Clarissa S. Holmes

Cognitive Function in Children With Type 1 Diabetes A meta-analysis

OBJECTIVE—To quantify the magnitude and pattern of cognitive difficulties in pediatric type 1 diabetes as well as the effects associated with earlier disease onset and severe hypoglycemia. RESEARCH DESIGN AND METHODS—Pediatric studies of cognitive function since 1985 were identified for study inclusion using MEDLINE and PsycInfo. Effect size (ES, Cohens d) between the diabetic and control groups, expressed in SD units, were calculated within cognitive domains to standardize meta-analysis test performance. RESULTS—The meta-analysis sample of 2,144 children consisted of 1,393 study subjects with type 1 diabetes and 751 control subjects from 19 studies. Overall, type 1 diabetes was associated with slightly lower overall cognition (ES −0.13), with small differences compared with control subjects across a broad range of domains, excluding learning and memory, which were similar for both groups. Learning and memory skills, both verbal and visual (−0.28 and −0.25), were more affected for children with early-onset diabetes (EOD) than late-onset diabetes (LOD), along with attention/executive function skills (−0.27). Compared with nondiabetic control subjects, EOD effects were larger, up to one-half SD lower, particularly for learning and memory (−0.49). Generally, seizures were associated with a negligible overall cognition ES of −0.06, with slight and inconsistent cognitive effects found on some measures, possibly reflecting the opposing effects of poorer versus better metabolic control. CONCLUSIONS—Pediatric diabetes generally relates to mildly lower cognitive scores across most cognitive domains. Cognitive effects are most pronounced and pervasive for EOD, with moderately lower performance compared with control subjects. Seizures are generally related to nominal, inconsistent performance differences.

Verbal Fluency and Naming Performance in Type I Diabetes at Different Blood Glucose Concentrations

The effect of serum glucose alterations on selected verbal skills was examined in a group of diabetic men between 18 and 35 yr of age. An artificial insulin infusion system was used to set and maintain glucose concentrations during testing at each of three levels: hypoglycemia (55 mg/dl), euglycemia (110 mg/dl), and hyperglycemia (300 mg/dl). Subjects were used as their own controls, with performance at euglycemia serving as the comparison standard. A double-blind crossover design was employed as described in Holmes et al. (see ref. 14). Results showed significantly disrupted naming or labeling skills at hypoglycemia, with a trend toward poorer performance at hyperglycemia. During hypoglycemia, rate of responding was slowed from 6% to 18%, compared with euglycemic performance, but accuracy was not impaired. In contrast, word recognition skills were not affected by deviations in glucose. These performance effects were not correlated with duration of disease except for one of the five tests administered. This one exception, on the most difficult task, was less notable than the general finding of no relation between disease duration (from 6 mo to 17.5 yr) and test performance. Thus, in addition to considering long-term consequences of blood glucose alterations, clinicians and diabetic patients may wish to consider acute neuropsychological consequences of disrupted euglycemia.

Sociodemographic Risk Factors to Disease Control in Children with Diabetes

This study examined the effects of sociodemographic variables such as ethnicity, socioeconomic status (SES), and family structure on disease control in 58 children with diabetes stratified by ethnicity and SES. Three dependent variables were chosen to evaluate the disease control of the study participants, including HbA1 values averaged over the year prior to study participation, number of hospitalizations, and number of hypoglycaemic blackouts. SES and family structure, but not ethnicity, were the primary risk factors to disease control. Children from low SES families were in poorer glycaemic control (mean HbA1 = 12.6 %) and experienced more episodes of hypoglycaemia‐related loss of consciousness (mean = 0.5 per patient) than did children from middle income families (mean HbA1 = 10.4 %; mean blackouts = 0.1 per patient). In addition, children from middle‐class, two‐parent families were in better metabolic control than all other groups. These results indicate that it may not be ethnicity per se, but other factors that often covary with ethnic status, that may pose a risk to the disease status of children and adolescents with diabetes.

Social and school competencies in children with short stature: longitudinal patterns.

Longitudinal evaluation of 47 children with short stature secondary to growth hormone deficiency (GHD), constitutional delay (CD), and Turners syndrome (TS) was undertaken approximately 3 years after initial assessment. Parent ratings of social and school competence indicated a developmental trend of poorer adjustment during early adolescence (ages 12 and 14), which was preceded (age 9) and followed (age 17) by age-appropriate functioning. Evaluation of social competence scores suggested that large organized group activities were avoided, although children had close friends with whom they interacted regularly. Children with short stature obtained age-expected scores for their involvement in solitary activities (i.e., hobbies and household chores) and tended to participate in individual sports (i.e., fishing, swimming), consistent with a pattern of withdrawal from large groups. Younger children with CD evidenced academic functioning at least 1 SD higher than children from all other groups, and this age-related effect may explain performance inconsistencies reported previously with other groups of CD children. Of the children studied, girls with TS experienced the greatest academic difficulty.

A Profile of Self-Care Behaviors in Emerging Adults With Type 1 Diabetes

Purpose The purpose of this study is to characterize daily diabetes self-care behaviors and to evaluate associations among self-care behaviors, psychosocial adjustment, and glycemic control in an understudied sample of emerging adults with type 1 diabetes. Methods Forty-nine emerging adults (65% women; ages 18-26 years) completed 2 diabetes interviews to assess self-care behaviors and self-report measures of psychosocial adjustment. Glycemic control was assessed via hemoglobin A1C. Results Diabetes self-care behaviors varied widely and were largely suboptimal; only a small percentage of participants demonstrated self-care behaviors consistent with national and international recommendations. Psychosocial adjustment was within normal limits and was unrelated to frequency of self-care behaviors in this sample. Mean glycemic control (8.3%) was higher than the recommended A1C level (< 7.0%) for this age group. Use of intensive (eg, multiple daily injections or pump) insulin regimens was related to better glycemic control. Conclusions The majority of emerging adults in this sample did not engage in optimal daily diabetes self-care. Intensive insulin therapy was associated with better glycemic control without corresponding psychosocial distress. Diabetes care behaviors could be improved in this age group, and emerging adults may benefit from targeted education and behavioral support to enhance diabetes self-management and optimize health outcomes.

Sociodemographic effects on biological, disease care, and diabetes knowledge factors in youth with type 1 diabetes:

Sociodemographic risk factors place youth with type 1 diabetes at higher risk for immediate and long-term health complications, yet research has still to disentangle the confounding effects of ethnicity, socioeconomic status (SES), and parental marital status. Group-oriented and variable-oriented analyses were conducted to investigate sociodemographic differences in biological, disease care, and diabetes knowledge factors in youth with type 1 diabetes. The sample included 349 youth, age 9–17 years (79.9% Caucasian, 71.3% lived with two biological parents, M SES = 46.24). Group t-tests confirmed commonly reported ethnic differences in HbA1c and disease care behaviors. However, variable-oriented analyses controlling for confounding sociodemographic influences showed most disease care effects attributed to ethnicity were better explained by SES. Results may inform development of diabetes literacy programs that integrate culturally sensitive lifestyle and language components for families of youth at risk of poor metabolic control.

Maternal depressive symptoms and disease care status in youth with type 1 diabetes.

OBJECTIVE The current study assessed relations among maternal depressive symptoms, poorer youth diabetes adherence, and glycemic control. Specifically, hypothesized mediating links of lowered expectations of parental involvement, less parental monitoring, and more conflict were examined. METHOD Participants included 225 mothers and their young adolescents, aged 11-14 years (M = 12.73 years, SD = 1.2) diagnosed with T1D. Maternal depressive symptoms and outcome expectancies for maternal involvement were evaluated with self-report questionnaires. Multisource, parent/youth, and multimethod assessment of adherence, parental monitoring, and conflict were evaluated during a baseline assessment from a larger randomized clinical trial. RESULTS The first hypothesized structural equation model demonstrated a good fit and indicated that more maternal depressive symptoms were directly associated with less parental monitoring and more conflict, which in turn each were associated with poorer adherence and glycemic control. Although higher involvement expectancies were associated with more monitoring and less conflict, they were not associated with other model variables. A second alternative model also fit the data well; poorer youth adherence was associated with more conflict that in turn related to maternal depressive symptoms. CONCLUSIONS Two models were tested by which maternal depressive symptoms and poorer youth adherence were interrelated via less monitoring and more conflict. Follow-up longitudinal evaluation can best characterize the full extent of these relations.

Factor structure of the Wide Range Assessment of Memory and Learning (WRAML) in children with insulin dependent diabetes mellitus (IDDM).

Maximum likelihood confirmatory factor analysis was performed with the Wide Range Assessment of Memory and Learning (WRAML) for a clinical sample of 246 children with insulin-dependent diabetes mellitus (IDDM). Consistent with previous literature examining the factor structure of the WRAML, findings supported the validity of a three-factor model including Verbal Memory, Visual Memory, and Attention/Concentration (AC) factors for this clinical sample. However, in contrast to previous factor analytic research, results also supported the validity of an alternative two-factor model consisting of a combined modality Memory/Learning (ML) factor and an AC factor. While the results suggest that the three-factor solution may provide an adequate characterization of memory and learning in the majority of this sample of children with IDDM, it appears that certain groups of children with IDDM, particularly those children with early disease onset and those who experience hypoglycemic seizures, may exhibit a specific profile of differences that may result in a lack of differentiation between the verbal and visual modalities.

Mealtime behavior and diabetes-specific parent functioning in young children with type 1 diabetes.

OBJECTIVE Management of meals and mealtime behavior is often challenging for parents of young children with Type 1 diabetes. Parent functioning related to diabetes care may directly affect mealtime behaviors and glycemic control. This study evaluated associations among diabetes-specific parent functioning, parent and child mealtime behaviors, and glycemic control. METHOD Parents of young children with Type 1 diabetes (n = 134) completed self-report measures assessing diabetes-specific functioning (hypoglycemia fear, diabetes self-efficacy, diabetes-related quality of life) and child and parent mealtime behaviors. Hemoglobin A1c and percentage of blood glucose values out of range (<70 mg/dL or >200 mg/dL) over a 30-day period were abstracted from medical charts as indicators of glycemic control. Structural equation modeling was utilized to evaluate predictors and related outcomes of child and parent mealtime behavior. RESULTS The proposed model fit the data very well. More frequent problematic child mealtime behaviors were associated with poorer glycemic control; however, more frequent problematic parent mealtime behaviors were marginally associated with better glycemic control. Poorer diabetes-specific parent functioning was associated with more frequent problematic child and parent mealtime behaviors. CONCLUSIONS Problematic child mealtime behaviors, such as disruptive behavior, present a significant risk for poorer glycemic control. Parents may engage in ineffective mealtime management strategies in an effort to meet glycemic recommendations and avoid hyperglycemia and hypoglycemia. Future research will help to determine whether parents may benefit from specific, developmentally appropriate behavioral strategies to manage meals and snacks and promote optimal diabetes management.

Postpubertal disease status in diabetes and factor structure anomaly on the WISC-R

Diabetic children have been found to display an anomalous factor structure on the Wechsler Intelligence Scale for Children-Revised (WISC-R) (Holmes, Cornwell, Dunlap, Chen, & Lee, 1992). The present study sought to extend this finding with a larger cross-regional sample of children to determine which, if any, demographic or disease factor(s) might be related to the anomalous structure. Results revealed that groups of older (> = 12 years) children and those with late disease onset (> = 5 years) exhibited an anomalous four-factor structure in which the traditional Perceptual Organization factor (II) split into two factors: Picture Completion and Picture Arrangement formed a visual discrimination factor; and Block Design and Object Assembly created a spatial conceptual factor. It is postulated that diabetic performance on this visual discrimination factor may reflect mild visual neuropathies, often associated with adolescence and postpubertal disease status.