Executive functioning, treatment adherence, and glycemic control in children with type 1 diabetes

The association between depressive symptoms and executive function in type 1 diabetes population: A scoping review

PURPOSE

The purpose of this study was to explore the existing literature on the relationship between depressive symptoms and executive function in patients with type 1 diabetes (T1DM) across the lifespan.

METHODS

The scoping review followed the PRISMA protocol by using three databases: PubMed, CINAHL, and PsycINFO on May 14, 2023. Primary research that included reported executive function and the association with depressive symptoms was included in the review.

RESULTS

Of 1470 de-duplicated publications identified, nine articles were included in the review. Five studies evaluated the T1DM population, while four studies evaluated T1DM and type 2 diabetes (T2DM) as an aggregate result. Three studies indicated an association between depressive symptoms and executive function in adults with T1DM, and four studies indicated an association between depressive symptoms and executive function in adults with either T1DM or T2DM. In general, participants who reported depressive symptoms also exhibited poor executive function. However, two studies did not find an association between depressive symptoms and executive function.

CONCLUSION

In summary, the seven studies in this review suggest that individuals with T1DM who report depressive symptoms are at a higher risk of poor executive function; a clear association between depressive symptoms and executive function in individuals with T1DM remains inconclusive. There is a need to explore this relationship in the future.

Global cognition and executive functions of older adults with type 1 diabetes mellitus without dementia

AIMS/INTRODUCTION

This study aimed to characterize the global cognition and executive functions of older adults with type 1 diabetes mellitus in comparison with type 2 diabetes mellitus.

MATERIALS AND METHODS

This study included 37 patients with type 1 diabetes mellitus aged ≥65 years and 37 age- and sex-matched patients with type 2 diabetes mellitus. Patients with dementia scoring <24 on the Mini-Mental State Examination were excluded. General cognition, memory, classic, and practical executive function were investigated.

RESULTS

Patients with type 1 diabetes mellitus demonstrated lower psychomotor speed scores on Trail Making Tests A and B (P < 0.001, P < 0.013) than those with type 2 diabetes mellitus. The dysexecutive syndrome behavioral assessment revealed similar results in patients with types 1 and 2 diabetes mellitus. The Wechsler Memory Scale-Revised verbal episodic memory and Montreal Cognitive Assessment Japanese version were similar in terms of general cognition, but worse delayed recall subset on the latter was associated with type 2 diabetes mellitus (P = 0.038). A worse Trail Making Test-A performance was associated with type 1 diabetes mellitus and age (P < 0.004, P < 0.029).

CONCLUSIONS

Executive function of psychomotor speed was worse in older outpatient adults without dementia with type 1 diabetes mellitus than in those with type 2 diabetes mellitus but with no significant differences in the comprehensive and practical behavioral assessment of dysexecutive syndrome. Patients with type 1 diabetes had more severely impaired executive function, whereas those with type 2 had greater impaired memory than executive function.

Managing type 1 diabetes of a child: Parents' perspectives

PURPOSE

Managing type 1 diabetes (T1D) challenges children and their parents. Parents need to learn the necessary skills and later transfer the responsibility of care to their children as they develop. The transition process involves autonomy in behaviour and decision-making. This study explores the shared management experiences of Taiwanese parents and their children with type 1 diabetes.

DESIGN AND METHODS

This study employed a qualitative design using a grounded theory approach. Purposive sampling was used at a medical centre in Taiwan for participant recruitment. Twenty-nine parents of children who had been diagnosed with T1D were interviewed in-depth. Data were analysed using constant comparison and repeated verification.

RESULTS

After a child was diagnosed with T1D, the parents initiated 'Life-long lesson: Growing together with the child on the road to normality'. Three main categories emerged: 'confronting the disease diagnosis', 'establishing supportive and collaborative involvement' and 'assisting the child in building a sense of belonging'. Sub-categories within each significant category were also included.

CONCLUSIONS

Taiwanese parents perhaps have a controlling or directive role for a long period in their child's lives and shared management of their health condition. This study's findings can help healthcare workers better understand the process of parents' shared management of T1D with their children and how to best communicate with children about the disease and care in accordance with the child's stage of development.

Sleep disturbances in children and adolescents with type 1 diabetes mellitus: Prevalence, and relationship with diabetes management

OBJECTIVE

A decline in sleep quality and regularity has been reported in patients with type 1 diabetes mellitus (T1D) in many studies. However, research on medical-based sleep disorders in patients with T1D is limited. Diagnosing sleep disorders is crucial, as it negatively impacts academic performance, cardiovascular health, and cognitive functions among children as well as essential skills for effective diabetes management. Our objective was to assess sleep disturbances in patients diagnosed with T1D and explore whether these patients experience significantly more sleep disturbances compared to their healthy peers.

METHODS

This study, designed as a cross-sectional case-control investigation, involved a cohort of 250 participants (144 T1D, 106 control cases) aged 6-15 years. The Sleep Disturbance Scale for Children (SDCS) scores of the T1D group were compared with those of the control group. Furthermore, the study explored the correlation between clinical/biochemical parameters and SDCS scores within the T1D group.

RESULTS

The mean age of individuals in the T1D group was 10.27 ± 3.25 years, while the control group had a comparable mean age of 10.48 ± 3.5 years (P = 0.303). Within the T1D group, the median duration of diabetes was 5 (1-15) years, and the median glycosylated hemoglobin A1c (HbA1c) level for the past one year was 8.4 %. Although there was no significant difference in total SDSC scores between the T1D and control groups, both groups exhibited average scores that remained close to the threshold indicative of sleep disturbances (>39). Notably, individuals with total SDSC scores surpassing 39 were identified at rates of 48.6 % in the T1D group and 47.6 % in the control group, respectively. Furthermore, disorders of arousal nightmares (DA) were more prevalent in T1D patients compared to their healthy peers (P = 0.049). Additionally, HbA1c showed a positive correlation with scores for disorders of excessive somnolence (DOES) and total scores (P < 0.001, R = 0.368; P = 0.003, R = 0.243).

CONCLUSION

Our study found that the prevalence of sleep disturbances among children and adolescents with T1D was not significantly higher than that observed in their healthy peers. Nevertheless, it is crucial to note that a notable portion, 48.6 % of T1D cases and 47.6 % of healthy cases, displayed sleep disturbances based on SDSC scores. To optimize diabetes management and proactively address potential challenges, incorporating routine screening for sleep disturbances in the monitoring of T1D patients can yield valuable benefits.

Executive Functioning, Daily Self-Regulation, and Diabetes Management while Transitioning into Emerging Adulthood

BACKGROUND

Executive functioning (EF) predicts better Type 1 diabetes (T1D) management in the high-risk years after high school, but the daily self-regulation processes involved are unclear.

PURPOSE

To examine whether EF is associated with daily self-regulation that minimizes one's exposure or buffers adverse reactions to daily diabetes problems, and to determine whether these patterns become stronger during the transition out of high school.

METHODS

A measurement burst design with convenience sampling was used. Seniors in high school with T1D (N = 207; 66% female) completed self-report (i.e., Behavioral Rating Inventory of Executive Functioning) and performance measures of EF (i.e., Delis-Kaplan Executive Function System). A 14-day daily diary assessing self-regulation failures, diabetes problems, affect, and indicators of diabetes management was completed at baseline and 1 year later.

RESULTS

Correlations and multilevel modeling were conducted. Lower self-reported EF problems were associated with lower average levels of daily self-regulation failures, and these variables were associated with fewer daily diabetes problems. In contrast, better EF performance was unrelated to average daily self-regulation failures, and was unexpectedly associated with more frequent diabetes problems in year 2. Equally across years, on days participants reported lower than their average levels of daily self-regulation failures, they had fewer diabetes problems, regardless of EF. On days with lower than average diabetes problems, participants reported better diabetes management indicators. EF generally did not buffer daily associations in either year.

CONCLUSIONS

Regardless of EF, promoting daily self-regulation may prevent diabetes problems and promote T1D management in daily life at this high-risk transitional time.

Association of ADHD symptoms with type 2 diabetes and cardiovascular comorbidities in adults receiving outpatient diabetes care

Background

The relationship between attention-deficit/hyperactivity disorder (ADHD) symptoms and type 2 diabetes mellitus (T2D) and its cardiovascular outcomes have not been sufficiently studied.

Methods

2,986 adults with T2D from the Joslin Diabetes Center at Upstate Medical University were assessed for ADHD-like symptoms, executive dysfunction, and emotional control using the Adult Self-Report Scale V1.1 (ASRS) expanded version. Surveys were sent electronically, and clinical data were obtained from the electronic medical record. Pearson chi-square test was used for categorical variables association. When ASRS scores were the dependent variable, negative binomial regression correcting for demographic variables that were associated with the ASRS scores was used.

Results

155 (49.2%) of respondents met DSM-5 criteria for ADHD using the ASRS scores; Only ten (3.6%) of respondents had an ICD10 diagnosis of ADHD in their medical record; Forty-three (13.7%) had either a diagnosis of ADHD in the medical history or were taking medications used by people with ADHD. Higher levels of ADHD-like symptoms were found in patients with T2D compared with population norms. There was a modest association of the ASRS executive dysfunction subscale with overall cardiovascular comorbidities (p = 0.03). However, the p-value did not survive the multiple testing correction. Both ADHD-like symptoms and symptoms associated with emotional control, however, were not associated with specific cardiovascular diseases, hypertension, or with HbA1c, LDL-cholesterol, triglycerides, ALT, creatinine, or eGFR.

Conclusion

Our results suggest that adults with T2D attending a tertiary care diabetes clinic are at risk for having ADHD-like symptoms, highlighting the importance of screening for ADHD symptoms in this specialty setting and referring undiagnosed adult patients for further assessment and treatment of ADHD. Larger studies are needed to clarify the relationship between ADHD-like symptoms, executive dysfunction, and emotional control with diabetic control and comorbidities.

Diabetes complications and cognitive function in young adults with youth-onset type 1 or type 2 diabetes: the SEARCH for Diabetes in Youth Study

Aims/hypotheses

People with type 1 (T1D) or type 2 diabetes (T2D) who also have diabetes complications can have pronounced cognitive deficits. It remains unknown, however, whether and how multiple diabetes complications co-occur with cognitive dysfunction, particularly in youth-onset diabetes.

Methods

Using data from the SEARCH for Diabetes in Youth study cohort, a prospective longitudinal cohort, we examined clustering of complications and their underlying clinical factors with performance on cognitive tests in young adults with youth-onset T1D or T2D. Cognition was assessed via the NIH Toolbox Cognition Battery. The main cognitive variables were age-corrected scores for composite fluid cognition and associated cognitive subdomains. Diabetes complications included retinopathy, microalbuminuria, and peripheral neuropathy (PN). Lipids, systolic blood pressure (SBP), hemoglobin A1c, and other clinical factors were included in the analyses. Clustering was applied separately to each group (T1D=646; T2D=165). A three-cluster(C) solution was identified for each diabetes type. Mean values and frequencies of all factors were compared between resulting clusters.

Results

The average age-corrected score for composite fluid cognition differed significantly across clusters for each group (p<0.001). People with T1D and the lowest average fluid cognition scores had the highest frequency of self-reporting at least one episode of hypoglycemia in the year preceding cognitive testing and the highest prevalence of PN. Persons with T2D and the lowest average fluid cognition scores had the highest SBP, the highest central systolic and diastolic blood pressures, and highest prevalence of PN.

Conclusions/interpretations

These findings highlight shared (PN) and unique factors (hypoglycemia in T1D; SBP in T2D) that could be targeted to potentially mitigate cognitive issues in young people with youth-onset diabetes.

Forty Years of Behavioral Diabetes Research: A Personal Journey

This article was adapted from the address Dr. Delamater delivered as the recipient of the American Diabetes Association's Richard R. Rubin Award for 2022. This award recognizes a behavioral researcher who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes in diverse populations. Dr. Delamater delivered the address in June 2022 at the Association's virtual 82nd Scientific Sessions. A webcast of this speech is available for viewing on the DiabetesPro website (https://professional.diabetes.org/webcast/stigma-diabetes-care%E2%80%94evidence-and-solutions-richard-r-rubin-award-lecture).

Associations of Executive Function With Diabetes Management and Glycemic Control in Adolescents With Type 1 Diabetes

AIMS

The aims of this study were to assess domains of executive function in relation to diabetes management and glycemic control in adolescents with type 1 diabetes and to compare adolescent self-report and parent proxy-report of adolescent executive function.

METHODS

Adolescents with type 1 diabetes (N = 169, 46% female, age 15.9 ± 1.3 years) and their parents completed self-report and parent proxy-report versions of the Behavior Rating Inventory of Executive Function (BRIEF).

RESULTS

Self-report and parent proxy-report BRIEF T scores were moderately to strongly correlated; parent proxy scores were significantly higher than self-report scores. Executive function problems (Global Executive Composite T score ≥60) occurred in 9% of adolescents by self-report and 26% by parent proxy-report. For almost all Metacognition Index scales, elevated (T score ≥60) parent proxy scores were associated with lower adherence, lower adolescent diabetes self-efficacy, and more parent involvement in diabetes management. Elevated scores on several Metacognition Index scales were associated with less pump use (Plan/Organize by self-report, Initiate by parent proxy-report, and Monitor by parent proxy-report) and higher A1C (Plan/Organize by self-report and parent proxy-report and Organization of Materials by parent proxy-report). The only significant associations for the Behavioral Regulation Index scales occurred for adherence (by parent proxy-report) and diabetes self-efficacy (by self-report and parent-report).

CONCLUSION

Adolescents with type 1 diabetes who have problems with metacognition may need additional support for diabetes self-management.

Adherence as a Predictor of Glycemic Control Among Adolescents With Type 1 Diabetes: A Retrospective Study Using Real-World Evidence

PURPOSE

Metabolic control among adolescents with type 1 diabetes mellitus (T1DM) is generally poor. Nonadherence is a contributor to this poor glycemic control, leading to adverse outcomes. The findings of studies reporting the association between adherence and glycemic control are conflicting. This study aimed to assess the level of adherence among adolescents with T1DM and its relationship with glycemic control.

METHODS

This was a retrospective, cross-sectional study that was conducted at Sidra Medicine, a state-of-the-art tertiary health care facility for women and children in Qatar. Mean blood or interstitial glucose monitoring frequency (BGMF) was used to assess adherence level among adolescents with T1DM, whereas glycemic control was assessed via documented glycated hemoglobin A_1c (HbA_1c). Adolescents who had a mean BGMF of ≥4 checks per day were considered adherent, and those who had an HbA_1c level of <7% were considered as having controlled diabetes. Correlational and logistic regression analyses were performed to assess the relationship between adherence and glycemic control, incorporating other covariates into the model.

FINDINGS

The rate of adherence among adolescents with T1DM in Qatar was 40.9%. Adherent adolescents had significantly lower median HbA_1c levels compared with nonadherent adolescents (9.0% vs. 9.7%; P = 0.002). A significant negative correlation was found between BGMF and HbA_1c level (correlation coefficient r_s = -0.325; P < .001). Approximately 97% of nonadherent adolescents compared with 87% of adherent adolescents had suboptimal diabetes control (HbA_1c ≥7%) (P = .016). Furthermore, nonadherent adolescents were 78% less likely to have controlled diabetes compared with adherent adolescents (adjusted odds ratio = 0.221; 95% CI, 0.063-0.778; P = 0.019). The combined effect of the determinants of glycemic control among adolescents with T1DM that were included in the multiple regression model was able to explain approximately 9% of the variances in glycemic control (Cox and Snell R² = 0.092).

IMPLICATIONS

The current findings suggest that nonadherence was highly prevalent among adolescents with T1DM and was a significant independent predictor of glycemic control, explaining 9% of the variability. This finding warrants further exploration of other possible predictors of poor glycemic control among the adolescent population. Comprehensive interventions, including educational, technological, and health service delivery aspects, aimed at improving adherence and ultimately optimizing glycemic control are warranted in adolescents with T1DM.

Metabolism and memory: α-synuclein level in children with obesity and children with type 1 diabetes; relation to glucotoxicity, lipotoxicity and executive functions

Background/Objectives

Children with obesity and those with type 1diabetes (T1D) exhibit subtle neurocognitive deficits, the mechanism of which remains unknown. α-synuclein plays a fundamental role in neurodegeneration. Moreover, its role in glucose and lipids metabolism is emerging. This study aims to assess whether α-synuclein is correlated with the degree of neurodegeneration in children with obesity and those with T1D in comparison to healthy controls and correlate it to various neurocognitive and metabolic parameters.

Subjects/Methods

Forty children with obesity, 40 children with T1D and 40 matched-healthy controls were assessed for anthropometric measurements and blood-pressure. Cognitive evaluation was performed using Stanford–Binet scale and Barkley Deficits in Executive Functioning (EF) Scale-Children and Adolescents. α-synuclein, fasting lipids and glucose were measured with calculation of the homeostatic model of insulin-resistance and estimated-glucose disposal rate.

Results

Children with obesity and those with T1D had significantly higher α-synuclein (p < 0.001) and total EF percentile (p = 0.001) than controls. α-synuclein was negatively correlated to total IQ (p < 0.001 and p = 0.001), and positively correlated with total EF percentile (p = 0.009 and p = 0.001) and EF symptom count percentile (p = 0.005 and p < 0.001) in children with T1D and obesity, respectively. Multivariate-regression revealed that α-synuclein was independently related to age (p = 0.028), diabetes-duration (p = 0.006), HbA1C% (p = 0.034), total IQ (p = 0.013) and EF symptom count percentile (p = 0.003) among children with T1D, and to diastolic blood-pressure percentile (p = 0.013), waist/hip ratio SDS (p = 0.007), total EF percentile (P = 0.033) and EF symptom count percentile (p < 0.001) in children with obesity.

Conclusion

α-synuclein could have a mechanistic role in neurocognitive deficit among children with obesity and T1D.

Parent-Child Conflict Moderates the Relationship Between Executive Functioning and Child Disruptive Behaviors in Youth with T1D

Executive function (EF) skills, parent-child conflict, and high blood glucose (BG) may impact child externalizing behaviors. We examined these child and parent factors in families of 5-9 year olds with recent-onset type 1 diabetes (T1D). Parents (N = 125) reported child EF, child externalizing behaviors, and conflict regarding T1D-specific tasks. We used self-monitoring BG uploads to calculate the percentage of time children had high BG (> 180 mg/dl). We entered data into a moderated path analysis using MPlus8. The path analysis revealed a positive direct effect for parent-reported child EF and child externalizing behavior (p < .01). Further, T1D-specific conflict moderated the positive association between parent-reported child EF and child externalizing behaviors (p < .05). Early screening of child EF, externalizing behavior, and family conflict may be particularly important in the recent-onset period of T1D. The introduction of T1D-related conflict after diagnosis may impact child externalizing behavior and limited child EF skills that pre-date diagnosis.

Self-regulation in children with vocal fold nodules: A multilevel analysis

INTRODUCTION

Vocal fold nodules (VNs) represent the most common cause of voice disorders in children. Phonotrauma related to chronic, repetitive, intense vocal activity is often cited as the proximate cause of VNs. However, diminished self-regulation (SR) may predispose some children toward extreme phonotraumatic voice use, thereby contributing secondarily to their development. This case-control study examined the association between features of SR and VNs in children.

METHOD

Parents of children with VNs (N = 40, Age Mean = 7.5, SD = 2.03 years) and vocally normal, medical controls (VNCs; N = 40, Age Mean = 7.6, SD = 1.54 years) completed the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2; Gioia, Isquith, Guy & Kenworthy, 2015), an inventory that evaluates components of SR in children.

RESULTS

Children with VNs, as compared with the vocally normal control group, were described as (i) impulsive (i.e., scoring significantly worse on the Behavior Regulation Index, BRI; P < 0.001, Cohen's d = 0.86), and (ii) emotionally dysregulated (i.e., scoring significantly worse on the Emotional Regulation Index, ERI; P < 0.001, Cohen's d = 0.81).

CONCLUSIONS

Diminished SR in some children with VNs may contribute to phonotraumatic vocal behaviors and potentially attenuate the effectiveness of voice therapy.

Executive Functioning Predicts Adaptive Functioning and Self-Care Independence in Pediatric Sickle Cell Disease

OBJECTIVE

This study examined the impact of executive functioning (EF) on adaptive functioning and self-care independence in pre-transition youth with sickle cell disease (SCD).

METHODS

Thirty-four youth with SCD (ages 12-18 years) completed a brief neuropsychological battery and their caregivers completed questionnaires assessing adaptive functioning, EF behaviors, and independence in completing self-care tasks, including disease management. Hierarchical linear regression analyses were utilized to investigate if EF predicted significantly more variability in adaptive functioning and self-care independence than what is accounted for by socioeconomic status (SES), disease knowledge, and estimated intellectual functioning.

RESULTS

Mean performance on standardized measures assessing working memory, processing speed, and EF skills fell in the low average range. Performance-based EF and caregiver-reported EF behaviors predicted variance in adaptive functioning and self-care independence above and beyond that accounted for by SES, disease knowledge, and intelligence, with moderate to large effect sizes.

CONCLUSIONS

EF skills may support the ability of youth with SCD to adequately achieve independence in self-care, including medical self-care, and other adaptive skills, which may increase the likelihood of successful transition to young adulthood. These findings provide support for the role of neuropsychological screening and individualized intervention in interdisciplinary transition programs.

College students' knowledge and management of food allergies

This study explored predictors of food allergy management in college students, including participants' reported allergy severity, history of allergic reactions, and allergy knowledge. Further, we compared allergy knowledge in participants with food allergy to a matched sample of college students without food allergy. Method: Participants were recruited from a larger nationwide study of knowledge and attitudes toward food allergy in college students, with purposeful oversampling of students with food allergies. Participants completed measures assessing their food allergy(ies), symptoms, history of reactions, and current allergy management behaviors. Participants with food allergies and control participants without food allergies completed a measure of food allergy knowledge. Results: Hierarchical regression revealed that food allergy knowledge accounted for an additional 20% of variance in students' allergy management behaviors, above and beyond severity and allergic reactions, R²=.39, F(3,48)=10.09, p<.001. There was not a statistically significant difference in food allergy knowledge between participants with food allergy and matched controls, t(49)=-1.85, p=.07, 95% CI=-1.42 to 0.06. Conclusions: This study suggests allergy knowledge is an important factor in food allergy management. Knowledge significantly predicted food allergy management behaviors above and beyond food allergy severity and recent food allergy reactions. College students with food allergies did not demonstrate greater knowledge than controls, suggesting a need for psychoeducational intervention to target college students' allergy knowledge as they transition to independent allergy management.

Dual diagnosis of type 1 diabetes mellitus and attention deficit hyperactivity disorder

BACKGROUND

Data regarding glycemic control in children and adolescents with a dual diagnosis of type 1 diabetes mellitus (T1DM) and attention-deficit/hyperactivity disorder (ADHD) are limited.

OBJECTIVE

To compare various aspects of diabetes control among youth with T1DM, between those with and without ADHD.

METHODS

In this cross-sectional study of youth with T1DM, 39 had ADHD (mean age 14.1 ± 2.8 years) and 82 did not (control group, mean age 12.6 ± 3.3 years). Health-related quality of life was assessed by a Diabetes Quality of Life (DQOL) questionnaire submitted to their parents. Glycemic data were downloaded from glucometers, pumps, and continuous glucose monitoring systems. HbA1c levels, hospitalizations, and severe hypoglycemic and diabetes ketoacidosis events were retrieved from the medical files.

RESULTS

Compared to the control group mean HbA1c level of the ADHD group was higher: 8.3 ± 1.1% versus 7.7 ± 1.0% (p = 0.005) and the percent of time that glucose level was in the target range (70-180 mg/dl) was lower: 48 ± 17% versus 59 ± 14% (p = 0.006). Mean glucose and glucose variability were higher in the ADHD group. Youth with ADHD who were not pharmacologically treated had worse HbA1c and more hospitalizations than those who were treated. DQOL did not differ between the control group, the treated ADHD group, and the untreated ADHD-Group.

CONCLUSIONS

Dual diagnosis of T1DM and ADHD during childhood leads to worse diabetes control, which is more pronounced in the context of untreated ADHD. Healthcare providers should be aware of the difficulties facing youth with T1DM and ADHD in coping with the current intensive treatment of diabetes.

Executive function mediates the link between externalizing behavior and HbA1c in children and adolescents with type 1 diabetes: A cross-national investigation

OBJECTIVE

Externalizing behavior (i.e., conduct problems, hyperactivity) and executive function (EF) problems in children and adolescents with type 1 diabetes (T1D) have been associated with worse diabetes-related and psychosocial outcomes but have not been examined in relationship to each other. We aimed to examine whether externalizing behavior is associated with HbA1c and whether this relationship is mediated by EF problems, specifically metacognition (i.e., ability to initiate, plan, organize and monitor behavior) and behavioral regulation (i.e., impulse control, regulation of emotion and behavior).

RESEARCH DESIGN AND METHODS

Cohorts of Belgian and Dutch parents of children and adolescents (6-18 years) with T1D filled out questionnaires on externalizing behavior (Strengths and Difficulties Questionnaire; SDQ) and EF (Behavior Rating Inventory of Executive Function; BRIEF) composite scales. Treating physicians collected HbA1c values. Mediation analyses were performed separately for the BRIEF composite Metacognition and Behavior Regulation scales, correcting for age, sex and diabetes duration.

RESULTS

The 335 parents of children and adolescents with T1D (mean age 12.3 ± 2.8 SD; mean HbA1c 7.6% ± 1.1 SD [60 mmol/mol ± 12.0 SD]; mean diabetes duration 5.3 ± 3.6 SD; 49.6% female) participated. Analyses showed that the association between externalizing behavior and HbA1c is mediated by metacognition (ab path Point estimate = 0.05 BCa CI 95% 0.02-0.08), and not behavioral regulation.

CONCLUSIONS

Results uncovered the influence externalizing behavior may have on EF problems in the metacognition domain, which in turn seem to influence HbA1c. Clinicians should be mindful of these EF problems when working with children and adolescents displaying externalizing behavior, and not only target behavioral but also cognitive processes.

The Relationship Between Executive Functioning, Type 1 Diabetes Self-Management Behaviors, and Glycemic Control in Adolescents and Young Adults

PURPOSE OF REVIEW

Understanding barriers to self-management behaviors and glycemic stability may inform specific needs for behavior change in adolescents and young adults with type 1 diabetes (T1D). The current review aims to systematically synthesize the literature on the relationships between executive functioning, self-management, and A1C in adolescents and young adults with T1D. Fifteen studies were retained in the current review. Study quality assessment for the majority of the studies were "Fair" or "Good."

RECENT FINDINGS

This review highlights several advances in research design, including use of longitudinal designs, data from multiple informants, and use of objective measures. Adolescents and young adults reported that more executive functioning weaknesses were related to decreased self-management behaviors and higher A1C. The current review demonstrated that self-perceived executive functioning weaknesses negatively impact self-management behaviors and A1C. Future research is needed to determine the utility of objective measures in assessing the relationships between executive functioning, T1D self-management, and A1C.

Executive Functioning in Adolescents with Chronic Musculoskeletal Pain

Adolescents with chronic pain often suffer significant impairment in physical, emotional, and social domains. Surprisingly little is known about executive functioning (EF) in youth with chronic pain or how EF deficits may contribute to functional impairment. Study participants included 60 adolescents between the ages of 12 and 17 years (M = 14.57). Thirty participants with chronic musculoskeletal pain and 30 age- and gender-matched healthy controls were recruited from a large Midwestern children's hospital in the United States. Participants completed the Behavior Rating Inventory of Executive Functioning (BRIEF-2) as well as multiple measures of functional impairment across key domains: school, social, emotional (anxiety, depression), and physical. Adolescents with chronic musculoskeletal pain reported significantly greater EF impairment compared to healthy age- and gender-matched peers. Clinically elevated risk levels of impairment were reported across all aspects of EF, with many adolescents in the chronic pain group scoring above the clinical risk cut off for working memory (52%), inhibition (45%), and cognitive flexibility (38%). EF was also significantly related to functional impairment across all domains. Findings suggest that EF may have an impact across several critical domains of functioning for youth with chronic pain.

Brain Function Differences in Children With Type 1 Diabetes: A Functional MRI Study of Working Memory

Glucose is a primary fuel source to the brain, yet the influence of dysglycemia on neurodevelopment in children with type 1 diabetes remains unclear. We examined brain activation using functional MRI in 80 children with type 1 diabetes (mean ± SD age 11.5 ± 1.8 years; 46% female) and 47 children without diabetes (control group) (age 11.8 ± 1.5 years; 51% female) as they performed a visuospatial working memory (N-back) task. Results indicated that in both groups, activation scaled positively with increasing working memory load across many areas, including the frontoparietal cortex, caudate, and cerebellum. Between groups, children with diabetes exhibited reduced performance on the N-back task relative to children in the control group, as well as greater modulation of activation (i.e., showed greater increase in activation with higher working memory load). Post hoc analyses indicated that greater modulation was associated in the diabetes group with better working memory function and with an earlier age of diagnosis. These findings suggest that increased modulation may occur as a compensatory mechanism, helping in part to preserve working memory ability, and further, that children with an earlier onset require additional compensation. Future studies that test whether these patterns change as a function of improved glycemic control are warranted.

Use of Ecological Momentary Assessment to Measure Self-Monitoring of Blood Glucose Adherence in Youth With Type 1 Diabetes

OBJECTIVE

Daily self-monitoring of blood glucose (SMBG) is essential for type 1 diabetes management yet is challenging during adolescence. Ecological momentary assessment (EMA) is the repeated sampling of behaviors and experiences in real time in the natural environment. The purpose of this study was to evaluate 1) the validity of self-reported SMBG values via text message-delivered EMA surveys compared with objective SMBG values via glucose meters and 2) in-the-moment motivators and barriers to performing SMBG in a pediatric type 1 diabetes population.

METHODS

Youth (n = 62, aged 11-21 years) with type 1 diabetes received three text messages daily for 10 days containing surveys inquiring about SMBG engagement. Objective SMBG values were downloaded from glucose meters.

RESULTS

On average, participants reported performing SMBG 4 times/day. Of the self-reported SMBG values, 39.6% were accurate. Inaccurate values included additions (i.e., self-reported value with no objective value), omissions (i.e., objective value with no self-reported value), and alterations (difference between self-report and objective SMBG values ≥10 mg/dL). Of the matched pairs of self-reported and objective SMBG values, 41.3% were altered. Bland-Altman plots determined that the mean difference between self-reported and objective glucose data were -5.43 mg/dL. Participants reported being motivated to check their blood glucose because it was important for their health, and reported barriers included wanting to ignore the task, forgetting, and not having devices.

CONCLUSION

Youth's self-reported SMBG values may not align with objective readings. The results of this study can facilitate future research to determine individual factors related to SMBG and accuracy of self-reporting.

Sleep, self-management, neurocognitive function, and glycemia in emerging adults with Type 1 diabetes mellitus: A research protocol

Type 1 Diabetes (T1D) affects 1.6 million Americans, and only 14% of emerging adults ages 18-25 years achieve targets for glycemic control (A1C < 7.0%). Sleep deficiency, including habitual short sleep duration (<6.5 hr total sleep time and high within-person variability in total sleep time), is associated with poorer glycemic control. Emerging adults with T1D have a more pronounced sleep extension on weekends compared with matched controls, consistent with sleep deficiency; however, associations among sleep variability and glycemic control have not been explored in this population. Sleep deficiency may affect the complex higher-order neurocognitive functioning needed for successful diabetes self-management (DSM). We report the protocol for an ongoing study designed to characterize sleep and the associations among sleep deficiency, neurocognitive function, DSM, diabetes quality of life, and glycemia among a sample of 40 emerging adults with T1D. We monitor sleep via wrist-worn actigraphy and glucose via continuous glucose monitoring concurrently over 14 days. We are collecting data on self-report and objective sleep, a 10-min psychomotor vigilance test on a PVT-192 device, a 3-min Trail Making Test on paper, and questionnaires, including twice-daily Pittsburgh sleep diaries using Research Electronic Data Capture (REDCap)^TM . Results from this study will be used to support the development and testing of the efficacy of a tailored sleep self-management intervention that may improve total sleep time, sleep variability, neurocognitive function, DSM, glycemic control, and glucose variability among emerging adults with T1D.

An artificial intelligence decision support system for the management of type 1 diabetes

Type 1 diabetes (T1D) is characterized by pancreatic beta cell dysfunction and insulin depletion. Over 40% of people with T1D manage their glucose through multiple injections of long-acting basal and short-acting bolus insulin, so-called multiple daily injections (MDI)^1,2. Errors in dosing can lead to life-threatening hypoglycaemia events (<70 mg dl^-1) and hyperglycaemia (>180 mg dl^-1), increasing the risk of retinopathy, neuropathy, and nephropathy. Machine learning (artificial intelligence) approaches are being harnessed to incorporate decision support into many medical specialties. Here, we report an algorithm that provides weekly insulin dosage recommendations to adults with T1D using MDI therapy. We employ a unique virtual platform³ to generate over 50,000 glucose observations to train a k-nearest neighbours⁴ decision support system (KNN-DSS) to identify causes of hyperglycaemia or hypoglycaemia and determine necessary insulin adjustments from a set of 12 potential recommendations. The KNN-DSS algorithm achieves an overall agreement with board-certified endocrinologists of 67.9% when validated on real-world human data, and delivers safe recommendations, per endocrinologist review. A comparison of inter-physician-recommended adjustments to insulin pump therapy indicates full agreement of 41.2% among endocrinologists, which is consistent with previous measures of inter-physician agreement (41-45%)⁵. In silico^3,6 benchmarking using a platform accepted by the United States Food and Drug Administration for evaluation of artificial pancreas technologies indicates substantial improvement in glycaemic outcomes after 12 weeks of KNN-DSS use. Our data indicate that the KNN-DSS allows for early identification of dangerous insulin regimens and may be used to improve glycaemic outcomes and prevent life-threatening complications in people with T1D.

Attentional bias to diabetes cues mediates disease management improvements in a pilot randomized controlled trial for adolescents with type 1 diabetes

For type 1 diabetes management, the role of attentional bias remains unclear. This secondary analysis examined type 1 diabetes attentional bias and adolescent type 1 diabetes management prior to and during a cognitive and behavioral intervention. Youth with type 1 diabetes and above target glycemic control were assigned to intervention or usual care control. Participants completed baseline and follow-up type 1 diabetes Stroop tasks, HbA1c tests, and blood glucose meter downloads. Intervention was associated with greater reductions in type 1 diabetes attentional bias than control, and these reductions partially mediated the effect of treatment on diabetes management behaviors. Type 1 diabetes attentional bias is a potential target to improve type 1 diabetes management.

Executive Functions and Adherence to Continuous Glucose Monitoring in Children and Adolescents with Type 1 Diabetes

Background: Continuous glucose monitoring (CGM) has a beneficial impact on diabetes control; however, its utilization within people with diabetes remains low. The success of CGM requires cluster of cognitive skills and executive functions (EF). We speculated that participants with high EF would be more adherent to CGM use. Materials and Methods: The study population included 85 children and adolescents between 5 and 18 years old being followed for type 1 diabetes. Participants and their parents completed three questionnaires-"Behavior Rating Inventory of Executive Function" (BRIEF), CGM satisfaction, and a questionnaire assessing reasons for discontinuing CGM use. Results: Sixty-one participants used CGM on a regular basis and 24 discontinued use. Adherent participants were significantly younger than participants with nonadherence to CGM (P = 0.011). No significant differences were found between gender, diabetes duration, or HbA1c. Females adhering to CGM had a significantly higher "organization of environment" skill than those with nonadherence to CGM (P = 0.023). Also, adherent participants older than 14 years had a higher "organization of environment" skill than participants with nonadherence to CGM (P = 0.032). No difference was found between the groups in other EF domains. Alarm fatigue was found to be the main reason for discontinuing CGM. Conclusions: Given the interplay between CGM adherence and EF, it is recommended that people with diabetes should receive training by a multidisciplinary team, including psychological counseling, before CGM use and thus preparing them to cope with the demands of CGM and to avoid false expectations.

Executive Cognitive Functions and Behavioral Control Differentially Predict HbA1c in Type 1 Diabetes across Emerging Adulthood

OBJECTIVES

To examine the contributions of two aspects of executive functioning (executive cognitive functions and behavioral control) to changes in diabetes management across emerging adulthood.

METHODS

Two hundred and forty-seven high school seniors with type 1 diabetes were assessed at baseline and followed up for 3 years. The baseline assessment battery included performance-based measures of executive cognitive functions, behavioral control, IQ estimate (IQ-est), and psychomotor speed; self-report of adherence to diabetes regimen; and glycated hemoglobin (HbA1c) assay kits as a reflection of glycemic control.

RESULTS

Linear and quadratic growth curve models were used to simultaneously examine baseline performance on four cognitive variables (executive cognitive functions, behavioral control, IQ, and psychomotor speed) as predictors of indices of diabetes management (HbA1c and adherence) across four time points. Additionally, general linear regressions examined relative contributions of each cognitive variable at individual time points. The results showed that higher behavioral control at baseline was related to lower (better) HbA1c levels across all four time points. In contrast, executive cognitive functions at baseline were related to HbA1c trajectories, accounting for increasingly more HbA1c variance over time with increasing transition to independence. IQ-est was not related to HbA1c levels or changes over time, but accounted instead for HbA1c variance at baseline (while teens were still living at home), above and beyond all other variables. Cognition was unrelated to adherence.

CONCLUSIONS

Different aspects of cognition play a different role in diabetes management at different time points during emerging adulthood years.

Adolescent Interventions to Manage Self-Regulation in Type 1 Diabetes (AIMS-T1D): randomized control trial study protocol

BACKGROUND

Self-regulation (SR), or the capacity to control one's thoughts, emotions, and behaviors in order to achieve a desired goal, shapes health outcomes through many pathways, including supporting adherence to medical treatment regimens. Type 1 Diabetes (T1D) is one specific condition that requires SR to ensure adherence to daily treatment regimens that can be arduous and effortful (e.g., monitoring blood glucose). Adolescents, in particular, have poor adherence to T1D treatment regimens, yet it is essential that they assume increased responsibility for managing their T1D as they approach young adulthood. Adolescence is also a time of rapid changes in SR capacity and thus a compelling period for intervention. Promoting SR among adolescents with T1D may thus be a novel method to improve treatment regimen adherence. The current study tests a behavioral intervention to enhance SR among adolescents with T1D. SR and T1D medical regimen adherence will be examined as primary and secondary outcomes, respectively.

METHODS

We will use a randomized control trial design to test the impact of a behavioral intervention on three SR targets: Executive Functioning (EF), Emotion Regulation (ER), and Future Orientation (FO); and T1D medical regimen adherence. Adolescents with T1D (n = 94) will be recruited from pediatric endocrinology clinics and randomly assigned to treatment or control group. The behavioral intervention consists of working memory training (to enhance EF), biofeedback and relaxation training (to enhance ER), and episodic future thinking training (to enhance FO) across an 8-week period. SR and treatment regimen adherence will be assessed at pre- and post-test using multiple methods (behavioral tasks, diabetes device downloads, self- and parent-report). We will use an intent-to-treat framework using generalized linear mixed models to test our hypotheses that: 1) the treatment group will demonstrate greater improvements in SR than the control group, and 2) the treatment group will demonstrate better treatment regimen adherence outcomes than the control group.

DISCUSSION

If successful, SR-focused behavioral interventions could improve health outcomes among adolescents with T1D and have transdiagnostic implications across multiple chronic conditions requiring treatment regimen adherence.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03688919; registered September 28, 2018.

Sleep-related disorders in patients with type 1 diabetes mellitus: current insights

Type 1 diabetes mellitus (T1DM) is an autoimmune condition that results from destruction of beta cells in the pancreas. Several reviews have concluded that sleep contributes to poor glycemic control, diabetes management, and diabetes-related complications in individuals with T1DM and represents an untapped opportunity for intervention. However, at the current juncture, the American Diabetes Association's Standards of Medical Care are devoid of recommendations about how to address sleep in the management of T1DM. This article summarizes reviews of sleep in youth and adults with T1DM and empirical studies that have examined various sleep parameters ranging from sleep disturbances (general, perceived sleep quality, sleepiness, awakenings, and sleep efficiency), sleep duration, sleep consistency, sleep-disordered breathing (SDB), and sleep architecture. The data show that many individuals with T1DM sleep less than recommendations; individuals with the poorest sleep have difficulties with diabetes management; and sleep deficiency including SDB often corresponds to several disease morbidities (neuropathy, nephropathy, etc). Mixed findings exist regarding direct associations of various sleep parameters and glycemic control. SDB appears to be just as prevalent, if not more, than other conditions that have been recommended for universal screening in individuals with T1DM. The article concludes with recommendations for collaborative research efforts to further elucidate the role of sleep in diabetes-related outcomes; investigations to test behavioral strategies to increase sleep quantity and consistency; and considerations for clinical care to address sleep.

Executive Function and Dysregulated Eating Behaviors in Pediatric Obesity

Objective

To examine the association between caregiver proxy report of executive function (EF) and dysregulated eating behavior in children with obesity.

Methods

Participants were 195 youth with obesity aged 8-17 years, and their legal guardians. Youth height, weight, demographics, depressive symptoms, eating behaviors, and EF were assessed cross-sectionally during a medical visit. Analyses of covariance, adjusted for child age, gender, race/ethnicity, standardized BMI, depressive symptoms, and family income were used to examine differences in youth EF across caregiver and youth self-report of eating behaviors.

Results

Youth EF differed significantly by caregiver report of eating behavior but not youth self-report. Post hoc analyses showed that youth with overeating or binge eating had poorer EF than youth without these eating behaviors.

Conclusions

Executive dysfunction, as reported by caregivers, in youth with obesity may be associated with dysregulated eating behaviors predictive of poor long-term psychosocial and weight outcomes. Further consideration of EF-specific targets for assessment and intervention in youth with obesity may be warranted.

Problems With Self-Regulation, Family Conflict, and Glycemic Control in Adolescents Experiencing Challenges With Managing Type 1 Diabetes

Objective

This study explored the associations between problems with self-regulation and glycemic control (HbA1c) in teens experiencing challenges with managing type 1 diabetes by examining greater diabetes-related family conflict and poorer adherence as serial mediators of the link between greater problems with self-regulation and higher HbA1c.

Methods

Teens experiencing challenges with managing type 1 diabetes (n = 93, HbA1c ≥8%, 96% White, 57% male) completed an HbA1c test, and their parents completed assessments including measures of adherence and family conflict related to diabetes management during an intake for a larger Web-based intervention study or fMRI study. Teen problems with self-regulation were indexed the Child Behavior Checklist using the dysregulation profile.

Results

Bivariate correlations found significant associations between greater problems with self-regulation, greater family conflict about diabetes management, poorer adherence, and higher HbA1c. However, only greater family conflict, and not adherence, significantly explained the association between greater self-regulation problems and higher HbA1c.

Conclusions

These findings suggest that among teens experiencing challenges with managing type 1 diabetes, interventions that decrease family conflict may be critical to promoting optimal glycemic control in those teens with greater problems with self-regulation.

A Web-Delivered Multicomponent Intervention for Adolescents with Poorly Controlled Type 1 Diabetes: A Pilot Randomized Controlled Trial

Background

Type 1 diabetes is associated with significant mortality and economic cost. Management of type 1 diabetes involves completing multiple daily adherence behaviors, and many adolescents struggle with self-management and show poor glycemic control.

Purpose

The purpose was to conduct an unblinded pilot randomized controlled parallel-group study of a web-delivered multicomponent intervention targeting self-monitoring of blood glucose, working memory, and parent supervision of diabetes care among adolescents with type 1 diabetes. Intervention components included high magnitude incentives for adolescents and parents, motivational and cognitive behavioral therapy and working memory training for adolescents, and training in contingency contracting for parents.

Methods

Adolescents (N = 114) with poorly controlled type 1 diabetes were screened, and N = 61 were randomized using minimum likelihood allocation to usual care (usual care, N = 31) or to a 25-week/15-session web-delivered intervention (WebRx, N = 30).

Results

At the end of treatment, adolescents in WebRx had higher self-monitoring of blood glucose (d = 0.58) (primary outcome), better visual spatial working memory (d = 0.48) and inhibition (d = 0.98), and lower HbA1c (d = 0.45) than those in usual care. WebRx parents reported more frequent review of the adolescent's glucometer (d = 1.30) and reduced family conflict (d = 0.56). Between-condition differences were maintained 6 months later in self-monitoring of blood glucose (d = 0.42), visual spatial working memory (d = 0.76), family conflict (d = 0.50), and HbA1c (d = 0.44).

Conclusions

Results showing sustained effects on self-monitoring of blood glucose and HbA1c support moving forward with a larger trial to test this innovative web-delivered and multicomponent intervention. ClinicalTrials.gov Number (NCT01722643).

Family Functioning, Medical Self-Management, and Health Outcomes Among School-Aged Children With Sickle Cell Disease: A Mediation Model

Background

Informed by the Pediatric Self-Management Model, the present study tested relationships between parent and family functioning, sickle cell disease (SCD) self-management, and health outcomes for children with SCD.

Method

83 children with SCD and a parent completed baseline data as part of a larger investigation of a family-based, problem-solving intervention for children with SCD (M age = 8.47). Youth and parents completed a measure of child health-related quality of life (HRQOL), and parents completed measures of family efficacy, parenting stress, and SCD self-management. SCD pain episodes and urgent health utilization information over the past year were obtained via medical chart review.

Results

SCD self-management mediated the relationship between parent-reported family efficacy and parent proxy HRQOL, as well as the relationship between parenting stress and child and parent proxy HRQOL. Mediation models were nonsignificant for outcomes beyond HRQOL, including SCD pain episodes and urgent health utilization.

Conclusion

Fostering family efficacy and reducing parenting stress may be meaningful intervention targets for improving SCD self-management and child HRQOL among school-aged children. Although findings were consistent with the Pediatric Self-Management Model in terms of HRQOL, the model was not supported for pain episodes or urgent health utilization, highlighting the need for multi-method, longitudinal research on the SCD self-management behaviors that are linked to preventable health outcomes.

Epilepsy Journey: A proof of concept trial of a Web-based executive functioning intervention for adolescents with epilepsy

OBJECTIVE

To examine the preliminary feasibility and acceptability of a Web-based program, Epilepsy Journey, to improve executive function behaviors in adolescents with epilepsy.

METHODS

We conducted a proof of concept single-arm pilot trial of Epilepsy Journey with 31 adolescents (average age = 15.3 ± 1.3 years) who had an epilepsy diagnosis and executive function (EF) deficits on the caregiver-report version of the Behavior Rating Inventory of Executive Function (BRIEF). Epilepsy Journey coupled a gamified problem-solving website comprised of 10 learning modules targeting EF deficits (eg, working memory, organization, problem-solving) with Skype sessions with a trained therapist. Outcomes included feasibility (attrition, sessions completed) and acceptability (satisfaction ratings). Exploratory analyses examined changes in caregiver-, self-, and teacher-reported BRIEF scores from baseline to posttreatment and at 2- and 5-month follow-ups.

RESULTS

Seventy-nine percent of participants completed the program. Satisfaction was high, with 97% of caregivers and adolescents rating the program as helpful and indicating they would recommend it to others. Caregivers and adolescents reported global improvements on the BRIEF, with caregivers reporting significant improvements on all BRIEF subscales. EF symptoms rebounded slightly between the 2- and 5-month follow-ups for some of the self- and caregiver-reported BRIEF scales. Notably, clinically meaningful improvements (eg, clinical/subclinical to normative levels) were reported for several caregiver-reported BRIEF subscales, including the Global Executive Composite (62% to 33-34%) and Metacognitive Index (74% to 41-42%) from baseline to 2- and 5-month follow-up.

SIGNIFICANCE

Findings suggest that a Web-based problem-solving intervention tailored to EF deficits for adolescents with epilepsy is both feasible and acceptable and may contribute to improvements in EF behaviors across domains.

Socioeconomic Inequality in Metabolic Control Among Children With Type 1 Diabetes: A Nationwide Longitudinal Study of 4,079 Danish Children

OBJECTIVE

To examine inequality in glycemic control by maternal educational level among children with type 1 diabetes in a setting with universal access to health care.

RESEARCH DESIGN AND METHODS

This was a longitudinal nationwide study of 4,079 Danish children with type 1 diabetes between the years 2000 and 2013. Children were divided into four groups based on mothers' education prebirth (≤high school [n = 1,643], vocational or 2-year college [n = 1,548], bachelor's degree [n = 695], ≥master's degree [n = 193]). Means of socioeconomic and treatment characteristics were compared between groups. HbA_1c and the number of daily glucose tests were compared repeatedly from onset until 5 years after onset across groups. HbA_1c was compared across daily blood glucose testing frequency and groups. Linear regression was used to compare HbA_1c across groups with and without adjustment for socioeconomic and treatment characteristics.

RESULTS

Large differences in HbA_1c across maternal education were found. The mean level of HbA_1c during follow-up was 59.7 mmol/mol (7.6%) for children of mothers with ≥master's degrees and 68.7 mmol/mol (8.4%) for children of mothers with ≤high school (difference: 9.0 mmol/mol [95% CI 7.5, 10.6]; 0.8% [95% CI 0.7, 1.0]). The associations were attenuated but remained significant after adjustment. Observable characteristics explained 41.2% of the difference in HbA_1c between children of mothers with ≤high school and mothers with ≥master's degree; 22.5% of the difference was explained by more frequent blood glucose monitoring among the children with the highly educated mothers.

CONCLUSIONS

Family background is significantly related to outcomes for children with type 1 diabetes, even with universal access to health care.

The Empowerment of Adolescents with Type 1 Diabetes Is Associated with Their Executive Functions

Background

Adolescence is a difficult period for young people with type 1 diabetes mellitus (T1DM), both in psychological and clinical terms. Empowerment therapy may support these patients, provided they are ready to change and have adequate executive functions to facilitate this change. Therefore, we hypothesise that the readiness of adolescents with T1DM to change is related to clinical features and/or their executive functions.

Methods

Using the Diabetes Empowerment Scale and the Behavioural Rating Inventory of Executive Function, we evaluated patients with T1DM duration of more than one year from three Polish diabetes centres of the PolPeDiab study group (N = 146). We related the data to features associated with disease and treatment and compared the results to those of adolescents without diabetes (N = 110).

Results

We observed that adolescents with T1DM had a higher rate of abnormal results in executive function tests than their peers without diabetes (p > 0.05). Diabetes empowerment in this group of patients decreased with disease duration (r = -0.25, p = 0.006) and increased with deteriorating metabolic control (HbA1c; r = 0.25, p = 0.006). The greater the deficiencies in executive functions among adolescents with T1DM, the greater their readiness to change. The relationship between executive functions and diabetes empowerment is partially gender-differentiated.

Conclusions

To conclude, we propose individualized diabetes education in this group of patients based on the assessment of readiness to change and executive functions.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effect of type 1 diabetes on the developing brain

The effect of type 1 diabetes on the developing brain is a topic of primary research interest. A variety of potential dysglycaemic insults to the brain can cause cellular and structural injury and lead to altered neuropsychological outcomes. These outcomes might be subtle in terms of cognition but appear to persist into adult life. Age and circumstance at diagnosis appear to play a substantial role in potential CNS injury. A history of diabetic ketoacidosis and chronic hyperglycaemia appear to be more injurious than previously suspected, whereas a history of severe hypoglycaemia is perhaps less injurious. Neurocognitive deficits manifest across multiple cognitive domains, including executive function and speed of information processing. Some evidence suggests that subtle brain injury might directly contribute to psychological and mental health outcomes. Impaired executive function and mental health, in turn, could affect patients' adherence and the ability to make adaptive lifestyle choices. Impaired executive functioning creates a potential feedback loop of diabetic dysglycaemia leading to brain injury, further impaired executive function and mental health, which results in suboptimal adherence, and further dysglycaemia. Clinicians dealing with patients with suboptimal glycaemic outcomes should be aware of these potential issues.

Sleep characteristics in young adults with type 1 diabetes

Only 14% of young adults with Type 1 Diabetes (T1D) achieve targets for glycemic control (HbA1C < 7.0%), with deterioration over time. Complex cognitive processes required to manage glycemia are vulnerable to sleep deficiency. Using Whittemore and Knafl's approach, we conducted an integrative review of research literature on sleep characteristics and glycemia in these young adults. Quality was assessed using the Mixed Methods Appraisal Tool (v. 2011). Multiple databases were searched for articles published in English in peer-reviewed journals from 2003 to 2018, using search terms 'sleep' and 'T1D' with age limiters 18-40. Of 218 studies initially retrieved, 17 original studies met the inclusion criteria. The following themes were identified in young adults with T1D: (1) They had poorer objective and subjective sleep quality, more variability, and impaired awakening response to hypoglycemia compared with controls; (2) They had poorer glycemic control that was associated with shorter sleep duration, poorer sleep quality, and less time in deep sleep; and (3) Hypoglycemia negatively impacted diabetes management, sleep quality, and next day functioning. Sleep deficiency, as indicated by short sleep duration is associated with a range of negative health outcomes for people with T1D; therefore, optimizing sleep should be a priority in practice and research.

Executive function and somatic problems in adolescents with above target glycemic control

Adolescents with type 1 diabetes may be at elevated risk for somatic problems. This study used cross-sectional, baseline data from an intervention to examine if problems with executive function (EF) were associated with greater somatic problems independent of poor adherence and disease severity in adolescents with type 1 diabetes and above target glycemic control. In addition, it examined whether certain types of EF skills, that is, metacognitive and behavior regulation, accounted for variance in somatic problems. Ninety-three adolescents completed a glycated hemoglobin (HbA1c) blood test and parents completed adherence, somatic problems, and EF questionnaires, which measured metacognitive, behavior regulation, and global EF. Greater somatic problems had significant bivariate associations with greater global (r = 0.42, P < 0.01), metacognitive (r = 0.43, P < 0.01), and behavior regulation EF problems (r = 0.31, P < 0.01), worse adherence (r = -0.39, P < 0.01), and poorer metabolic control (r = 0.26, P < 0.05). However, when adherence, metabolic control, and EF subscales were examined together in the same model, only greater global EF problems (b = 0.15, P < 0.01) and metacognitive EF problems (b = 0.16, P < 0.01) were independently associated with greater somatic problems; behavior regulation EF problems were not independently associated with greater somatic problems when controlling for adherence. Metacognitive EF problems may predict somatic problems in adolescents with above target glycemic control above and beyond physical symptoms related to disease management, underscoring the importance of proper assessment and treatment of these distinct somatic problems.

Youth With Type 1 Diabetes Taking Responsibility for Self-Management: The Importance of Executive Functioning in Achieving Glycemic Control: Results From the Longitudinal DINO Study

OBJECTIVE

Successful self-management of type 1 diabetes requires cognitive skills such as executive functioning (EF). In the transition to adolescence, youth take over responsibility for diabetes management. We set out to test: 1) the association between EF and glycemic control over time and 2) whether this association was moderated by: a) youth, shared, or parent responsibility for diabetes management and b) youth's age.

RESEARCH DESIGN AND METHODS

Within the Diabetes IN DevelOpment study (DINO), parents of youth with type 1 diabetes (8-15 years at baseline; N = 174) completed a yearly assessment over 4 years. Glycemic control (HbA_1c) was derived from hospital charts. Youth's EF was measured using the Behavior Rating Inventory of Executive Functioning (BRIEF)-parent report. The Diabetes Family Responsibility Questionnaire (DFRQ)-parent report was used to assess diabetes responsibility (youth, shared, and parent). Linear generalized estimating equations were used to analyze data including youth's sex, age, and age of diabetes onset as covariates.

RESULTS

Relatively more EF problems are significantly associated with higher HbA_1c over time (β = 0.190; P = 0.002). More EF problems in combination with less youth responsibility (β = 0.501; P = 0.048) or more parental responsibility (β = -0.767; P = 0.006) are significantly associated with better glycemic control over time. Only age significantly moderates the relationship among EF problems, shared responsibility, and glycemic control (β = -0.024; P = 0.019).

CONCLUSIONS

Poorer EF is associated with worse glycemic control over time, and this association is moderated by responsibility for diabetes management tasks. This points to the importance of EF when youth take over responsibility for diabetes management in order to achieve glycemic control.

Sleep and type 1 diabetes in children and adolescents: Proposed theoretical model and clinical implications

Youth with type 1 diabetes mellitus (T1D) experience more sleep disturbances and shorter sleep durations compared to their healthy peers. Researchers have now uncovered the negative mental health and physical health outcomes associated with poor sleep in youth with T1D. The field of T1D sleep research currently operates under the broad notion that sleep behaviors impact treatment adherence, which ultimately lead to worse long-term health outcomes. This model however does not explain how behavior influences T1D management and sleep outcomes on a day-to-day basis, leading to difficulties in providing tailored treatment recommendations. In this review, we present a theoretical framework that describes the recursive cycle between sleep behaviors, T1D outcomes, and symptoms of negative affect/stress over a 24-hour period. This model is guided by the sleep literature, showing a clear relationship between poor sleep and negative affect, and the T1D literature demonstrating a link between poor sleep and disease management for youth with T1D. Further, emerging literature indicates a need for additional parent sleep assessment considering that T1D management and fear of hypoglycemia negatively impact parent sleep behaviors. Recommendations are provided to move the field toward effective intervention studies and new areas of research to evaluate and modify the proposed model.

Adolescent Emotional Control Moderates Benefits of a Multicomponent Intervention to Improve Type 1 Diabetes Adherence: A Pilot Randomized Controlled Trial

Objective

We previously tested via randomized controlled trial a novel intervention for adolescents with type 1 diabetes and above-target glycemic control that combined web-delivered incentives for self-monitoring of blood glucose (SMBG) and brief web counseling with working memory training and parental contingency contracting training. Results showed improved SMBG and decreased glycosylated hemoglobin (HbA1c) at 6- and 12-month follow-ups. However, it has not been elucidated if improvements in SMBG mediated the immediate benefits of this treatment on HbA1c nor if this intensive intervention uniquely benefited a subgroup of adolescents with higher problems in emotional control.

Methods

Adolescents with type 1 diabetes and above-target glycemic control (n = 61) were randomized to receive the 6-month intervention (n = 30) or usual care (n = 31). Adolescents completed the Behavior Rating Inventory of Executive Function-Self-Report, problems with emotional control subscale at baseline, and provided meter downloads to assess frequency of SMBG and completed an HbA1c blood draw at baseline and 6 months later.

Results

At 6-month follow-up, improvements in SMBG mediated the effects of receiving the treatment on having lower average HbA1c. Further, problems in emotional control moderated the benefits of the intervention on improvements in SMBG and in turn HbA1c. Only adolescents with above average problems in emotional control evidenced improvements in SMBG in response to treatment, which then explained lower HbA1c levels at 6-month follow-up.

Conclusions

This multicomponent, web-delivered intervention provided unique benefits for improving SMBG and lowering HbA1c in teens with higher problems in emotional control.

Poor Metabolic Control in Children and Adolescents With Type 1 Diabetes and Psychiatric Comorbidity

OBJECTIVE

Type 1 diabetes is associated with an increased risk of psychiatric morbidities. We investigated predictors and diabetes outcomes in a pediatric population with and without psychiatric comorbidities.

RESEARCH DESIGN AND METHODS

Data from the Danish Registry of Childhood and Adolescent Diabetes (DanDiabKids) and National Patient Register were collected (1996-2015) for this population-based study. We used Kaplan-Meier plots to investigate whether age at type 1 diabetes onset and average glycated hemoglobin (HbA_1c) levels during the first 2 years after onset of type 1 diabetes (excluding HbA_1c at debut) were associated with the risk of being diagnosed with a psychiatric disorder. Mixed-effects linear and logistic regression models were used to analyze HbA_1c, BMI, severe hypoglycemia (SH), or ketoacidosis as outcomes, with psychiatric comorbidities as explanatory factor.

RESULTS

Among 4,725 children and adolescents with type 1 diabetes identified in both registers, 1,035 were diagnosed with at least one psychiatric disorder. High average HbA_1c levels during the first 2 years predicted higher risk of psychiatric diagnoses. Patients with psychiatric comorbidity had higher HbA_1c levels (0.22% [95% CI 0.15; 0.29]; 2.40 mmol/mol [1.62; 3.18]; P < 0.001) and an increased risk of hospitalization with diabetic ketoacidosis (1.80 [1.18; 2.76]; P = 0.006). We found no associations with BMI or SH.

CONCLUSIONS

High average HbA_1c levels during the first 2 years after onset of type 1 diabetes might indicate later psychiatric comorbidities. Psychiatric comorbidity in children and adolescents with type 1 diabetes increases the risk of poor metabolic outcomes. Early focus on the disease burden might improve outcomes.

Executive Function Predicting Longitudinal Change in Type 1 Diabetes Management During the Transition to Emerging Adulthood

OBJECTIVE

The objective of this study was to examine 1) whether teens' glycemic control and adherence to type 1 diabetes treatment regimen worsen during the transition from late adolescence to emerging adulthood, and 2) whether teens' executive function (EF), as measured by performance and self-reported problems with EF, is predictive of these changes (after controlling for general intelligence).

RESEARCH DESIGN AND METHODS

High school seniors with type 1 diabetes (N = 236; mean age 17.74 years) were assessed at three yearly time points. At baseline, during the senior year of high school, participants completed a self-report measure of problems with EF and performance-based measures of EF and general intelligence (IQ). Glycemic control was determined on the basis of results collected from HbA1c assay kits, and teens reported their adherence at all three time points.

RESULTS

HbA1c increased significantly across the three time points and adherence declined. EF performance was not associated with adherence or HbA1c at baseline, nor with changes in adherence over time. However, better EF performance predicted slower increases in HbA1c over time (i.e., slope) while controlling for IQ. Teens' self-reported problems with EF were associated with worse glycemic control and poorer adherence at baseline (i.e., intercept), but they did not predict changes in either HbA1c or adherence over time (i.e., slope).

CONCLUSIONS

Abilities involved in performance on EF tests may be one resource for maintaining better glycemic control during the transition to emerging adulthood. Assessment of such EF abilities may allow for the identification of individuals who are most at risk for deterioration of glycemic control during this transition.

Previously undiagnosed attention-deficit/hyperactivity disorder associated with poor metabolic control in adolescents with type 1 diabetes

BACKGROUND

Managing modern diabetes treatment requires efficient executive functions. Patients with attention-deficit/hyperactivity disorder (ADHD) and type 1 diabetes have poor metabolic control and present with ketoacidosis more often than patients without ADHD.

OBJECTIVE

To assess whether patients with type 1 diabetes and with indications of executive problems met criteria for ADHD, and to investigate whether these patients had difficulties achieving metabolic control.

METHODS

In a hospital-based study, including 3 pediatric departments at hospitals in Stockholm and Uppsala, Sweden, questionnaires regarding executive problems had been filled out by 12- to 18-year-old patients with type 1 diabetes and their parents. Out of 166 patients with completed questionnaires, 49 were selected for a clinical study due to reported executive problems/ADHD symptoms. However, 7 already had a diagnosis of ADHD, 21 denied follow-up, 8 did not respond, leaving 13 adolescents for the clinical assessment.

RESULTS

Of the clinically assessed adolescents, 9 (6 girls) met criteria for ADHD. Patients who did not respond to the follow-up and patients who were diagnosed with ADHD within the study, showed to a larger extent than the other study groups high HbA1c levels (>70 mmol/mol, 8,6%). HbA1c >70 mmol/mol (8.6%) was associated with diagnosed ADHD (prior to or within the study), odds ratio 2.96 (95% confidence interval 1.02-8.60).

CONCLUSION

Patients with type 1 diabetes and poor metabolic control should be assessed with regard to ADHD. There is a need for paying special attention to girls with poor metabolic control.

Altered Brain Dynamics in Patients With Type 1 Diabetes During Working Memory Processing

It is now generally accepted that diabetes increases the risk for cognitive impairment, but the precise mechanisms are poorly understood. A critical problem in linking diabetes to cognitive impairment is that patients often have multiple comorbidities (e.g., obesity, hypertension) that have been independently linked to cognitive deficits. In the study reported here we focused on young adults with and without type 1 diabetes who were virtually free of such comorbidities. The two groups were matched on major health and demographic factors, and all participants completed a verbal working memory task during magnetoencephalographic brain imaging. We hypothesized that patients would have altered neural dynamics in verbal working memory processing and that these differences would directly relate to clinical disease measures. Accordingly, we found that patients had significantly stronger neural responses in the superior parietal cortices during memory encoding and significantly weaker activity in parietal-occipital regions during maintenance compared with control subjects. Moreover, disease duration and glycemic control were both significantly correlated with neural responses in various brain regions. In conclusion, young healthy adults with type 1 diabetes already have aberrant neural processing relative to their peers without diabetes, using compensatory responses to perform the task, and glucose management and duration may play a central role.

A Systematic Review and Meta-analysis of Executive Function Performance in Type 1 Diabetes Mellitus

OBJECTIVE

The aims of the study were to examine the current evidence for executive function (EF) performance differences between groups with type 1 diabetes mellitus (T1DM) and nondiabetic control groups during adolescence and early adulthood and to explore the relationships between EF and diabetes-related risk factors.

METHODS

A systematic review of the literature examining EF performance in groups with T1DM was conducted according to the PRISMA guidelines. Electronic database searches for published and unpublished literature yielded a final set of 26 articles after application of inclusion and exclusion criteria. A meta-analysis was conducted on a subset of these articles (n = 17) comparing EF performance in T1DM and control groups, across a total sample size of 1619.

RESULTS

Sixteen of 26 studies found significantly lower EF on at least one task in groups with T1DM. Meta-analyses of the performance difference between T1DM groups and control groups without diabetes showed that inhibition (g = -0.28, p < .001), working memory (g = -0.34, p < .001), set-shifting (g = -0.31, p = .012), and overall EF performance across these domains (g = -0.42, p < .001) were all significantly lower in groups with T1DM. Performance on specific EF domains also seemed to be differentially associated with early age of diabetes onset, chronic hyperglycemia and its complications, and severe hypoglycemia.

CONCLUSIONS

T1DM and its associated risk factors are related to subtle impairments across the inhibition, working memory, and set-shifting domains of EF. Lower EF may be a key factor contributing to behavioral and clinical problems experienced by individuals with T1DM.