Screening for diabetes distress and depression in routine clinical care for youth with type 1 diabetes

OBJECTIVE

The purpose of this study is to examine diabetes distress as a potential mediator of the relationship between depression symptoms and diabetes outcomes, including hemoglobin A1c (hemoglobin A1c [HbA1c]) and diabetes management behaviors in a clinical sample of adolescents and young adults.

METHODS

In a pediatric diabetes clinic, 716 youth (ages 12-21 years) completed measures of diabetes distress (Problem Areas in Diabetes-Teen [PAID-T]), a single-item of diabetes distress, and depression (Patient Health Questionnaire [PHQ-9]) as part of standard care. Electronic health records were extracted for the "Six Habits" and glycemic management (HbA1c).

RESULTS

Overall, 3.6% (n = 26) of adolescents had clinically elevated diabetes distress and depression symptoms, 5.0% had diabetes distress alone, 8.7% had depression symptoms alone, and 82.7% had neither clinical elevation of diabetes distress nor depression symptoms. Results of mediation analysis demonstrated diabetes distress (both full and single-item measures) fully mediated the relationship between depression symptoms and HbA1c (p < .001). Also, mediation analysis results showcase incomplete mediation of the effect of the Six Habits score on HbA1c appears by PAID-T Diabetes Distress.

CONCLUSIONS

In a clinical sample of youth with type 1 diabetes, both depressive symptoms and diabetes distress are associated with HbA1c. Furthermore, diabetes distress fully mediates the relationship between depressive symptoms and HbA1c. As part of standard clinical care, the single-item screener for diabetes distress captured similar results as the full-scaled PAID-T. With limited clinical resources, providers may consider focusing assessment and interventions on the psychological factor of diabetes distress within the diabetes clinic to maximize the impact on glycemic control and consider the use of single-item screening to identify distress.

Psychosocial Interventions for Children and Young People With Visible Differences Resulting From Appearance-Altering Conditions, Injury, or Treatment Effects: An Updated Systematic Review

OBJECTIVE

Children and young people with visible differences can experience psychosocial difficulties, such as anxiety and teasing by others. Interventions targeting difficulties have previously been reviewed by Jenkinson et al. This review aimed to identify and critically assess recent studies evaluating the effectiveness of psychosocial interventions for children and young people with visible differences on psychosocial wellbeing, self-esteem, and social experiences and compare the findings with Jenkinson et al. using a replacement review process.

METHODS

Inclusion criteria are as follows: studies with participants aged 0-18 years with visible differences; investigating a psychosocial intervention; including comparison with an alternative intervention, control group, or pre- and post-intervention; and including a quantitative measure assessed pre- and post-intervention. Exclusion criteria are as follows: participants with body dysmorphic disorder or appearance changes due to eating disorders or obesity and studies not written in English. MEDLINE, AMED, and PsycInfo were searched and grey literature was included. Results were reviewed against eligibility criteria, data were extracted, and studies were evaluated using the Cochrane Risk of Bias 2 tool.

RESULTS

Using Jenkinson et al. as one source of studies, 24 studies were included evaluating a range of interventions such as social interaction skills training, residential social camps, and cognitive behavioral therapy. Risk of bias was high in 20 studies and of some concern in four studies.

CONCLUSION

There is some evidence of the effectiveness of hypnotherapy, a relaxation response resiliency program, integrative body-mind-spirit group, and therapeutic patient education, but more rigorous research is needed to confirm their impact on psychosocial outcomes.

Parent Perspectives of School/Daycare Experiences in Young Children Newly Diagnosed With Diabetes

OBJECTIVE

A central part of family adjustment to a new diagnosis of type 1 diabetes (T1D) is integrating T1D management into the child's school/daycare. This may be particularly challenging for young children who rely on adults for their diabetes management. This study aimed to describe parent experiences with school/daycare during the first 1.5 years following a young child's T1D diagnosis.

METHODS

As part of a randomized controlled trial of a behavioral intervention, 157 parents of young children with new-onset (<2 months) T1D reported on their child's school/daycare experience at baseline and at 9- and 15-month post-randomization. We used a mixed-methods design to describe and contextualize parents' experiences with school/daycare. Qualitative data were collected via open-ended responses, and quantitative data were collected from a demographic/medical from.

RESULTS

While most children were enrolled in school/daycare at all time points, over 50% of parents endorsed that T1D affected their child's enrollment, rejection, or removal from school/daycare at 9 or 15 months. We generated five themes related to parents' school/daycare experiences: Child factors, Parent factors, School/Daycare factors, Cooperation between Parents and Staff, and Socio-historical factors. Parents of younger children and those with lower subjective socioeconomic status were significantly more likely to endorse challenges with school/daycare enrollment.

CONCLUSIONS

School/daycare settings present challenges for parents of young children with T1D. Changes may need to occur across contexts to support early childhood education, including advocacy resources for parents to navigate school policies, increased training for school staff, and healthcare team outreach initiatives to parents and schools.

Findings from a Randomized Controlled Trial of SMART: An EHealth Intervention for Mild Traumatic Brain Injury

OBJECTIVE

The aim of this study was to examine the efficacy of the SMART (Self-Management After Recent Traumatic brain injury) program and potential moderators.

METHODS

Parallel randomized controlled trial (ClinicalTrials.gov Identifier: NCT03498495) was conducted. Eligibility criteria included treatment for mild traumatic brain injury in the emergency department and age 11-18 years. Participants were assigned equally to SMART (n = 35) or usual care (UC; n = 36). SMART included symptom monitoring and online modules supporting the return to activities and symptom management. Coping and quality of life (QoL) (primary outcomes) and post-concussive symptoms (secondary outcome) were assessed at baseline and weekly for 4 weeks.

RESULTS

Groups did not differ in coping, QoL, or return to pre-injury symptom levels at any time point. Problem-focused engagement (PFE) moderated group differences over time (p = .02). At high PFE, UC participants reported lower QoL at time 1 (effect size [ES] = 0.60); SMART participants did not report a decline at any point. At low PFE, SMART participants reported declining QoL from pre-injury to time 1 (ES = 0.68), whereas UC participants reported an increase from time 1 to 3 (ES = 0.56). PFE also moderated group differences on the Health and Behavior Inventory (HBI) cognitive (p = .02) and somatic symptom scales (p = .05). At high PFE, SMART participants reported a more rapid return to pre-injury levels than UC participants (p = .05). Resilience also moderated group differences in QoL and HBI cognitive recovery.

CONCLUSION

Effectiveness of the SMART app varied based on preinjury coping styles and resilience, underscoring the potential need to tailor treatments to individual characteristics.

A Scoping Review and Proposed Framework for Coping in Youth With a History of Psychological Trauma and Chronic Pain

OBJECTIVE

Psychological trauma (e.g., abuse, neglect) and posttraumatic stress symptoms (PTSS) commonly occur in pediatric pain populations and may be related to various maladaptive coping strategies, which may in turn affect short- and long-term pain-related outcomes in youth. Accordingly, the current scoping review and conceptual framework seeks to identify important gaps in the field's current understanding of how coping impacts outcomes in youth who have experienced trauma/PTSS and pediatric chronic pain and explores avenues for future investigation.

METHODS

A scoping review of the literature was performed in Medline, Embase, Cochrane Library, PsycInfo, and Sociological Abstracts. Eligibility criteria included pediatric populations experiencing chronic pain, trauma, adverse childhood events, and/or PTSS and associated coping mechanisms. Nine research papers were selected and used to support the conceptual framework. The framework builds upon the work of Compas et al.'s' model of control-based coping (Compas et al., 2006; Compas & Harding Thomsen, 1999) and outlines the potential effects of trauma and/or PTSS and pain on coping and pain-related outcomes (e.g., pain chronicity, functional outcomes) in pediatric chronic pain populations.

RESULTS

A history of chronic pain and psychological trauma and/or PTSS in youth may contribute to increased risk for maladaptive coping and in turn, poorer pain-related and psychosocial outcomes long-term.

CONCLUSIONS

Findings from the current scoping review and proposed conceptual framework will guide future research and treatment efforts for youths experiencing pain and trauma and/or PTSS and thereby enhance long-term outcomes.

Parents' Experiences of Their Child's Solid-Organ Transplant: A Meta-Ethnography of Qualitative Studies

OBJECTIVE

The aim of this paper was to conduct a systematic review and meta-ethnography of qualitative studies examining the experiences of parents adjusting to life after the solid organ transplant (SOT) of their child.

METHODS

A systematic review of the literature was conducted to identify qualitative studies that examined this topic. The search retrieved 4,964 studies to review against inclusion criteria. A total of 21 studies were included in the meta-ethnography. A reciprocal translation was conducted to compare themes identified in each study. A line of argument synthesis was then conducted in order to integrate the similarities and differences between all of the studies into a new interpretative context.

RESULTS

The synthesis identified four themes: (a) adjusting to life after transplant, (b) factors that facilitate adjustment, (c) factors that disrupt adjustment, and (d) changes caused by transplant. As a result of the synthesis, a new interpretation of parents' experiences of adjusting to life after the SOT of their child was constructed. A summary figure is presented.

CONCLUSION

This review found that while parents may struggle to adapt to life post-transplant and the demands of caring for their child, the experience can also result in the development of new skills, a new appreciation for life, and viewing the self in a more positive manner. A better understanding of parental experiences will promote the development of more effective interventions for the adjustment of parents and families to post-transplant life.

Coping Trajectories and the Health-Related Quality of Life of Childhood Cancer Survivors

OBJECTIVE

To identify coping trajectories from diagnosis through survivorship and test whether particular trajectories exhibit better health-related quality of life (HRQOL) at 5 years post-diagnosis.

METHODS

Families of children with cancer (ages 5-17; M = 10.48, SD = 4.03) were recruited following a new diagnosis of cancer (N = 248). Three follow-up assessments occurred at 1-year (N = 185), 3-years (N = 101), and 5-years (N = 110). Mothers reported on children's coping using the Responses to Stress Questionnaire for Pediatric Cancer. Survivor HRQOL was measured at 5-year follow-up using self-report on the PedsQL 4.0. Longitudinal patterns of coping were derived using Latent Class Growth Analysis and mean-levels of survivor-report HRQOL were compared across classes.

RESULTS

Two primary control coping trajectories emerged, "Moderate and Stable" (50%) and "Low-moderate and Decreasing" (50%), with no significant differences in HRQOL across trajectories. Three secondary control coping trajectories emerged, "Moderate-high and Increasing" (54%), "Moderate and Stable" (40%), and "High and Increasing" (6%), with survivors in the last trajectory showing better HRQOL. Two disengagement coping trajectories emerged, "Low and Stable" (85%) and "Low and Variable" (15%), with no significant differences in HRQOL across trajectories.

CONCLUSIONS

Coping trajectories were relatively stable from diagnosis to 5 years. A small group of survivors with high and increasing secondary control coping over time, per mother-report, reported better HRQOL. Future research should consider tailoring coping interventions to children with cancer to improve survivors' HRQOL.

Psychosocial Functioning Among Caregivers of Childhood Cancer Survivors Following Treatment Completion

OBJECTIVE

To inform efforts to better support caregivers of children with cancer during the transition from treatment to survivorship, this study sought to characterize caregiver mental health-related quality of life (HRQOL) and anxiety, and examine the influence of family psychosocial risk and caregiver problem-solving on these outcomes.

METHOD

Participants included 124 caregivers (child age M = 10.05 years; SD = 4.78), 12-19 months from the conclusion of cancer-directed treatment. Participants' self-reported mental HRQOL, anxiety, and problem-solving were compared with community norms using t-tests. Correlations and hierarchical multiple regressions examined the influence of psychosocial risk and problem-solving on caregiver mental HRQOL and anxiety.

RESULTS

Overall, caregivers reported HRQOL and anxiety within normal limits. Caregivers also reported more adaptive patterns of problem-solving than community norms. Subsets of caregivers reported clinical levels of psychosocial risk (11%) and at-risk levels of mental HRQOL (2.5%) and anxiety (5.7%). Females reported greater anxiety than males. Psychosocial risk and negative problem orientation (NPO) were both related to poorer mental HRQOL and greater anxiety (r = .40-.51, p's < .001). Positive problem orientation related to better mental HRQOL and lower anxiety (r = .18-.21, p's < .05). Impulsivity/carelessness and avoidance were associated with greater anxiety (r = .19-.25, p's < .05). Only NPO accounted for additional variance in mental HRQOL and anxiety, over and above psychosocial risk and demographic characteristics.

CONCLUSIONS

The majority of caregivers appear to be resilient and experience limited distress during the off therapy period. Targeting negative cognitive appraisals (NPO) through cognitive-behavioral therapy or problem-solving skills training may further improve caregiver psychosocial functioning.

Caregiver Religious Coping and Posttraumatic Responses in Pediatric Hematopoietic Stem Cell Transplant

OBJECTIVE

Caregivers often experience their child's hematopoietic stem cell transplant (HCT) treatment as traumatic. Although many caregivers develop posttraumatic stress symptoms (PTSS) in response to supporting their child through HCT, other caregivers demonstrate posttraumatic growth (PTG). Religious coping may contribute to these different adjustment trajectories; however, more information is needed to clarify the unique associations of positive versus negative religious coping on caregiver PTSS and PTG in the context of pediatric HCT. This study aimed to examine the relationships between negative and positive religious coping on caregivers PTSS and PTG while controlling for caregiver sex, self-efficacy, and social support.

METHODS

Caregivers (N = 140) of youth admitted to the hospital for their first HCT were asked to complete self-report measures of their use of positive and negative religious coping, PTSS, PTG, social support, and self-efficacy. Two hierarchical linear regressions were conducted to test hypotheses.

RESULTS

Greater positive religious coping, but not negative religious coping, was associated with caregivers reporting more PTG in response to pediatric HCT. More negative religious coping, but not positive religious coping, was associated with caregivers experiencing greater PTSS.

CONCLUSIONS

Engaging in positive religious coping appears to promote better caregiver adjustment to pediatric HCT, whereas negative religious coping may increase caregiver risk for developing PTSS. Screening caregivers' religious beliefs, including the type of religious coping they employ, could inform providers regarding the best approach to supporting caregivers towards a growth trajectory and mitigate PTSS.

Children's Pain During IV Induction: A Randomized-Controlled Trial With the MEDi® Robot

OBJECTIVE

This study examined the impact of a humanoid robot (MEDi®) programmed to teach deep breathing as a coping strategy, on children's pain and fear as primary and secondary outcomes, respectively, during intravenous (IV) line placement. The completion of IV induction was also examined as an exploratory outcome.

METHODS

In this randomized controlled, two-armed trial, 137 children (4-12 years) were recruited in Short Stay Surgery at a tertiary pediatric hospital. Patients were randomly assigned to standard care (SC) with Ametop© only (N = 60) or SC and robot-facilitated intervention (N = 59) before induction. Pain and fear before, during, and after IV insertion were rated by patients and observers.

RESULTS

No significant differences were found between groups and there were no changes over time for pain or fear (ps > .05). Exploratory analyses show that patients in the MEDi® group were 5.04 times more likely to complete IV induction, compared to SC, Fisher's exact test: X2 (1) = 4.85, p = .04, φc = 0.22, odds ratio = 5.04, 95% CI [1.06, 24.00].

CONCLUSION

This study was the first to examine children's IV induction experience when provided MEDi® support. Reasons for nonsignificance, limitations, and research suggestions were made.

The Cyclical Relation Between Chronic Pain, Executive Functioning, Emotional Regulation, and Self-Management

OBJECTIVE

To propose a new model outlining a hypothesized cyclical relation between executive functioning, emotional regulation, and chronic pain in adolescence and to highlight the likely importance of such a relation for self-management behavior and pain-related disability.

METHODS

A review of the existing literature that critically explores the role of executive functioning in understanding chronic pain experiences and self-management in adolescence in order to develop the Cyclical model Of Pain, Executive function, emotion regulation, and Self-management (COPES).

RESULTS

Growing evidence points towards a potential cyclical relation between chronic pain and impaired executive functioning, which forms the basis of COPES. The COPES model proposes that the relative immaturity of executive functioning in adolescence negatively influences their ability to engage with self-management, which in turn increases adolescents' disability due to pain and contributes to the maintenance of chronic pain, which perpetuates the reduced capacity of executive functioning. The moderating influence of flexible parental support is hypothesized to offset some of these influences. However, the available evidence is limited due to methodological shortcomings such as large variety in executive functioning operationalization, reliance on self-report and cross-sectional designs.

CONCLUSIONS

It is anticipated that the COPES model will stimulate more systematic, theory-driven research to further our understanding of the links between executive functioning, chronic pain, self-management, and wellbeing. Such enhanced understanding has the potential to drive forward intervention development and refinement aimed at improving self-management uptake and adherence amongst adolescents with chronic pain.

Reciprocal Links Between Physical Health and Coping Among Adolescents With Cystic Fibrosis

OBJECTIVE

Adolescents with cystic fibrosis (CF) often face a unique set of difficulties and challenges as they transition to adulthood and autonomy while also managing a progressive illness with a heavy treatment burden. Coping styles have been related to changes in physical health among youth with chronic illness more generally, but the directionality of these links has not been fully elucidated. Therefore, the objective of this study was to evaluate bidirectional links between coping styles and physical health indicators among adolescents with CF over time.

METHODS

Adolescents (N = 79, 54% female) recruited from inpatient and outpatient CF clinics at two sites completed questionnaires assessing secular and religious/spiritual coping styles at two time points (18 months apart, on average). Health indicators including pulmonary functioning, nutritional status, and days hospitalized were obtained from medical records.

RESULTS

More frequent hospitalizations predicted lower levels of adaptive secular coping over time. However, poorer pulmonary functioning predicted higher levels of positive religious/spiritual coping. The number of days hospitalized was related to adaptive secular coping and negative religious/spiritual coping.

CONCLUSIONS

Among youth with CF, physical health functioning is more consistent in predicting coping strategies than the reverse. Poorer pulmonary functioning appears to enhance adaptive coping over time, suggesting resilience of adolescents with CF, while more frequent hospitalizations may inhibit the use of adaptive coping strategies. Findings support the use of interventions aimed at promoting healthy coping among hospitalized adolescents with CF.

Randomized Trial of a Positive Psychology Intervention for Adolescents With Type 1 Diabetes

OBJECTIVE

To evaluate the effects of a positive psychology intervention for adolescents with type 1 diabetes (T1D) on adherence, glycemic control, and quality of life.

METHODS

Adolescents with T1D (n = 120) and their caregivers were randomized to either an Education (EDU) (n = 60) or Positive Affect (PA) intervention (n = 60). Adolescents in the PA group received the intervention reminders (gratitude, self-affirmation, parental affirmation, and small gifts) via text messages or phone calls over 8 weeks. Questionnaires were completed by adolescents and caregivers and clinical data (glucometer and HbA1c) were collected at baseline 3 and 6 months. Data were analyzed using generalized linear modeling.

RESULTS

After adjusting for covariates, adolescents in the PA group demonstrated significant improvement in quality of life at 3 months, compared to the EDU group, but this was not sustained at 6 months. Similarly, the PA group showed a significant decrease in disengagement coping at 3 months but not at 6 months. There was no significant intervention effect on blood glucose monitoring, but the odds of clinically significantly improvement (checking at least one more time/day) were about twice as high in the PA group as the EDU group. No significant effects were found for glycemic control.

CONCLUSIONS

A positive psychology intervention had initial significant, positive effects on coping and quality of life in adolescents with T1D. A more intensive or longer-lasting intervention may be needed to sustain these effects and to improve adherence and glycemic control.

Development and Validation of the Parent-Preschoolers Diabetes Adjustment Scale (PP-DAS)

OBJECTIVE

This article extends work on a social-ecological model of caregiver adjustment and describes the: (a) development and (b) validation of the Parent-Preschoolers Diabetes Adjustment Scale (PP-DAS), a broad measure of caregiver adjustment.

METHODS

Participants were caregivers (nstudy1 = 51; nstudy2 = 177) of very young children (<6 years old) with Type 1 diabetes (T1D). In study 1, researchers and stakeholders collaborated to develop 92 items using the 5 domains of a social-ecological model of caregiver adjustment to the challenges of raising a very young child with T1D, and parents and researchers provided feedback on these items. In study 2, confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were used to examine the factor structure of the PP-DAS. Reliability and validity were also examined.

RESULTS

After review by parents and researchers, 52 items were removed resulting in the 40-item version used in study 2. The CFA demonstrated poor fit with the five proposed domains of the social-ecological model, so an EFA was conducted and supported a different five-factor solution. Twenty items were removed due to low factor loadings or communalities, resulting in a final 20-item measure. The PP-DAS demonstrated adequate internal consistency (α's = .73-.84), convergent validity with parent psychological functioning and self-efficacy in T1D management, and criterion validity with hemoglobin A1c and adherence.

CONCLUSIONS

The PP-DAS is a valid and reliable measure of adjustment in caregivers of very young children with T1D. The PP-DAS may help identify caregivers who are having adjustment difficulties and would benefit from additional support.

A Prospective Examination of Child Avoidance Coping and Parental Coping Assistance After Pediatric Injury: A Mixed-Methods Approach

OBJECTIVE

Millions of children experience injuries annually, and avoidance coping increases risk of negative emotional and physical outcomes after injury. Little is known about how children select avoidance coping strategies. Parents may help their children cope with an injury by encouraging or discouraging the use of specific strategies, such as avoidance coping. The present study examined parental influence of child use of avoidance coping post-injury.

METHODS

Children ages 8-13 (65% male; 50% White) hospitalized for pediatric injury and their parents (N = 96 child-parent dyads) participated in an interview and discussion task about coping at baseline, and then completed coping/coping assistance measures at three time points: T1 (within 2 weeks post-injury), T2 (6-weeks post-injury), and T3 (12-weeks post-injury).

RESULTS

When presented with an ambiguous situation in the observational interview and discussion task, the number of avoidance coping solutions offered by children independently as well as during a discussion with their parent predicted the child's ultimate avoidance versus non-avoidance coping choice. The number of avoidance coping solutions offered by parents did not predict children's final choice to use avoidance coping. Longitudinal data suggest that parent encouragement of avoidance coping predicted child avoidance coping within the first 6-weeks post-trauma.

CONCLUSIONS

Our study suggests that child avoidance coping is multifaceted and may result from both parent encouragement as well as independent decisions by children. Future research may explore additional factors that influence child avoidance coping, outside of parental suggestion, in response to trauma exposure.

Executive Functioning Mediates the Relationship Between Pain Coping and Quality of Life in Youth With Sickle Cell Disease

Objective

Sickle cell disease (SCD) is a lifelong condition characterized by pain, which is associated with reduced health-related quality of life (HRQL). Data suggest that patients with SCD vary in how they cope and their neurocognitive abilities. This study aimed to characterize executive functioning and pain coping styles in children with SCD experiencing a range of pain frequency (i.e., chronic, episodic, and asymptomatic) and to examine whether executive functioning mediates the relationship between pain coping and HRQL.

Method

Participants included 100 children and adolescents with SCD between the ages of 8 and 18 years (M = 13.53, SD = 2.8) and their parents who were recruited during outpatient SCD clinic visits in a children's hospital. Children completed questionnaires related to pain experience and pain coping. Parents completed questionnaires about demographic information, their child's executive functioning, and HRQL.

Results

Pain intensity, executive dysfunction, and engagement in emotion-focused coping (i.e., internalizing/catastrophizing and externalizing) predicted poor HRQL. In addition, engagement in emotion-focused coping predicted executive dysfunction. Multivariate analysis of covariance revealed executive functioning did not differ based on pain frequency; however, executive functioning was a significant mediator that helped explain the relationships between distraction and emotion-focused coping techniques on HRQL.

Conclusion

Findings support that executive functioning is an important factor in understanding the relationship between pain coping and HRQL in youth with SCD. Future research is warranted to examine the potential impact of executive functioning on the utility of interventions targeting adaptive pain coping in youth with SCD.

Topical Review: Resilience Resources and Mechanisms in Pediatric Chronic Pain

OBJECTIVE

To apply resilience theory and the extant literature to propose a resilience-risk model for pediatric chronic pain and provide an agenda for research and clinical practice in pediatric chronic pain resilience. 

METHOD

Literature review to develop a resilience-risk model for pediatric chronic pain.

RESULTS

The chronic pain literature has identified unique individual and social/environmental resilience resources and pain-related resilience mechanisms that promote pain adaptation. These data support our ecological resilience-risk model for pediatric chronic pain, and the model highlights novel directions for clinical and research efforts for youth with chronic pain.

CONCLUSIONS

The examination of pediatric chronic pain from a strengths-based approach might lead to novel clinical avenues to empower youth to positively adapt and live beyond their pain.