Alan M. Delamater

Psychological care of children and adolescents with diabetes

A substantial research base developed over the past four decades provides evidence for the significant role of psychosocial factors in the management of type 1 diabetes in children and adolescents (1–6). This chapter reviews the main findings from the studies of psychological adjustment, psychiatric disorders, neurocognitive and educational functioning, family dynamics, social support, stress and coping, quality of life, and behavioral interventions in children and adolescents with type 1 diabetes. Based on these research findings, recommendations for optimal psychological care are offered. The research base for the psychological care of young people with type 2 diabetes is sparse. Therefore, this chapter does not address type 2 diabetes specifically. The International Society of Pediatric and Adolescent Diabetes (ISPAD) Consensus Guidelines 2000 stated that ‘‘Psychosocial factors are the most important influences affecting the care and management of diabetes’’ and went on to make the following three general recommendations (7):

Executive Functioning, Treatment Adherence, and Glycemic Control in Children With Type 1 Diabetes

OBJECTIVE The primary aim of the study was to investigate the relationship among executive functioning, diabetes treatment adherence, and glycemic control. RESEARCH DESIGN AND METHODS Two hundred and thirty-five children with type 1 diabetes and their primary caregivers were administered the Diabetes Self-Management Profile to assess treatment adherence. Executive functioning was measured using the Behavior Rating Inventory of Executive Functioning and glycemic control was based on A1C. RESULTS Structural equation modeling indicated that a model in which treatment adherence mediated the relationship between executive functioning and glycemic control best fit the data. All paths were significant at P < 0.01. CONCLUSIONS These results indicate that executive functioning skills (e.g., planning, problem-solving, organization, and working memory) were related to adherence, which was related to diabetes control. Executive functioning may be helpful to assess in ongoing clinical management of type 1 diabetes.

Changes in Treatment Adherence and Glycemic Control During the Transition to Adolescence in Type 1 Diabetes

OBJECTIVE To test models of unidirectional and bidirectional change between treatment adherence and glycemic control in youth with type 1 diabetes. RESEARCH DESIGN AND METHODS We conducted a 2-year longitudinal, multisite study of 225 youth with type 1 diabetes recruited at the cusp of adolescence (aged 9–11 years) to describe the mutual influences of glycemic control as measured by HbA1c and treatment adherence as measured by blood glucose monitoring frequency (BGMF) during the transition to adolescence. RESULTS HbA1c increased from 8.2 to 8.6% (P < 0.001) and BGMF decreased from 4.9 to 4.5 checks per day (P < 0.02) during the 2-year period. Changes in the BGMF slope predicted changes in HbA1c. A change (increase) in HbA1c was associated with a change (decrease) in BGMF of 1.26 (P < 0.001) after controlling for covariates. CONCLUSIONS The magnitude of the effect of declining treatment adherence (BGMF) on glycemic control in young adolescents may be even greater than declines observed among older adolescents. BGMF offers a powerful tool for targeted management of glycemic control for type 1 diabetes during the critical transition to adolescence.

Twenty-First Century Behavioral Medicine: A Context for Empowering Clinicians and Patients With Diabetes A consensus report

In the past decades, the sophistication of treatments for diabetes has increased dramatically, and evidence for effective interventions has proliferated. As a result, it is now possible to achieve excellent glucose control and reduce the risk of many of the complications associated with the disease. Despite these advances, however, many people with diabetes have less than optimal metabolic control and continue to suffer from preventable complications. The gap between optimal evidence-based medicine and actual practice can be great, dependent not only on the ability of the clinician to make changes in practice patterns but also on the central role of the patient in implementing optimal management plans in daily life. With recognition of the centrality of patients’ actions to achieve optimal outcomes must come awareness that those actions reflect much more than simple “self-control.” In addition to individual characteristics, the environment in which behaviors are enacted has great influence, from family eating patterns to the design of neighborhoods to workplace and national health policies. For patients and clinicians, these factors create the context or environment in which behaviors are enacted. Diabetes provides a prime example of this fundamental interaction of individual characteristics with the ecological or contextual factors. For example, Pima Indians living in the U.S. have the highest prevalence of type 2 diabetes of any population in the world, yet Pimas living traditional lifestyles in Mexico have relatively low levels of diabetes. Ample evidence links genetics to diabetes within the Pima population, but exposure to an obesogenic environment is critical to expression of this very strong genetic propensity (1). This interplay between the individual and the context in which he or she behaves is commonly cited in discussions of personal health choices and health and social policies. These perspectives have shifted in …

Psychological care of children and adolescents with type 1 diabetes

Alan M Delamatera, Maartje de Witb, Vincent McDarbyc, Jamil Malikd and Carlo L Acerinie aDepartment of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA; bDepartment of Medical Psychology, EMGO Institute for Health & Care Research, VU University Medical Center, Amsterdam, Netherlands; cDepartment of Psychology, National Children’s Research Centre and Our Lady’s Children’s Hospital, Dublin, UK; dNational Institute of Psychology, Center of Excellence, Quaid-i-Azam University, Islamabad, Pakistan; and eDepartment of Paediatrics, University of Cambridge, Cambridge, UK

Internet Psycho-Education Programs Improve Outcomes in Youth With Type 1 Diabetes

OBJECTIVE The purpose of this study was to determine the efficacy of two Internet-based psycho-educational programs designed to improve outcomes for youth with type 1 diabetes transitioning to adolescence. RESEARCH DESIGN AND METHODS The study was a multisite clinical trial of 320 youth (aged 11–14 years; 37% minority; 55% female) randomized to one of two Internet-based interventions: TeenCope or Managing Diabetes. Primary outcomes were HbA1c and quality of life (QOL). Secondary outcomes included coping, self-efficacy, social competence, self-management, and family conflict. Data were collected at baseline and after 3, 6, and 12 months online. Youth were invited to cross over to the other program after 12 months, and follow-up data were collected at 18 months. Analyses were based on mixed models using intent-to-treat and per-protocol procedures. RESULTS Youth in both groups had stable QOL and minimal increases in HbA1c levels over 12 months, but there were no significant differences between the groups in primary outcomes. After 18 months, youth who completed both programs had lower HbA1c (P = 0.04); higher QOL (P = 0.02), social acceptance (P = 0.01), and self-efficacy (P = 0.03) and lower perceived stress (P = 0.02) and diabetes family conflict (P = 0.02) compared with those who completed only one program. CONCLUSIONS Internet interventions for youth with type 1 diabetes transitioning to adolescence result in improved outcomes, but completion of both programs was better than only one, suggesting that these youth need both diabetes management education and behavioral interventions. Delivering these programs via the Internet represents an efficient way to reach youth and improve outcomes.

ISPAD Clinical Practice Consensus Guidelines 2014. Psychological care of children and adolescents with type 1 diabetes.

Alan M Delamatera, Maartje de Witb, Vincent McDarbyc, Jamil Malikd and Carlo L Acerinie aDepartment of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA; bDepartment of Medical Psychology, EMGO Institute for Health & Care Research, VU University Medical Center, Amsterdam, Netherlands; cDepartment of Psychology, National Children’s Research Centre and Our Lady’s Children’s Hospital, Dublin, UK; dNational Institute of Psychology, Center of Excellence, Quaid-i-Azam University, Islamabad, Pakistan; and eDepartment of Paediatrics, University of Cambridge, Cambridge, UK

Adherence and Glycemic Control among Hispanic Youth with Type 1 Diabetes: Role of Family Involvement and Acculturation

OBJECTIVE To assess whether family involvement and acculturation were related to adherence and glycemic control among Hispanic youth with type 1 diabetes (T1D). METHODS Hispanic youth with T1D (n = 111; M age = 13.33; 53% female) and parents completed questionnaires that assessed diabetes-related family involvement (distribution of responsibility for diabetes, family support for diabetes), acculturation (linguistic acculturation, generational status), and adherence. HbA1c levels indexed glycemic control. RESULTS Better adherence was associated with less adolescent independent responsibility, more family support for diabetes, and more recent immigration (fewer generations of the family living in US). Family support mediated the relationship between responsibility and adherence. Better glycemic control was associated with higher levels of parental education and adherence. CONCLUSIONS Family support for diabetes is important for adherence among Hispanic youth with T1D. Research should examine aspects of recent immigration that contribute to better adherence and the impact of supportive interventions on diabetes care.

Obesity and Type 2 Diabetes in Children: Epidemiology and Treatment

The incidence of overweight and obesity among children has increased dramatically in recent decades, with about one-third of children in the U.S. currently being either overweight or obese. Being overweight in early childhood increases risk for later obesity. There is evidence for the efficacy of family-based behavioral treatment to control weight and improve health outcomes. Obesity-related health risks have been documented, including metabolic syndrome. There is also increasing incidence of type 2 diabetes (T2D) among youth in recent years, with obesity and family history of T2D generally present. Lower income and ethnic minority status are associated with both obesity and T2D in youth. Most youth with T2D do not achieve optimal glycemic control, and are at high risk for later health complications. Obesity and T2D represent significant public health issues with potentially great personal and societal cost. Research addressing the prevention of obesity and T2D among youth is urgently needed.

Parental self-efficacy and morbidity in pediatric asthma.

This study investigated the relationship between parental self-efficacy and asthma-related morbidity. Participants included 139 parents of children (ages 5–8) who were diagnosed with asthma and were primarily from lower-income and minority backgrounds. Parents completed a 22-item measure of self-efficacy; factor analysis was conducted on this measure, yielding two factors: learned helplessness and self-efficacy. Correlational analyses indicated that higher scores on the learned helplessness factor were significantly related to increased asthma-related morbidity for the majority of morbidity variables. The self-efficacy factor was significantly related to days of school missed. Regression analyses conducted with the factor scores and the morbidity variables provide further support that the learned helplessness factor accounts for a significant amount of the variance in asthma morbidity for many of the variables studied, while the self-efficacy factor was related to only a few. Although improving health outcomes of children with asthma is a multifaceted process, the results of this study suggest that targeting parental self-efficacy, particularly with parents who are experiencing high levels of perceived learned helplessness, may be a helpful component of an intervention program with this population.