Margaret Grey

Personal and family factors associated with quality of life in adolescents with diabetes.

OBJECTIVE Quality of life is an important criterion for assessing outcomes of treatment in chronic illness related to psychosocial well-being. The purpose of this study was to evaluate the factors that influence quality of life in adolescents with IDDM. RESEARCH DESIGN AND METHODS Self-reports were obtained from 52 adolescents (age 13-20 years, mean 16.1 ± 1.9 [mean ± SD], diabetes duration 8.2 ± 3.4 years, 49% female) using the following scales: Diabetes Quality of Life for Youths, Childrens Depression Inventory, Issues in Coping with Diabetes, Diabetes Family Behavior Scale, Family Adaptability and Cohesion, Self-Efficacy for Diabetes, and the Adolescent Coping Orientation. Metabolic control was measured by HbA1c. RESULTS Teenagers whose diabetes had the greater impact (R2 = 0.48) and were less satisfied (R2 = 0.45) felt that management was more difficult (r = 0.56) and that diabetes was more upsetting (r = 0.63). They also used fewer rebellion strategies for coping (r = −0.44), had lower diabetes self-efficacy (r = −0.36), and had more depressive symptoms (r = 0.61). Higher impact was also associated with higher family warmth and caring (r = −0.54) and lower family adaptability (r = −0.42). Teenagers who were more worried (R2 = 0.37) about their diabetes felt that management was more difficult (r = 0.40) and that diabetes was more upsetting (r = 0.58), and they used less rebellion (r = −0.49) and more ventilation (r = 0.42) to cope, had lower diabetes (r = −0.40) and medical (r = −0.30) self-efficacy, were more depressed (r = 0.55), and their families were less warm and caring (r = −0.33). HbA1c levels were not associated with quality of life or any other psychosocial factors except in teenagers who perceived their families as providing more guidance and control. These teenagers had lower HbA1c values than those whose families were less involved. CONCLUSIONS Even teenagers who are successfully achieving HbA1c goals of therapy may perceive diabetes as having a negative impact on their lives, be depressed, and find diabetes difficult to manage. Diabetes treatment teams need to pay equal attention to the psychosocial needs to the quiet, nonrebellious teen with well-controlled diabetes from a supportive family as they do to the rebellious adolescent with poorly controlled diabetes.

Depression in type 1 diabetes in children: Natural history and correlates

The combination of diabetes and depression in children and adolescents is largely unstudied. The purpose of this article is to review the literature on the natural history and correlates of comorbid diabetes and depression in children and adolescents. Children with diabetes have a two-fold greater prevalence of depression, and adolescents up to three-fold greater, than youth without diabetes. Correlates of depression and diabetes include gender, poorer metabolic control, and family behaviors. Very little is known about treatment in these youth, and more studies are indicated.

Processes of Self‐Management in Chronic Illness

PURPOSE Self-management is a dynamic process in which individuals actively manage a chronic illness. Self-management models are limited in their specification of the processes of self-management. The purpose of this article is to delineate processes of self-management in order to help direct interventions and improve health outcomes for individuals with a chronic illness. DESIGN Qualitative metasynthesis techniques were used to analyze 101 studies published between January 2000 and April 2011 that described processes of self-management in chronic illness. METHODS Self-management processes were extracted from each article and were coded. Similar codes were clustered into categories. The analysis continued until a final categorization was reached. FINDINGS Three categories of self-management processes were identified: focusing on illness needs; activating resources; and living with a chronic illness. Tasks and skills were delineated for each category. CONCLUSIONS This metasynthesis expands on current descriptions of self-management processes by specifying a more complete spectrum of self-management processes. CLINICAL RELEVANCE Healthcare providers can best facilitate self-management by coordinating self-management activities, by recognizing that different self-management processes vary in importance to patients over time, and by having ongoing communication with patients and providers to create appropriate self-management plans.

Short-term Effects of Coping Skills Training as Adjunct to Intensive Therapy in Adolescents

OBJECTIVE Given the urgent need to develop effective programs that improve the ability for adolescents to achieve metabolic control equivalent to programs studied in the Diabetes. Control and Complications Trial, we have undertaken a clinical trial to determine if a behavioral intervention (coping skills training [CST]) combined with intensive diabetes management can improve metabolic control and quality of life in adolescents implementing intensive therapy regimens. RESEARCH DESIGN AND METHODS A total of 65 youths between the ages of 13 and 20 years, who elected to initiate intensive insulin therapy, were randomly assigned to one of two groups: the intensive management with CST group and the intensive management without CST group. CST consists of a series of small group efforts designed to teach adolescents the coping skills of social problem-solving, social skills training, cognitive behavior modification, and conflict resolution. Data were collected at pre-intervention and at 3 months following the use of the Self-Efficacy for Diabetes scale, Childrens Depression Inventory, Issues in Coping with IDDM scale, and the Diabetes Quality of Life: Youth scale. Clinical data (HbA1c, adverse effects) were collected monthly. RESULTS The experimental and control groups were comparable on all measures at baseline. Results show that adolescents who received CST had lower HbA1c and better diabetes self-efficacy and were less upset about coping with diabetes than adolescents receiving intensive management alone. In addition, adolescents who received the CST found it easier to cope with diabetes and experienced less of a negative impact of diabetes on quality of life than those who did not receive CST. CONCLUSIONS CST is useful in improving not only an adolescents metabolic control, but also their quality of life. As more pediatric providers aim for improved control, in adolescents with diabetes, the addition of this behavioral intervention may be helpful in achieving metabolic and life goals.

Translating the Diabetes Prevention Program to Primary Care: A Pilot Study

Background: Research on the translation of efficacious lifestyle change programs to prevent type 2 diabetes into community or clinical settings is needed. Objective: The objective of this study was to examine the reach, implementation, and efficacy of a 6-month lifestyle program implemented in primary care by nurse practitioners (NPs) for adults at risk of type 2 diabetes. Methods: The NP sites (n = 4) were randomized to an enhanced standard care program (one NP and one nutrition session) or a lifestyle program (enhanced standard care and six NP sessions). These NPs recruited adults at risk of diabetes from their practice (n = 58), with an acceptance rate of 70%. Results: The program reached a diverse, obese, and moderately low income sample. The NPs were able to successfully implement the protocols. The average length of the program was 9.3 months. Attendance was high (98%), and attrition was low (12%). The NPs were able to adopt the educational, behavioral, and psychosocial strategies of the intervention easily. Motivational interviewing was more difficult for NPs. Mixed-model repeated-measures analysis indicated significant trends or improvement in both groups for nutrition and exercise behavior. Participants of the lifestyle program demonstrated trends for better high-density lipoprotein (HDL) and exercise behavior compared with the enhanced standard care participants. Twenty-five percent of lifestyle participants met treatment goals of 5% weight loss compared with 11% of standard care participants. Discussion: A lifestyle program can be implemented in primary care by NPs, reach the targeted population, and be modestly successful. Further research is indicated.

Clinical and psychosocial factors associated with achievement of treatment goals in adolescents with diabetes mellitus

PURPOSE To examine the following questions with regard to the initiation of a new intensive management program for adolescents with Type 1 diabetes mellitus: (a) What clinical and psychosocial factors are associated with achievement of metabolic control treatment goals after 1 year? and (b) What baseline clinical and psychosocial factors are associated with improvement in the quality of life after 12 months? METHODS Eighty-one subjects (of 83 who began; aged 14.3 +/- 2.0 years at entry; 48 females, 33 males; 95% white; diabetes duration 8.9 +/- 3.9 years) with Type 1 diabetes completed 12 months of follow-up in a study of intensified treatment of diabetes. Assessments at baseline and at 12 months used the Diabetes Quality of Life for Youth scale, the Self-efficacy for Diabetes Scale, the Childrens Depression Inventory, the Issues in Coping with Diabetes Scale, and the Diabetes Family Behavior Scale. Data were analyzed using multiple and logistic regression. RESULTS From a baseline of >9%, HbA1c levels decreased to a mean of 7.8 +/- 0.7%, with 30% of the subjects achieving our treatment goal of <or=7.2%. Logistic regression demonstrated that achievement of goal levels of HbA1c were associated with better metabolic control at study entry (p = .05), participation in coping skills training (p = .003), and more parental participation in guidance and control (p = .05). Multiple regression analysis demonstrated that participation in coping skills training with lower impact of diabetes on quality of life at baseline and less depression at baseline contributed significantly to the variance (0.57) in quality of life at 12 months. CONCLUSIONS Providers need to pay particular attention to adolescents with poorer metabolic control and impact of diabetes on quality of life when they intensify their treatment because they are less likely to reach treatment goals. Furthermore, behavioral interventions such as coping skills training may help teens achieve their goals.

Psychosocial Status of Children With Diabetes in the First 2 Years After Diagnosis

OBJECTIVE The purpose of this study was to determine the pattern of adjustment over time of a cohort of children with newly diagnosed diabetes compared with a cohort of peer-selected children without diabetes over the first 2 years after the diagnosis of insulin-dependent diabetes mellitus (IDDM). RESEARCH DESIGN AND METHODS Children (n = 89 with IDDM, n = 53 without IDDM) ages 8–14 years were studied with the Childrens Depression Inventory, State-Trait Anxiety Inventory for Children, Child and Adolescent Adjustment Profile, Self-Perception Profile for Children, and a general health scale. Initial data were collected within 6 weeks of the diagnosis of IDDM and at 3, 6, 12, and 24 months thereafter. RESULTS There were no demographic differences between the two groups. Initially, children with diabetes were more depressed, more dependent, and more withdrawn than their peers. By 1 year postdiagnosis, there were no significant differences in psychosocial status between the two groups. By 2 years postdiagnosis, depression, dependency, and withdrawal were significantly higher in children with diabetes than in their peers without IDDM. Self-perceived competence remained similar between the two groups at all time points. CONCLUSIONS After an initial period of adjustment, children with IDDM have equivalent psychosocial status to children without IDDM, but by 2 years after diagnosis, they have experienced twice the amount of depression and adjustment problems as their peers. Interventions should be aimed at this critical period between 1 and 2 years postdiagnosis.

Coping and Adaptation in Children with Diabetes

The purpose of this study was to investigate the influence of age, coping behavior, and self-care on psychological, social, and physiologic adaptation in preadolescents and adolescents with diabetes. Children (N = 103) with insulin-dependent diabetes mellitus (IDDM) between 8 and 18 years of age and their parents participated in the study. Findings indicated that preadolescent children were significantly less depressed, less anxious, coped in more positive ways, had fewer adjustment problems, and were in better metabolic control than their adolescent counterparts. Age and secondary sexual development were related to psychosocial adaptation and. metabolic control of the diabetes. Further, those who coped by avoiding their problems and who were more depressed were the most likely to have problems in both adjustment and metabolic control with 56% of the variance in metabolic control explained by the variables studied. These findings indicate that preadolescents and adolescents cope differently with a chronic illness, and that interventions should be designed to identify and help those with inappropriate coping styles.

Psychological Experience of Parents of Children With Type 1 Diabetes A Systematic Mixed-Studies Review

Purpose The purpose of this review is to describe the prevalence of psychological distress in parents of children with type 1 diabetes (T1DM), the relationship between parental psychological distress and health outcomes, and parents’ psychological experience of having a child with T1DM. Clinical and research implications are presented. Method A systematic mixed-studies review was undertaken to review the quantitative and qualitative research on the parental experience of having a child with T1DM. A total of 34 articles met the inclusion criteria and were included in the review. Results The prevalence of parental psychological distress across all studies ranged from 10% to 74%, with an average of 33.5% of parents reporting distress at diagnosis and 19% of parents reporting distress 1 to 4 years after diagnosis. Parental psychological distress in parents of children with T1DM, regardless of how it was defined, was associated with higher child self-report of stress and depressive symptoms, more problematic child behavior, and lower child self-report of quality of life. Parental psychological distress also had negative effects on diabetes management. Themes of the qualitative synthesis indicated that parents perceived T1DM as a difficult diagnosis that contributed to significant family disruption. Adjustment occurred over time; however, ongoing stress was experienced. Conclusions Screening for psychological distress in parents of children with T1DM is indicated, and preventive interventions are needed.

A nurse-coaching intervention for women with type 2 diabetes.

PURPOSE The purpose of this pilot study was to determine the efficacy of a 6-month nurse-coaching intervention that was provided after diabetes education for women with type 2 diabetes. METHODS In this pilot study, 53 women were randomized to the nurse-coaching intervention or a standard care control condition. The nurse-coaching intervention consisted of 5 individualized sessions and 2 follow-up phone calls over 6 months. The nurse-coaching sessions included educational, behavioral, and affective strategies. Data were collected on physiologic adaptation (hemoglobin A1c [A1C] and body mass index [BMI]), self-management (dietary and exercise), psychosocial adaptation (diabetes-related distress and integration), and treatment satisfaction at baseline, 3 months, and 6 months. RESULTS Women in the treatment group demonstrated better diet self-management, less diabetes-related distress, better integration, and more satisfaction with care, and had trends of better exercise self-management and BMI. The A1C levels improved in both groups at 3 months, yet the difference between the groups was not significant. Attendance at nurse-coaching sessions was 96%. CONCLUSIONS This nurse-coaching intervention demonstrates promise as a means of improving self-management and psychosocial outcomes in women with type 2 diabetes.