, depression, relationship with spouse and family health in parent domain.

CONCLUSION

The intervention program was significantly effective in reducing the amount of HbA1c in diabetic children, and also reduced the intensity of psychosocial problems such as depression, anxiety and stress in the mothers caring for children with type 1 diabetes.

Efficacy and implementation of an Internet psychoeducational program for teens with type 1 diabetes

OBJECTIVE

The purpose of the study was to evaluate the participation and preliminary efficacy of an Internet psychoeducational program (Teens.Connect) shown to be efficacious under controlled conditions compared with an open-access diabetes website for youth (Planet D) on the primary outcomes of A1C and quality of life (QoL), and secondary outcomes of psychosocial and behavioral factors.

RESEARCH DESIGN AND METHODS

Teens with type 1 diabetes (n = 124, 11-14 yr) from two clinical sites were randomly prescribed one of the programs and completed baseline, 3-month and 6-month data. A1C was obtained from clinic records. Participation data included number of log ins, posts to the discussion board, and lessons completed (Teens.Connect only). Descriptive and mixed model analyses were used.

RESULTS

Eighty-five percent (85%) of consented teens registered for their prescribed program. Satisfaction and log ins were similar between groups (satisfaction ranged 3.3-3.5/5; mean log ins = 14/teen). Posts to the discussion forum were higher in Planet D (mean = 28 vs. 19). Participation in the Teens.Connect lessons was low, with only 69% of teens completing any lesson. After 6 months there were no significant differences in A1C, QoL or secondary outcomes between groups. Teens in the Teens.Connect group reported lower perceived stress over time (p < 0.01).

CONCLUSIONS

Teens do not actively participate in an Internet psychoeducational program when they do not have frequent reminders, which may have contributed to a lack of treatment effect. Teens have many competing demands. Strategic implementation that includes targeted reminders and family support may be necessary to assure participation and improvement in health outcomes.

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.

Emerging Adults with Type 1 Diabetes during the First Year Post-High School: Perceptions of Parental Behaviors

Among 182 emerging adults with type 1 diabetes (93% White and 57% female), changes during the year post-high school were examined in perceptions of diabetes-specific conflict with parents, parent-youth shared responsibility, parental tangible aid, and parental autonomy support, as well as the moderating effects of living situation, gender, years with diabetes, and glycemic control. A linear mixed effects model, controlling for baseline values, tested the changes in and relationships among these variables over time. Changes over time in parent-youth conflict were moderated by living independently of parents; autonomy support and shared responsibility were moderated by years with diabetes; and tangible aid was moderated by glycemic control. Future longitudinal research needs to examine whether changes in parental behaviors lead to positive or negative diabetes outcomes among these emerging adults with diabetes.

Parent-adolescent dyads: association of parental autonomy support and parent-adolescent shared diabetes care responsibility

PURPOSE

Parent-adolescent shared responsibility for diabetes care is advocated by experts to achieve beneficial diabetes and psychosocial outcomes for adolescents with type 1 diabetes. Parental autonomy support may be a way to facilitate this sharing. In this dyadic study, we examined parental diabetes-specific autonomy support experienced by adolescents with type 1 diabetes and their parents (n = 89 dyads), and its association with their experience of shared diabetes care responsibility.

METHODS

Path analysis was used to test an Actor-Partner Interdependence Model for parental autonomy support effects on shared responsibility. This was a secondary analysis of data from 89 parent-early/mid-adolescent dyads.

RESULTS

Actor effects were identified. Parents' and adolescents' perceptions of parental autonomy support were associated with their respective reports of shared diabetes care responsibility. One partner effect was identified. Adolescents' reports of parental autonomy support were associated with parents' reports of shared responsibility. Parents and adolescents held similar views of autonomy support but discrepant views of shared responsibility. Older adolescents perceived less parental autonomy support.

CONCLUSION

Increasing parental autonomy support may facilitate parent-adolescent sharing of diabetes care responsibility. Adolescent and parent perceptions influence each other and need to be considered when working with them to strengthen parental autonomy support.

Initial findings: primary diabetes care responsibility among emerging adults with type 1 diabetes post high school and move out of parental home

BACKGROUND

Emerging adults with diabetes are assuming diabetes care responsibility, graduating from high school and leaving their parental homes. We examined: (1) how diabetes care responsibility changed in relation to time (high school to post high school) and living situation (living independently or not of parents) and (2) the association of diabetes self-efficacy, worry about hypoglycaemia, gender and glycaemic control with these changes in responsibility among emerging adults with type 1 diabetes.

METHODS

  During the last 6 months in high school (T1), 113 participants completed diabetes care responsibility (total, daily and non-daily), diabetes self-efficacy and worry about hypoglycaemia scales. Participants again completed the responsibility scales post high school graduation (T2). We used a linear mixed-effects model with diabetes self-efficacy, worry about hypoglycaemia, time since graduation, living situation, gender and glycaemic control as independent variables; and diabetes care responsibility (total, daily and non-daily) as dependent variables. Moderation involving diabetes self-efficacy, worry about hypoglycaemia, gender and glycaemic control was also tested.

FINDINGS

  Diabetes care responsibility increased over time for total (P < 0.001), daily (P= 0.002) and non-daily (P < 0.001), but the associations of self-efficacy and gender with diabetes care responsibility were moderated by living situation. Self-efficacy was negatively related to total (P= 0.006), daily (P= 0.010) and non-daily (P= 0.030) responsibility for those not living independently while positively related only to total responsibility (P= 0.028) for those living independently. Being female was positively related to total (P= 0.007) and non-daily (P= 0.001) responsibility for those living independently.

CONCLUSION

  Diabetes care responsibility increased from high school to post high school among these emerging adults with diabetes. There is a complex relationship between self-efficacy, gender and responsibility related to living independently of parents for these youth.

A framework for the youth with type 1 diabetes during the emerging adulthood transition

Emerging adulthood, a developmental period from late adolescence to the late twenties, is a critical transition for youths with type 1 diabetes. This article proposes a framework for emerging adults with diabetes during this transitional time, integrating theoretical writings on transitions and emerging adulthood with empirical findings from younger adolescents with diabetes, about whom more is known. Key health, developmental, and behavioral outcomes are proposed, as well as key influential personal and environmental characteristics. Influential transitional events for this age group are also discussed relative to these outcomes and to personal and environmental characteristics. This framework provides a guide for longitudinal studies on the transition to young adulthood among emerging adults with type 1 diabetes. Identifying key times and influential factors will provide information for designing future effective interventions to improve glycemic control and quality of life for these youths as they transition to adulthood.

Ascertaining children's wishes and feelings about hospital life

It is increasingly accepted that children have the right to have their views taken into consideration by healthcare providers. Children's opinions and experiences of hospitalisation are essential for monitoring and evaluating the effectiveness of health services provision. In this paper we report on children's views and wishes about hospital and healthcare professionals. The children held both positive and negative views of hospital and healthcare professionals. Dissatisfaction was caused by insufficient information, lack of involvement, and inadequate play facilities. Their wishes were mainly concerned with the need for more information and more involvement in communication interactions with doctors and nurses. They wished to express their opinions, ask questions and receive information about care and procedures. They recommended that healthcare professionals make a better effort to listen and to take account of their views.

Parent and adolescent perspectives about adolescent vaccine delivery: practical considerations for vaccine communication

We surveyed parents of adolescents (n=430) and their adolescents ages 15-17 years (n=208) in 9 primary-care settings in Monroe County, NY to assess perceptions about adolescent vaccine delivery. Parents and adolescents most wanted to discuss vaccine side effects and the diseases prevented with the adolescents' provider. Those who perceived vaccines as very safe were more accepting of adolescent vaccines. Most participants agreed with vaccinating the teen during a mild illness and with providing multiple vaccines concomitantly. Participants most preferred medical, as opposed to other settings, for receipt of adolescent vaccines. For parents and adolescents who are wary of vaccination, strategies are needed to enhance communication about risks and benefits of vaccinations.

Improving glycaemic control and life skills in adolescents with type 1 diabetes: a randomised, controlled intervention study using the Guided Self-Determination-Young method in triads of adolescents, parents and health care providers integrated into routine paediatric outpatient clinics

BACKGROUND

Adolescents with type 1 diabetes face demanding challenges due to conflicting priorities between psychosocial needs and diabetes management. This conflict often results in poor glycaemic control and discord between adolescents and parents. Adolescent-parent conflicts are thus a barrier for health care providers (HCPs) to overcome in their attempts to involve both adolescents and parents in improvement of glycaemic control. Evidence-based interventions that involve all three parties (i.e., adolescents, parents and HCPs) and are integrated into routine outpatient clinic visits are lacking. The Guided Self-Determination method is proven effective in adult care and has been adapted to adolescents and parents (Guided Self-Determination-Young (GSD-Y)) for use in paediatric diabetes outpatient clinics. Our objective is to test whether GSD-Y used in routine paediatric outpatient clinic visits will reduce haemoglobin A1c (HbA1c) concentrations and improve adolescents' life skills compared with a control group.

METHODS/DESIGN

Using a mixed methods design comprising a randomised controlled trial and a nested qualitative evaluation, we will recruit 68 adolescents age 13-18 years with type 1 diabetes (HbA1c > 8.0%) and their parents from 2 Danish hospitals and randomise into GSD-Y or control groups. During an 8-12 month period, the GSD-Y group will complete 8 outpatient GSD-Y visits, and the control group will completes an equal number of standard visits. The primary outcome is HbA1c. Secondary outcomes include the following: number of self-monitored blood glucose values and levels of autonomous motivation, involvement and autonomy support from parents, autonomy support from HCPs, perceived competence in managing diabetes, well-being, and diabetes-related problems. Primary and secondary outcomes will be evaluated within and between groups by comparing data from baseline, after completion of the visits, and again after a 6-month follow-up. To illustrate how GSD-Y influences glycaemic control and the development of life skills, 10-12 GSD-Y visits will be recorded during the intervention and analysed qualitatively together with individual interviews carried out after follow-up.

DISCUSSION

This study will provide evidence of the effectiveness of using a GSD-Y intervention with three parties on HbA1c and life skills and the feasibility of integrating the intervention into routine outpatient clinic visits. Danish Data Association ref nr. 2008-41-2322.

TRIAL REGISTRATION

ISRCTN54243636.

Associations between parent and child pain and functioning in a pediatric chronic pain sample: A mixed methods approach

This study employed a mixed-method design to test sex-specific parent-child pain associations. Subjects were 179 chronic pain patients aged 11-19 years (mean = 14.34; 72% female) presenting for treatment at a multidisciplinary, tertiary clinic. Mothers and children completed questionnaires prior to their clinic visit, including measures of children's pain, functioning and psychological characteristics. Mothers also reported on their own pain and psychological functioning. Interviews were conducted with a sub-sample of 34 mothers and children prior to the clinic visit and analyzed using a grounded theory approach. The quantitative data suggest stronger mother-daughter than mother-son pain relationships. The qualitative data suggest that girls' pain and pain-related disability is related to an overly enmeshed mother-daughter relationship and the presence of maternal models of pain, while boys' pain and disability is linked to male pain models and criticism and to maternal worry and solicitousness. Boys and girls appear to have developmentally incongruous levels of autonomy and conformity to maternal expectations. The mixed-method data suggest distinct trajectories through which mother and father involvement may be linked to chronic pain in adolescent boys and girls.

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.

Teenagers' perceptions of factors affecting decision-making competence in the management of type 1 diabetes

AIMS

Decision-making is an important prerequisite for empowerment. The aim of this study was to explore teenagers' perceptions of factors affecting decision-making competence in diabetes management.

BACKGROUND

A previous study that assessed an empowerment programme for teenagers with diabetes showed no effects on metabolic control or empowerment outcomes, which is not in accordance with results from studies on adult diabetes patients. The definition of empowerment highlights the patient's own responsibility for decision-making. Earlier studies have shown that many teenagers' may not be mature in decision-making competence until late adolescence. To explore the significance of decision-making competence on the effectiveness of empowerment education we wanted to explore teenagers' own view on factors affecting this competence.

DESIGN

An explorative, qualitative interview study was conducted with 31 teenagers with type 1 diabetes, aged 12-17 years.

METHODS

The teenagers were interviewed two weeks after completing an empowerment education programme. The interviews were analysed using qualitative content analysis.

RESULTS

Five categories stood out as important for decision-making competence: cognitive maturity, personal qualities, experience, social network and parent involvement. Based on the content in the interviews and the five categories, we made an interpretation and formulated an overall theme: 'Teenagers deserve respect and support for their short-comings during the maturity process'.

CONCLUSION

Our conclusion is that teenagers deserve respect for their immature decision-making competence. Decision-making competence was described as cognitive abilities, personal qualifications and experience. To compensate for the deficiencies the teenagers deserve constructive support from their social network and the essential support is expected to come from their parents.

RELEVANCE TO CLINICAL PRACTICE

These findings can be useful for diabetes team members in supporting teenagers with diabetes and their parents both in individual meetings and when planning and delivering group education.

Families' lived experience one year after a child was diagnosed with type 1 diabetes

AIM

This paper is a report of a study to elucidate families' lived experience of diabetes one year after a child was diagnosed with type 1 diabetes.

BACKGROUND

The incidence of type 1 diabetes is rapidly increasing worldwide, with a shift towards younger age groups. This illness is treated by means of an intensive management regimen that often disrupts the child's usual activities and requires disease-focused behaviours from the child and his or her family. However, research elucidating families' lived experience from the perspective of all its members is sparse.

METHOD

A hermeneutic phenomenological study was carried out in 2004, based on interviews one year after diagnosis with 11 consecutively chosen Swedish-speaking family members with children aged between 9 and 14 years.

FINDINGS

The families described their one year of lived experience as living an ordinary yet different life. They experienced their lives to be neither particularly difficult nor as easy as they had been before the child was diagnosed with diabetes. Related themes were 'feeling acceptance yet frustration', 'being healthy yet invisibly ill', 'feeling independent yet supervised' and 'feeling confident yet insecure'.

CONCLUSION

It may be helpful if healthcare professionals make use of the knowledge and experience of families living with the illness to meet their specific needs, especially when the affected child is experiencing fluctuating blood sugar levels. Thus, health-promoting collaboration should be tailor-made for every individual and proceed from each family's everyday life.

Adolescent Autonomy and Family Functioning Are Associated With Headache-related Disability

OBJECTIVES

The aims of this study were to examine the relationships between a range of family factors, including autonomy and general family functioning, on headache outcomes (ie, pain and functional impairment) in adolescents with recurrent headaches.

METHODS

Forty nine adolescents, ages 11 to 16 years, (mean age=13.5 y, 63% female) receiving treatment through pediatric neurology for recurrent headaches were enrolled. Adolescents and their parents completed measures of pubertal status, pain, functional impairment, parental solicitousness, behavioral autonomy, depressive symptoms, and family functioning.

RESULTS

Lower levels of adolescent autonomy (r=0.53, P<0.01) and less healthy family functioning (r=0.32, P<0.01) were significantly related to higher levels of functional impairment. In multivariate regression analyses controlling for pain intensity, pubertal status, and depressive symptoms, parent and family variables added significant variance in the prediction of functional impairment (r change=0.21, P<0.05). Both adolescent autonomy (beta=0.38, P<0.05) and general family functioning (beta=0.34, P<0.05) were significant individual predictors of adolescent functional impairment.

DISCUSSION

This study extends research on family factors and adolescent headache-related pain and disability. Future research is needed to discover whether family based interventions helping adolescents to acquire appropriate and supportive levels of autonomy may be useful in reducing headache-related disability.

Assessment of an empowerment education programme. A randomized study in teenagers with diabetes

AIMS

To determine the effects of an empowerment programme on glycaemic control and empowerment, and to study the role of parental involvement.

METHODS

The wait-list design is a randomized controlled trial lasting for 6 months, after which the control group participate in the same education programme as the intervention group. After 6 months, data from the two groups are analysed together (pre/post). Thirty-two teenagers with Type 1 diabetes (12-17 years) completed an empowerment group education programme, meeting weekly for 6 weeks. They were also offered an extra meeting together with their parents, which resulted in three groups: together with parents, only parents and no parent involvement at all. HbA(1c) was measured before intervention and after 6, 12, 18 and 24 months, and empowerment before, and 6 and 12 months after.

RESULTS

HbA(1c) and empowerment were similar in the intervention group and the control group 6 months after intervention. In pre/post analysis, HbA(1c) was significantly higher 6 and 12 months after intervention in teenagers > 14 years (from 8.4% to 9.3%; P < 0.05 to 9.6%; P < 0.01), but returned to baseline 18 months after the programme. In teenagers < or = 14 years of age, HbA(1c) did not change during the study. The teenagers felt more ready for changes after the programme than before (3.9 sd = 0.5 to 4.1 sd = 0.5; P < 0.05). In the teenagers in the group that involved their parents, there was a significant decrease in HbA(1c) 12 and 24 months after intervention, from 8.9% (sd = 1.1) to 7.6% (sd = 1.3; P < 0.05, confidence interval 0.37, 2.26).

CONCLUSION

This empowerment programme for teenagers with diabetes showed no positive glycaemic or empowerment effects. Empowerment programmes for diabetic teenagers in early and middle adolescence should include parental involvement.

Type 1 diabetes and prolonged fasting

AIMS

Fasting is common in several religions. The aims of this study were to determine if prolonged fasting (> 25 h) is safe for individuals with Type 1 diabetes and to identify factors associated with success.

METHODS

Patients intending to fast were instructed on insulin dose adjustments, frequent glucose monitoring and when to terminate the fast using a standard protocol. Clinical and epidemiological factors were recorded and a comparison was made between successful and unsuccessful fasters.

RESULTS

Of 56 subjects who intended to fast, 37 (65%) were successful. Individuals terminated their fast in the presence of either hypoglycaemia or hyperglycaemia and adherence to the protocol was high. There were no serious side-effects of fasting. Successful fasters had greater reductions in insulin dosage and higher HbA(1c). There were no differences between individuals taking intermittent insulin injections and those with continuous infusion pumps.

CONCLUSIONS

Persons with Type 1 diabetes can participate safely in prolonged fasts provided they reduce their usual insulin dose significantly and adhere to guidelines regarding glucose monitoring and indications for terminating fasting.

Self-efficacy, outcome expectations, and diabetes self-management in adolescents with type 1 diabetes

The goal of this research was to develop and evaluate measures of adolescent diabetes management self-efficacy and outcome expectations that reflect developmentally relevant, situation-specific challenges to current diabetes regimens. Self-efficacy for diabetes management, expected outcomes of adherence, adherence to the diabetes regimen, and glycemic control were assessed in 168 adolescents (ages 10-16 years) with type 1 diabetes. Factor analyses indicated a single scale for self-efficacy and two distinct factors representing positive and negative outcome expectations. Reliability and predictive validity of the new scales were supported. In regression analyses, self-efficacy and the interaction of self-efficacy with expectations of positive outcomes were significantly associated with diabetes self-management adherence and glycemic control in older adolescents. The effect of self-efficacy was greatest when adolescents had stronger beliefs in the beneficial outcomes of adherence. These brief measures can be used to identify youths at risk of poor diabetes self-management. Interventions targeting self-efficacy may lead to improved diabetes self-management.

Parent and adolescent versions of the diabetes-specific parental support for adolescents' autonomy scale: development and initial testing

OBJECTIVE

To develop and initially test the psychometric properties of parent and adolescent versions of the Diabetes-Specific Parental Support for Adolescents' Autonomy Scale.

METHODS

Data-based scale items were developed, analyzed for content validity, and then piloted with 43 adolescents with type 1 diabetes and their parents. Psychometric properties of the scales were then determined with 100 adolescents with type 1 diabetes and their parents.

RESULTS

Content validity indices of .80 or greater were obtained for 26 items. Item analysis in the pilot and large-sample groups resulted in 22 items being deleted. Principal Components Analysis of the remaining four items indicated one factor in both parent and adolescent versions, accounting for 50-62% of variance and with Cronbach alpha coefficients of .67-.80.

CONCLUSIONS

This newly developed parsimonious scale, initially tested to be reliable, and valid, will facilitate research on parental support for adolescents' development of diabetes management autonomy.