Recent Rates of Substance Use Among Adolescents and Young Adults with Type 1 Diabetes in the USA.

PURPOSE OF REVIEW: Substance use is a major public health problem in adolescents and young adults (AYA) and is particularly dangerous for AYA with type 1 diabetes (T1D) due to additional health consequences related to T1D. Rates of substance use among AYA with T1D are difficult to ascertain. Currently, we aim to provide a summary of published rates of substance use, over the last 10 years, among AYA with T1D in the USA. RECENT FINDINGS: This review included a database search, abstract screening, and synthesizing of articles published in the last 10 years that reported rates of substance use among AYA with T1D. We also compared rates to national survey data from the Center for Disease Control and Substance Abuse and Mental Health Services Administration. Of 138 articles, 123 abstracts were excluded due to non-relevance or because they were conducted outside of the USA; 15 articles were evaluated, and 8 provided original data on AYA with T1D. These 8 studies were summarized and compared to nationwide survey data. Most of the published rates of substance use among AYA with T1D were similar to national survey data for alcohol, tobacco, and marijuana. Rates of illicit drug use were lower among AYA with T1D. Despite additional health consequences, alcohol, tobacco, and marijuana use is about as prevalent among AYA with T1D as in the general US population. These findings emphasize the importance of conducting more research in this area, developing effective interventions, and incorporating prevention into standard clinical practices.

Risky self-management behaviors in adolescents with type 1 diabetes: Measurement validation for the Diabetes-Specific Risk-Taking Inventory.

OBJECTIVE: Among persons with type 1 diabetes (T1D), adolescents often experience the greatest challenge achieving optimal treatment engagement and glycemic targets. Risk-taking behaviors often increase during adolescence and may interfere with engagement in T1D care. We developed the Diabetes-Specific Risk-Taking Inventory (DSRI) to assess risky T1D self-management behaviors in adolescents with T1D. In the current study, we aimed to examine the DSRI's psychometric properties. RESEARCH DESIGN AND METHODS: We surveyed a national sample of 224 adolescents from the T1D Exchange registry (M age = 16.9 ± 1.1, 49% female, M A1c = 8.5% ± 1.3, 76.8% on insulin pumps) in a cross-sectional design. Participants completed the DSRI and measures of engagement, general risk-taking, and executive functioning and reported on incidence of severe hypoglycemia and diabetic ketoacidosis over the past year. RESULTS: The DSRI demonstrated reliability (internal consistency: α = 0.89; test-retest reliability: r = 0.86, p < 0.01). Concurrent validity was demonstrated through significant associations between the DSRI and T1D engagement (r = -0.75), general risk-taking (r = 0.57), executive dysfunction (r = 0.34), and report of severe hypoglycemia over the past year (r = 0.22). The DSRI accounted for unique variance in adolescents' most recent glycated hemoglobin, above and beyond other variables, indicating its incremental validity. CONCLUSIONS: Overall, initial psychometrics suggest the DSRI is a reliable and valid measure of risks that adolescents may take with their T1D care. This innovative self-report measure has potential to be an actionable clinical tool to screen for high-risk behaviors not routinely assessed in T1D clinical care.

The Diabetes-Specific Risk-Taking Inventory: Piloting a New Measure for Adolescents With Type 1 Diabetes.

OBJECTIVE: We sought to develop and pilot a new measure, the Diabetes-Specific Risk-Taking Inventory (DSRI), to assess unhealthy risk-taking behaviors among adolescents with type 1 diabetes. METHODS: Thirteen diabetes health care providers, 30 adolescents with type 1 diabetes (aged 15-19 years, 60% female, mean A1C 8.7% [72 mmol/mol], and 33% on insulin pumps), and the adolescents' caregivers rated the perceived riskiness of each item on the DSRI. Adolescents completed the DSRI, for which they reported how often they engaged in 34 behaviors that could place them at risk for acute complications of type 1 diabetes or out-of-range blood glucose levels. Adolescents also completed the risk-taking subscale from the Risk-Taking and Self-Harm Inventory for Adolescents, and parents completed the parent-proxy Diabetes Management Questionnaire. Mean A1C during the previous year was obtained via medical chart review. RESULTS: Results indicated good content validity and feasibility for using the DSRI in a research context, as 100% of adolescents who consented to the study completed the measure. The DSRI was positively correlated with general risk-taking and negatively correlated with diabetes management, indicating preliminary evidence of convergent validity. The DSRI also correlated with A1C. CONCLUSION: This pilot study extends our previous work in developing a conceptual model for illness-specific risk-taking. The DSRI is a promising new measure to assess illness-specific risk-taking, including unhealthy risk-taking behaviors, for adolescents with type 1 diabetes.

Diabetes-Specific Risk-Taking in Young Adulthood: A Closer Look.

Risk-taking behaviors are not a new phenomenon for young adults (YAs) and are an important aspect of understanding decision-making for YAs with diabetes. This article builds on a previous model of diabetes-specific risk-taking by providing other examples of risky situations and behaviors that are specific to YAs with type 1 diabetes, reviewing models of risk-taking behavior, and discussing how these models might inform clinical care for YAs with diabetes.

Knowledge and attitudes on pharmacogenetics among pediatricians.

Increasing enthusiasm for clinical pharmacogenetic testing and the availability of pharmacogenetic-based guidelines indicate that pediatricians will increasingly be expected to interpret and apply pharmacogenetic test results into medical care. Previous studies have identified a lack of knowledge on pharmacogenetics across many physician specialties; however, this has not been systematically assessed among pediatricians. To evaluate pediatrician knowledge, attitude, and educational interest in pharmacogenetics, we surveyed physician cohorts from both the United States (U.S.) and Japan. A total of 282 pediatricians (210 from the U.S. and 72 from Japan) participated in an anonymous survey (online or hardcopy) on pharmacogenetics knowledge, perception, and education. Over 50% of all respondents had >10 years of clinical experience and >75% had some prior education in genetics. However, <10% felt they were familiar with pharmacogenetics, which was very consistent with <20% of the U.S. pediatricians correctly responding to a codeine/CYP2D6 pharmacogenetics knowledge question and <10% of U.S. pediatricians being aware of the Clinical Pharmacogenetics Implementation Consortium (CPIC). Despite being generally unfamiliar with pharmacogenetics, >80% of all respondents indicated that implementation of clinical pharmacogenetic testing will improve efficacy and safety, and that pediatricians should be capable of applying this testing to their practice. Moreover, the majority (83.1%) were interested in educational opportunities on pharmacogenetics, particularly on result interpretation and therapeutic recommendations. Taken together, these data indicate that although practical knowledge of pharmacogenetics among pediatricians in the U.S. and Japan is currently very low, their interest in clinical pharmacogenetics and related education is high, which will likely facilitate future implementation.

Screening and support for emotional burdens of youth with type 1 diabetes: Strategies for diabetes care providers.

Multiple sources of burden for youth with type 1 diabetes (T1D) impact key outcomes including quality of life, self-management, and glycemic control. Professional diabetes organizations recommend diabetes care providers screen for psychosocial and behavioral challenges and implement strategies to support youth with T1D. The purpose of this article is to review the literature and recommend practical strategies medical providers can use for screening and behavioral support for youth with diabetes and their families. As part of their routine medical care, diabetes care providers are well-positioned to identify and intervene to address emotional distress related to the burdens of living with diabetes. In collaboration with multidisciplinary team members, including psychologists and mental health professionals, medical providers may be able to successfully implement brief behavioral strategies for screening and providing emotional support.

Profiles of Neuropsychological Functioning in Children and Adolescents with Spina Bifida: Associations with Biopsychosocial Predictors and Functional Outcomes.

OBJECTIVES: The current study examined neuropsychological performance among children with spina bifida (SB) to determine biological and functional correlates of distinct "profiles" of cognitive functioning. METHODS: A total of 95 children with SB myelomeningocele (ages, 8-15 years) completed a neuropsychological assessment battery. Hierarchical and non-hierarchical cluster analyses were used to identify and confirm a cluster solution. Hypothesized predictors of cluster membership included lesion level, number of shunt surgeries, history of seizures, age, ethnicity, socio-economic status, and family stress. Outcomes included independence, academic success, expectations for the future, and quality of life. RESULTS: Ward's cluster method indicated a three-cluster solution, and was replicated with two other cluster analytic methods. The following labels were applied to the clusters: "average to low average" (n=39), "extremely low to borderline" (n=27), and "broadly average with verbal strength" (n=29). Socio-econimc status, lesion level, and seizure history significantly predicted group membership. Cluster membership significantly predicted independence, academic success, parent expectations for the future, and child reported physical quality of life. CONCLUSIONS: Findings from this study suggest qualitatively different cognitive profiles exist among children with SB, and the relevance of neuropsychological functioning for day-to-day adaptive functioning and quality of life. Clinical implications and future research are discussed. (JINS, 2016, 22, 804-815).

Practical strategies to enhance executive functioning and strengthen diabetes management across the lifespan.

The complex type 1 diabetes (T1D) management regimen places extra demands on one's ability to plan, organize, and problem-solve, a set of skills described as executive functioning (EF). Research on the relation between EF and T1D management has been mounting and suggest that deficits in EF skills likely interfere with optimal management. However, given the substantial EF demands of T1D management, any person with T1D, including those without clinically significant deficits, could likely benefit from strategies to improve diabetes-related EF skills. The current review outlines typical EF development across the lifespan and suggests behavioral strategies (e.g., environmental modifications) from the EF literature and clinical experience to enhance EF skills at each period of development. When executive dysfunction is suspected, formal neuropsychological assessment is recommended as EF concerns can be a significant problem of their own, or they could be an indicator of another psychological disorder, such as depression or dementia.

Text messaging to enhance glucose monitoring and self-care in teens with type 1 diabetes: Teens' perceptions predict outcomes.

AIMS: We assessed association between how teens with type 1 diabetes (T1D) perceived a text-messaging (TM) reminder system to check glucose levels and how their perceptions related to their responsiveness to TM reminders to check glucose levels. METHODS: Teens received TM reminders 1-4 times daily to check glucose levels and to reply with the result. Qualitative assessments were performed quarterly. Teens were categorized by perceptions expressed at the majority of the visits and their TM responsiveness over 18 months. RESULTS: There were 135 teens (51 % male), with a mean age of 14.8 ± 1.2 years, receiving TM reminders. Distribution of participants' perceptions was 37 % positive (POS), 35 % neutral (with both positive and negative responses (POS/NEG)), and 28 % negative (NEG). Teens with POS perceptions about TM reminders were more likely to respond with a glucose value to the TM reminders than teens with NEG or POS/NEG perceptions (p = 0.002). Youth with POS perceptions and TM responsiveness on ≥ 50 % of days had an 0.81 % improvement in their HbA1c (p = 0.004) over 18 months. CONCLUSIONS: Teens with POS perceptions to TM reminders were likely to respond and their responsiveness yielded glycemic benefit, suggesting need to consider opinions of teens with T1D to maximize their intervention engagement and resulting benefits.

A camp-based psychosocialiIntervention to promote independence and social function in individuals with spina bifida: moderators of treatment effectiveness.

PURPOSE: To replicate and extend O'Mahar and colleagues' (O'Mahar, K., Holmbeck, G. N., Jandasek, B., & Zuckerman, J. [2010]. A camp-based intervention targeting independence among individuals with spina bifida. Journal of Pediatric Psychology, 35, 848-856) findings in a new and larger sample of youth and young adults with spina bifida who participated in a modified camp-based intervention targeting independence and social skills. Moderators of intervention effectiveness and clinical significance were examined. METHOD: In all, 119 campers aged 7-41 years participated in an intervention that included goal setting and interactive workshops. Campers and parents completed measures of campers' goal attainment, independence, and social functioning at preintervention and postintervention; counselors reported on campers' goal attainment daily throughout the intervention. RESULTS: Parents and campers reported improvements in campers' goal attainment, management of health-related self-care, and independence. Although benefits were found for most campers, cognitive functioning and family income moderated some outcomes. Campers who improved most on their social goals perceived the intervention to be more effective. CONCLUSIONS: Further support is provided for the effectiveness of a camp-based intervention targeting independence and social skills for individuals with spina bifida. More attention should be directed toward those with cognitive difficulties and low-income backgrounds.

A longitudinal assessment of early pubertal timing as a predictor of psychosocial changes in adolescent girls with and without spina bifida.

OBJECTIVE: A longitudinal comparison of adolescent girls with and without spina bifida (SB), regarding the effects of early pubertal timing on girls' depressive symptoms, mother-daughter conflict, and emotional distancing. METHODS: 62 mother-daughter dyads (31 with SB and 31 without) reported on psychosocial outcomes at 5 time points (ages 8/9 to 16/17 years). RESULTS: A pubertal timing × SB status interaction predicted emotional distancing (T2), conflict (T2, T5), and depressive symptoms (T4), such that early maturing girls without SB reported the greatest increase in each outcome. Main effects of pubertal timing predicted emotional distancing (T4), conflict (T4), and depressive symptoms (T2, T3, T5). Findings were not always consistent across reporters, assessments of pubertal timing, and time-points. CONCLUSIONS: Although early maturing girls in both groups may experience greater psychosocial difficulties, early maturing girls without SB may be most at-risk. The somewhat reduced impact of early pubertal timing in girls with SB is discussed.

Mother-adolescent agreement regarding decision-making autonomy: a longitudinal comparison of families of adolescents with and without spina bifida.

OBJECTIVE: Longitudinal comparison of mother and adolescent agreement regarding decision-making autonomy for adolescents with and without spina bifida (SB). METHODS: Forty-two mother-adolescent dyads of adolescents with SB and 55 comparison dyads reported on who was responsible for decision-making across five waves of data collection, beginning at age 8 or 9 years through age 16 or 17 years. RESULTS: The proportion of tasks that dyads agreed were decided by adolescents increased over time for both samples beginning at age 12 or 13 years, but appeared to be delayed by roughly two years for youth with SB and was lower for youth with SB from lower socioeconomic (SES) backgrounds. Mothers and adolescents with low SES demonstrated higher proportions of tasks that dyads agreed were decided by mothers. CONCLUSIONS: SB and low SES are risk factors for lower levels of agreed-upon decision-making autonomy. Future studies should examine how parent-adolescent agreement regarding autonomy relates to psychosocial outcomes.

Associations of diabetes self-management characteristics, HbA1c, and psychosocial outcomes with depressive symptoms in a contemporary sample of adolescents with type 1 diabetes.

AIMS: We sought to examine the associations between diabetes self-management, HbA1c, and psychosocial outcomes with the frequency of depressive symptoms. METHODS: We surveyed 301 teens (50% male, 22% non-white), mean age of 15.0±1.3 years, diabetes duration of 6.5±3.7 years. Biomedical variables: daily frequency of blood glucose monitoring of 4.5±1.9, 63% insulin pump use, mean HbA1c 8.5±1.1% (69±12 mmol/mol); 15% of the sample achieved the target HbA1c of <7.5% (<58 mmol/mol). RESULTS: Nearly 1 in 5 (18%, n=54) adolescents reported significant depressive symptoms and, of those participants, slightly under half reported moderate/severe depressive symptoms. Teens with moderate/severe depressive symptoms (CES-D scores ≥24) were more likely to be female, have parents without a college education, and not utilize insulin pumps. Teens with more depressive symptoms reported higher diabetes family conflict, higher diabetes burden, and lower quality of life. In the group reporting no depressive symptoms (10%), scores on psychosocial variables and diabetes treatment variables were the most favorable. CONCLUSION: In our sample, the presence of depressive symptoms appears to relate to both diabetes treatment and quality of life. In addition, studying teens without depressive symptoms can help us learn more about protective factors that potentially buffer against depressive symptoms and that are associated with better outcomes.

Profiles of Depressive Symptoms and Diabetes Distress in Preadolescents With Type 1 Diabetes.

OBJECTIVES: Diabetes distress and depressive symptoms are common psychosocial concerns for people with diabetes. These are related, yet distinct, mood states, which have each been related to diabetes management and glycated hemoglobin (A1C) among adolescents and adults with diabetes. However, they have not been examined concurrently in preadolescents with type 1 diabetes. Understanding the overlaps and distinctions between diabetes distress and depressive symptoms in youth would help guide decisions about psychosocial screening in diabetes clinical practice. In this study, we aimed to categorize preadolescents based on clinical cutoffs of concurrently administered measures of depressive symptoms and diabetes distress, and identify clinical and demographic characteristics of each group. METHODS: One hundred eighty youth (age range, 9 to 13 years; age [mean ± standard deviation], 11.3±1.3 years; 55% female; 56% Caucasian; mean A1C, 8.4±1.6% [68 mmol/mol]) completed measures of diabetes distress, depressive symptoms and quality of life. Daily blood glucose monitoring frequency was calculated from meter download. A1C values were obtained from electronic medical records. RESULTS: Depressive symptoms and diabetes distress each significantly correlated with A1C and quality of life. Although most (69%) participants had no clinically significant elevations in either diabetes distress or depressive symptoms, 14% had elevated depressive symptoms only and 17% had elevated distress without concurrent elevated depressive symptoms. Groups differed based on A1C, quality of life and insurance status. CONCLUSIONS: Routine assessment of both depressive symptoms and diabetes distress may help to identify preadolescents with type 1 diabetes who require psychosocial support.

Analysis of Suicide After Cancer Diagnosis by US County-Level Income and Rural vs Urban Designation, 2000-2016.

Importance: Studies suggest the risk of suicide among people with cancer diagnosis is higher compared with the general population. However, little is known about how suicide risk among people diagnosed with cancer might vary according to area-level income and rurality. Objective: To examine whether the risks and patterns of suicide mortality among people with a cancer diagnosis differ by US county-level median income and rural or urban status. Design, Setting, and Participants: A retrospective, population-based cohort study following up individuals who were diagnosed with cancer between January 1, 2000, and December 31, 2016, was conducted. The Surveillance, Epidemiology, and End Results Program 18 registries (SEER 18) database was used to obtain data on persons diagnosed with a first primary malignant tumor. Comparisons with the general US population were based on mortality data collected by the National Center for Health Statistics. Analyses were conducted from February 22 to October 14, 2020. Exposures: County-level median household income and urban or rural status. Main Outcomes and Measures: Standardized mortality ratios (SMRs) of suicide deaths and annual percentage changes (APCs) of SMRs. Results: The SEER 18 database included 5 362 782 persons with cancer diagnoses living in 635 counties. Most study participants were men (51.2%), White (72.2%), and older than 65 years (49.7%). Among them, 6357 persons died of suicide (SMR, 1.41; 95% CI, 1.38-1.44). People with cancer living in the lowest-income counties had a significantly higher risk (SMR, 1.94; 95% CI, 1.76-2.13) than those in the highest-income counties (SMR, 1.30; 95% CI, 1.26-1.34). Those living in rural counties also had significantly higher SMR than those in urban counties (SMR, 1.81; 95% CI, 1.70-1.92 vs SMR, 1.35; 95% CI, 1.32-1.39). For all county groups, the SMRs were the highest within the first year following cancer diagnosis. However, among people living in the lowest-income counties, the risk remained significantly high even after 10 or more years following cancer diagnosis (SMR, 1.83; 95% CI, 1.31-2.48). The comparative risk of suicide mortality within 1 year following cancer diagnosis significantly decreased over the years but then plateaued in the highest-income (2005-2015: APC, 2.03%; 95% CI, -0.97% to 5.13%), lowest-income (2010-2015: APC, 4.80%; 95% CI, -19.97% to 37.24%), and rural (2004-2015: APC, 1.83; 95% CI, -1.98% to 5.79%) counties. Conclusions and Relevance: This cohort study showed disparities in suicide risks and their patterns among people diagnosed with cancer by county-level income and rural or urban status. The findings suggest that additional research and effort to provide psychological services addressing these disparities among people with cancer may be beneficial.

Text Message Intervention for Teens with Type 1 Diabetes Preserves HbA1c: Results of a Randomized Controlled Trial.

Aims: Teens with type 1 diabetes (T1D) often struggle with diabetes self-management, which may lead to suboptimal self-care and worsening hemoglobin A1c (HbA1c). Innovative strategies are needed to improve self-care and protect against glycemic decline, especially during adolescence. We aimed to assess the impact on HbA1c of two interventions, problem-solving and text messaging, in teens with T1D. Methods: In a two-site randomized controlled trial, teens (N = 301) 13-17 years of age with T1D were randomized to one of the four groups using a 2 × 2 factorial design: Teenwork (TW), Text Messaging (Text), TW+Text, or Usual Care. TW intervention included problem-solving aimed at improving T1D self-care for blood glucose (BG) monitoring and insulin bolus dosing. Text intervention involved text reminders to check BG. The primary outcome was change in HbA1c from baseline to 12 months. Results: At baseline, teens (51% female, 78% white, 59% pump-treated) were (mean ± SD) 15.0 ± 1.3 years, had diabetes duration of 6.5 ± 3.7 years, and HbA1c 8.5% ± 1.1%. There was no significant difference in HbA1c over time by study group. Responsiveness to text reminders by teens in the TEXT and TW+TEXT predicted glycemic benefit; TW did not. Conclusions: Despite no HbA1c difference by study group, greater response to text message reminders to check BG led to better glycemic control and no deterioration in HbA1c; the problem-solving intervention did not. Given the high penetration of mobile phones and the wide acceptance of text messaging among teens in general, it is encouraging that a text messaging intervention can preserve HbA1c, thus preventing the expected deterioration in glycemic control often seen in teens with T1D.

ADHD and Attention Problems in Children With and Without Spina Bifida.

Objectives: To identify differences in the diagnosis and treatment of attention deficit/hyperactivity disorder (ADHD) between typically developing children and children with spina bifida. Method: Sixty-eight children with spina bifida and 68 demographically matched, typically developing children participated in a larger, longitudinal study. Rates of maternal, paternal, and teacher reports of attention problems, as well as rates of maternal reports of ADHD diagnosis, diagnosing provider, pharmaceutical treatment, mental health treatment, and academic accommodations were obtained at 5 time points over a period of 8 years and were compared across groups. Results: Children with spina bifida were more likely to have an ADHD diagnosis and attention problems. Attention problems and ADHD diagnoses were first reported at earlier time points for children with spina bifida than typically developing children. Among children with ADHD or attention problems, children with spina bifida were more likely to be treated with medication, but they were just as likely to use mental health services and receive resource services at school. Conclusions: Children with spina bifida were diagnosed with ADHD and identified as having attention problems more frequently and at an earlier age. This finding could be due to earlier symptom development, greater parental awareness, or more contact with providers. Among those with ADHD or attention problems, stimulant medication was more likely to be prescribed to children with spina bifida, despite research that suggests it may not be as beneficial for them. Further research on the effectiveness of ADHD pharmacological treatment for children with spina bifida is recommended.

Adherence in adolescents with Type 1 diabetes: strategies and considerations for assessment in research and practice.

Suboptimal adherence remains a significant concern for adolescents with Type 1 diabetes, the treatment regimen for which is complex and includes numerous behaviors. Accurate assessment of adherence is critical for effective healthcare and to measure trial outcomes. Without a valid biomarker of adherence, assessment strategies must rely on measuring management behaviors. This paper provides an overview of approaches to measure adherence, with an emphasis on contemporary, validated measures that are appropriate for current diabetes care. Objective measures include electronic data from diabetes management devices. Subjective measures include self/parent-report questionnaires, structured interviews and diaries/logbooks. Practical strategies for selecting measurement approaches for clinical and research purposes are reviewed, and implications of adherence assessment for clinical care delivery and adherence-promotion are discussed.