Jessica C. Kichler

Improving Depression Screening for Adolescents With Type 1 Diabetes

OBJECTIVE: Depression is common among adolescents, but rates increase significantly in the presence of chronic health conditions. Outpatient screening for depression is recommended but rarely formally conducted due to barriers of implementation. METHODS: To provide a model for depression screening of youth with chronic health conditions, a standard process using a self-administered electronic version of the Children’s Depression Inventory (CDI) was developed. Quality improvement methodology and traditional analytic approaches were used to test the feasibility and outcomes of routine screening in patients 13 to 17 years of age with type 1 diabetes. RESULTS: Of the 528 eligible adolescents, 509 (96%) received at least 1 depression screen during the first year. The process was tested and refined in over 1200 patient encounters, which resulted in an increase in depression screening rates from <5% to a median of 85% over the initial 12 months. Both patients and staff reported acceptance of screening on qualitative surveys. Elevated CDI scores (≥16) were found in 8% of the sample; moderate scores (10–15) in 12% of the sample. Low risk scores were found in 80% of the sample. Higher CDI scores correlated with lower blood glucose monitoring frequency and higher hemoglobin A1c, confirming the link between more depression symptoms and poorer diabetes management and control. Suicidal ideation was endorsed in 7% of the population. CONCLUSIONS: Systematic depression screening in adolescents with type 1 diabetes can be reliably implemented with clinically significant results. A systematic approach, such as described in this study, can serve as a model for other chronic health conditions.

Adolescents and Type 2 Diabetes Mellitus: A Qualitative Analysis of the Experience of Social Support

Objective. Research on how adolescents with type 2 diabetes mellitus (T2DM) understand and use social support is limited. Therefore, we explored how adolescents with T2DM experience and perceive social support. Methods. Adolescents with T2DM were interviewed, and data were qualitatively analyzed using Consensual Qualitative Research methodology. Results. Four themes emerged: support for nondiabetes and diabetes-specific behaviors, feelings of belonging, and disclosure. All participants expressed emotional and self-care-specific support. For some, disclosure and a sense of belonging with others who had diabetes often led to support elicitation. Participants also expressed a fear of disclosing their diabetes to others. Discussion. Adolescents with T2DM value tangible and emotional support for behaviors both related and not related to diabetes. Fear of disclosure was a typical experience with disclosure often limited to close friends and family. Recommendations for health professionals to assist adolescents in promoting appropriate disclosure and means of requesting support are discussed.

Topical Review: Applying Positive Development Principles to Group Interventions for the Promotion of Family Resilience in Pediatric Psychology

As described in the call for this special issue, resilience is often defined as “achieving one or more positive outcomes despite exposure to significant risk or adversity” (Hilliard, Harris, & WeissbergBenchell, 2012, p. 739). Resilience is particularly relevant to pediatric psychology, as youth and their families are tasked with overcoming risk factors simply by the nature of a child’s diagnosis of a disease/chronic illness and subsequent medical management demands. In addition to identifying key resilience factors within this population, it is critical to develop empirically supported clinical interventions to promote healthy biological, psychological, and social development; reduce youth psychopathology; and enhance optimal health outcomes. Although conceptually similar to the classic resilience/risk models, the positive development approach offers a distinct theoretical framework that can be used successfully in intervention development. This article describes exemplars of both resilience and positive development interventions for youth with Type 1 diabetes (T1D) and their families.

Play as a mechanism of working through medical trauma for children with medical illnesses and their siblings

Children’s reactions to medical trauma have been recorded through play. In this study, participants were 15 children with medical illnesses, 14 siblings of children with a medical illness, and 6 children in the community who did not have any ill family members. Children participated in play groups and their play with medical toys was videotaped and coded for themes that would provide a window on their perspectives. The play of children with medical illnesses and siblings was similar. Medical play was a mechanism for imaginal coping and working through stress related to medical experiences. In contrast, children in the comparison group did not engage in much medical play and when they did, they did not demonstrate a rich play experience with detailed medical stories. Future research should focus on ways to use play therapy techniques to help medically ill children and their siblings cope with their feelings and reactions to medical events related to chronic illness.

Assessing Measurement Invariance of the Diabetes Stress Questionnaire in Youth With Type 1 Diabetes

OBJECTIVE To evaluate the factor structure and measurement invariance of the Diabetes Stress Questionnaire (DSQ), a measure of diabetes-specific stress, across sex, age (<9th grade vs. ≥9th grade), and glycemic control (optimal vs. suboptimal). METHODS Data from 318 adolescent participants were pooled from four archival data sets and the ongoing Predicting Resiliency in Youth with Type 1 Diabetes study in which the DSQ was completed. Confirmatory factor and measurement invariance analyses were conducted to confirm the proposed factor structure and measurement invariance across sex, age, and glycemic control. RESULTS The DSQ factor structure was found to have an acceptable fit, which was invariant across sex, age, and glycemic control. CONCLUSIONS When using the DSQ, differences in diabetes-related stress with respect to sex, age, or glycemic control can be considered meaningful. This study supports the DSQ as an evidence-based and well-established assessment of perceived diabetes stress in youth with type 1 diabetes.

Psychosocial Patient-Reported Outcomes in Pediatric and Adolescent Diabetes: a Review and Case Example.

Purpose of ReviewThe purpose of this review is to define psychosocial patient-reported outcomes (PROs) relevant to pediatric and adolescent diabetes populations. Potential domains for PROs include a spectrum of emotional, behavioral, social, physical, overall health, and/or care management areas. A literature review of potential PRO measures, selection criteria, and implementation strategies including a case example will be presented.Recent FindingsAmong the pediatric, adolescent, and emerging adult populations, research indicates a relative higher risk for distress, depression, anxiety, and eating disorders as compared to peers without diabetes. Use of PRO measures can expand providers’ focus beyond glycemic control, or simply hemoglobin A1c, to better appreciate the impact of diabetes on the whole child/adolescent, and provide services that address patients’ individually identified needs, which are most salient to them.SummarySuccessful selection and implementation of psychosocial PRO measures should be designed to include pathways for real-time provider interaction with the patient and respective PRO data to guide clinical care.

Learning about Activity and Understanding Nutrition for Child Health (LAUNCH): Rationale, design, and implementation of a randomized clinical trial of a family-based pediatric weight management program for preschoolers

Obesity affects nearly 2 million preschool age children in the United States and is not abating. However, research on interventions for already obese preschoolers is limited. To address this significant gap in the literature, we developed an intervention targeting obesity reduction in 2 to 5year olds, Learning about Activity and Understanding Nutrition for Child Health (LAUNCH). This paper describes the rationale, design, participant enrollment, and implementation of a 3-arm randomized, parallel-group clinical trial comparing LAUNCH to a motivational-interviewing intervention (MI) and standard care (STC), respectively. Whereas LAUNCH was designed as a skills based intervention, MI focused on addressing the guardians motivation to make changes in diet and activity and providing tools to do so at the guardians level of readiness to implement changes. Child body mass index z-score was the primary outcome, assessed at pretreatment, posttreatment (Month 6), and 6 and 12month follow-ups (Months 12 and 18). Mechanisms of weight change (e.g., dietary intake, physical activity) and environmental factors associated with weight (e.g., foods available in the home, caregiver diet) were also assessed. This study is unique because it is one of the few randomized controlled trials to examine a developmentally informed, clinic and home skills based behavioral family intervention for preschoolers who are already obese. Being obese during the preschool years increases the likelihood of remaining obese as an adult and is associated with serious health conditions; if this intervention is successful, it has the potential to change the health trajectories for young children with obesity.

Children with chronic illnesses: factors influencing family hardiness

The current study assessed factors related to family hardiness in families of children coping with medical procedures related to a chronic illness. Participants were 68 parents of children with chronic illnesses, who were receiving complex medical treatment at a local hospital. Parents completed a scale assessing family hardiness and a semi-structured interview assessing their positive and negative coping strategies and those of their child. A linear regression analysis was used to examine the relationship between several predictors, including child age, number of medical conditions for the child, family income, number of positive and negative parent and child coping strategies, and family hardiness (outcome variable). Results indicated that parents of older children and children who exhibited negative coping strategies reported lower family hardiness. Older children may have had their chronic illness for a longer period of time, which could be wearing for the children and their families. Results of this study suggested that negative child coping may have deleterious effects on the family, and nurses and other health professionals should provide ideas for positive child coping and consider collaboration with mental health providers when they identify children facing emotional problems.

Pain reports in children and adolescents with type 1 diabetes mellitus

The purpose of this study is to examine prevalence rates of pain reports in youth with type 1 diabetes mellitus (T1DM) and potential predictors of pain. Pain is a common and debilitating symptom of diabetic polyneuropathies. There is currently little research regarding pain in youth with T1DM. It was predicted that self-care and general health factors would predict pain as suggested by the general pain literature. Participants (N = 269) ranged in age from 13 to 17 years; youth had a mean time since diagnosis of 5.8 years. Data collected included diabetes self-management variables, ratings of the patient’s current functioning and pain intensity (‘current’), and information collected about experiences that occurred in the time preceding each appointment (‘interim’). About half of the youth (n = 121, 49.0%) reported any interim pain across both appointments. Female adolescents and those individuals who were physically active and/or utilized health-care system more acutely were more likely to report interim central nervous system pain. Improved diabetes self-management and increased level of physical activity may reduce experiences of pain and increase the quality of life of youth with T1DM. Regular monitoring of both current and interim pain experiences of youth with T1DM is recommended.

PedsQL 3.2 Diabetes Module for Children, Adolescents, and Young Adults: Reliability and Validity in Type 1 Diabetes

OBJECTIVE The objective of the study was to report on the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for children, adolescents, and young adults with type 1 diabetes. RESEARCH DESIGN AND METHODS The 33-item PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were completed in a 10-site national field test study by 656 families of patients ages 2–25 years with type 1 diabetes. RESULTS The 15-item Diabetes Symptoms Summary Score and 18-item Diabetes Management Summary Score were derived from the factor analysis of the items. The Diabetes Symptoms and Diabetes Management Summary Scores evidenced excellent reliability (patient self-report α = 0.88–0.90; parent proxy report α = 0.89–0.90). The Diabetes Symptoms and Diabetes Management Summary Scores demonstrated construct validity through medium to large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.43–0.67, P < 0.001). HbA1c was significantly correlated with the Diabetes Symptoms and Diabetes Management Summary Scores (r = −0.21 to −0.29, P < 0.001). Minimal clinically important difference scores ranged from 5.05 to 5.55. CONCLUSIONS The PedsQL 3.2 Diabetes Module Diabetes Symptoms and Diabetes Management Summary Scores demonstrated excellent measurement properties and may be useful as standardized patient-reported outcomes of diabetes symptoms and diabetes management in clinical research, clinical trials, and practice in children, adolescents, and young adults with type 1 diabetes.