Predicting healthcare utilization in youth with type 1 diabetes: The importance of family level variables.

OBJECTIVE: Little is known about how family factors impacting treatment adherence in type 1 diabetes are directly associated with unplanned healthcare utilization (e.g., emergency room visits and hospital admissions). Given the substantial financial burden of diabetes, understanding predictors of healthcare utilization in particular is important to inform behavioral interventions aimed toward improving adherence. RESEARCH DESIGN AND METHODS: The current study examined the relationship between family-level variables and healthcare utilization in a sample of 239 youth with type 1 diabetes and their parents. Healthcare utilization was determined via parent report and chart review. Parent- and youth-reports regarding levels of family conflict, youth autonomy, and parent support related to diabetes management were obtained via questionnaire, and negative reciprocity was obtained by coding observations of parent and youth interactions. Generalized Estimating Equations were used to examine the longitudinal association between healthcare utilization and family-level factors. RESULTS: Higher levels of observed negative reciprocity were associated with more frequent hospital admissions, while higher levels of youth-reported parent involvement in diabetes management were associated with fewer hospital admissions and ED visits. CONCLUSIONS: These findings highlight how family-level factors are directly related to healthcare utilization and point to the continued importance of integrating family-focused behavioral interventions in routine medical care for improving type 1 diabetes outcomes and reducing healthcare costs.

Society of Pediatric Psychology Workforce Survey: Factors Related to Compensation of Pediatric Psychologists.

Objective: To summarize compensation results from the 2015 Society of Pediatric Psychology (SPP) Workforce Survey and identify factors related to compensation of pediatric psychologists. Methods: All full members of SPP ( n = 1,314) received the online Workforce Survey; 404 (32%) were returned with usable data. The survey assessed salary, benefits, and other income sources. The relationship between demographic and employment-related factors and overall compensation was explored. Results: Academic rank, level of administrative responsibility, and cost of living index of employment location were associated with compensation. Compensation did not vary by gender; however, women were disproportionately represented at the assistant and associate professor level. Conclusions: Compensation of pediatric psychologists is related to multiple factors. Longitudinal administration of the Workforce Survey is needed to determine changes in compensation and career advancement for this profession over time. Strategies to increase the response rate of future Workforce Surveys are discussed.

Predicting Health Resilience in Pediatric Type 1 Diabetes: A Test of the Resilience Model Framework.

OBJECTIVES: This research examined whether individual and family-level factors during the transition from late childhood to early adolescence protected individuals from an increased risk of poor glycemic control across time, which is a predictor of future diabetes-related complications (i.e., health resilience). METHODS: This longitudinal, multisite study included 239 patients with type 1 diabetes and their caregivers. Glycemic control was based on hemoglobin A1c. Individual and family-level factors included: demographic variables, youth behavioral regulation, adherence (frequency of blood glucose monitoring), diabetes self-management, level of parental support for diabetes autonomy, level of youth mastery and responsibility for diabetes management, and diabetes-related family conflict. RESULTS: Longitudinal mixed-effects logistic regression indicated that testing blood glucose more frequently, better self-management, and less diabetes-related family conflict were indicators of health resilience. CONCLUSIONS: Multiple individual and family-level factors predicted risk for future health complications. Future research should develop interventions targeting specific individual and family-level factors to sustain glycemic control within recommended targets, which reduces the risk of developing future health complications during the transition to adolescence and adulthood.

A 3-year prospective study of parent-child communication in early adolescents with type 1 diabetes: relationship to adherence and glycemic control.

OBJECTIVE: To examine changes in parent-child communication patterns and their relation to glycemic control and treatment adherence using observational data in a 3-year prospective multisite study of youth with type 1 diabetes aged 9-11 years at baseline and their families (n = 217). METHODS: Adolescents and caregivers participated in a diabetes problem-solving discussion. Families were rated on negative and positive communication and interactions using the Interaction Behavior Code. RESULTS: Maternal and paternal negative communication decreased over time, whereas adolescent and maternal positive communication and positive reciprocity increased. Baseline preadolescent youth and maternal positive communication predicted adherence 3 years later. Changes in family communication did not predict changes in glycemic control or adherence. CONCLUSIONS: During the transition to adolescence, family communication changed in unexpected and positive ways. Additionally, the relationship of baseline family communication to subsequent adherence suggests the need to assess family communication concerning diabetes-related management during preadolescence.

Patterns and predictors of paternal involvement in early adolescents' type 1 diabetes management over 3 years.

OBJECTIVE: To document trajectories of paternal involvement in diabetes management and examine bidirectional associations with diabetes outcomes across early adolescence. METHODS: 3-year prospective assessment of paternal involvement, diabetes self-management, and glycemic control among 136 youth (age 9-12 at baseline) and their mothers and fathers. RESULTS: Unconditional growth curves demonstrated decreasing amount (maternal report: F(1,128) = 14.79; paternal report: F(1,111) = 12.95, ps < 0.01) and level of contribution (maternal report: F(1,131) = 23.6, p < .01) of paternal involvement. Controlling for covariates, lower youth self-management predicted an increasing slope in fathers' self-reported amount of involvement (b = -0.15 to -0.22, p < .05), and higher levels of fathers' self-reported level of contribution predicted a decreasing slope in youths' self-reported self-management (b = -0.01, p < .05). CONCLUSIONS: Like mothers, fathers' involvement declines modestly during early adolescence. Different aspects of paternal involvement influence or are influenced by youths' self-management. Communication about ways to enhance fathers' involvement before this transition may help prevent or reduce declining diabetes management and control common in adolescence.

Identification and prediction of group-based glycemic control trajectories during the transition to adolescence.

OBJECTIVE: To identify trajectories of glycemic control over a period of 3 years in a pediatric sample of youth diagnosed with Type 1 diabetes transitioning to adolescence. A second aim was to examine a set of modifiable individual and family level baseline predictors of glycemic control group membership. METHODS: This multisite, prospective study included 239 children and adolescents (ages 9-11 years at baseline) diagnosed with Type 1 diabetes and their caregivers. Glycemic control was based on hemoglobin A1c (HbA1c) collected at 6-month intervals over a period of 3 years. Predictors of glycemic control membership included baseline global executive functioning, diabetes self-management, diabetes-specific family conflict, blood glucose monitoring frequency, and relevant individual and family level covariates. RESULTS: Group-based trajectory analyses were used to describe patterns of glycemic control from baseline to 36 months and 3 trajectories were identified: low risk (42.9%), elevated risk (44.6%), and high risk (12.1%) subgroups. Baseline maternal-reported family conflict, blood glucose monitoring frequency, and gender were significant predictors of glycemic control group membership. Higher levels of baseline family conflict, lower frequency of blood glucose monitoring, and female gender were associated with elevated and high-risk group membership. CONCLUSIONS: These findings underscore the importance of examining trajectories of HbA1c across time. These results suggest that problematic trajectories of glycemic control are evident during the transition to adolescence. Furthermore, there are modifiable individual and family level characteristics that predict group membership and hence could be targeted in interventions to ensure adequate glycemic control is maintained over time and that risks for diabetes-related complications are reduced.

Patterns of self-management in pediatric type 1 diabetes predict level of glycemic control 2 years later.

OBJECTIVE: To determine if 3 distinct self-management patterns (i.e., maladaptive, moderate/mixed, and adaptive) observed at baseline, 1 year, and 2 years in a sample of youth with type 1 diabetes and their caregivers predicted mean differences in adolescent's subsequent glycemic control. METHODS: This study is a descriptive, multisite, prospective study that examined a sample of youth diagnosed with type 1 diabetes (ages 9-11 years at baseline). Youth and their maternal and paternal caregivers provided information about the youth's self-management patterns at baseline, 1 year, and 2 years using the Diabetes Self-Management Profile structured interview. Glycemic control (hemoglobin A1c: HbA1c) was examined at baseline and 6, 12, 18, and 24 months. RESULTS: Three distinct self-management patterns were observed at 1 year and 2 years, which were conceptually consistent with previously reported baseline self-management patterns. Youth identified by their maternal caregivers as having adaptive self-management patterns at baseline had better glycemic control across 2 years compared with those in the maladaptive and mixed self-management groups. Similarly, maternal reports suggested that youth with less adaptive self-management patterns generally had worse glycemic control over time and HbA1c values above the American Diabetes Association recommendations. Youth and paternal caregiver reports yielded more variable findings. CONCLUSIONS: Findings underscore the stability of self-management patterns in pediatric type 1 diabetes and the need for preventive interventions that are tailored to specific patterns of self-management associated with risk for problematic glycemic control.

Diabetes management and glycemic control in youth with type 1 diabetes: test of a predictive model.

The objective of this study was to test a comprehensive model of biologic (pubertal status), family (communication and conflict), and psychological influences (behavioral autonomy) on diabetes management and glycemic control in a sample of youth (N = 226) with type 1 diabetes recruited during late childhood/early adolescence (ages 9-11 years). The study design was a prospective, multisite, multi-method study involving prediction of diabetes management and glycemic control 1 year post-baseline. The primary outcome measures included diabetes management behaviors based on the Diabetes Self-Management Profile (DSMP) administered separately to mothers and youth and glycemic control measured by glycated hemoglobin (HbA1c) obtained by blood samples and analyzed by a central laboratory to ensure standardization. Our hypothesized predictive model received partial support based on structural equation modeling analyses. Family conflict predicted less adequate glycemic control 1 year later (p < 0.05). Higher conflict predicted less adequate diabetes management and less adequate glycemic control. More advanced pubertal status also predicted less adequate glycemic control, but behavioral autonomy did not. Family conflict is an important, potentially clinically significant influence on glycemic control that should be considered in primary and secondary prevention in the management of type 1 diabetes in youth.

Mother-father informant discrepancies regarding diabetes management: associations with diabetes-specific family conflict and glycemic control.

OBJECTIVE: To examine the relationship of mother-father informant discrepancies regarding diabetes management to diabetes-specific family conflict and glycemic control. METHODS: One hundred thirty-six mothers and fathers of youth with Type 1 diabetes reported on the youth's diabetes management, diabetes-specific family conflict, and amount of paternal involvement in diabetes care. Glycosylated hemoglobin A1c (HbA1c) was used to measure glycemic control. RESULTS: As hypothesized, mother-father discrepancies regarding diabetes management were positively associated with frequency of diabetes-specific family conflict. Contrary to hypotheses, mother-father discrepancies regarding diabetes management predicted poorer glycemic control for youth with less involved fathers only. CONCLUSIONS: Results highlight the importance of caregivers being consistent about pediatric illness management and support the idea that informant discrepancies represent an important window into the functioning of the family system.

Fathers' involvement in preadolescents' diabetes adherence and glycemic control.

OBJECTIVE: To examine the relationship of paternal involvement in diabetes care with adherence and glycemic control. METHODS: One hundred and thirty-six mothers and fathers of preadolescents (aged 9-12 years) with type 1 diabetes reported on paternal involvement. Adherence was measured by interview and blood glucose meter downloads. Mothers' and fathers' ratings of paternal involvement in diabetes care were compared. We evaluated three structural equation models linking paternal involvement with adherence and glycemic control. RESULTS: Mothers and fathers reported similar amounts of paternal involvement, yet mothers rated paternal involvement as more helpful. The data supported a model indicating links between more paternal involvement and higher HbA1c and between lower adherence and higher HbA1c. Mediation and moderation models were not supported. DISCUSSION: Although paternal involvement was not directly associated with treatment adherence, it was associated with poorer glycemic control. Some fathers may increase their involvement in response to suboptimal glycemic outcomes.

Identification of self-management patterns in pediatric type 1 diabetes using cluster analysis.

OBJECTIVES: This study identified three distinct patterns of self-management groups for a sample of 239 youth (9-11 years) with type 1 diabetes and their maternal and paternal caregivers, and assessed their relationship to glycemic control (HbA1c). METHODS: Youth and their maternal and paternal caregivers were administered the diabetes self-management profile (DSMP) to assess self-management. Glycemic control was based on hemoglobin A1c. RESULTS: Two-step cluster analysis identified three different self-management groups based on youth, maternal, and paternal reports. Analysis of variance indicated that the pattern of less optimal diabetes self-management was associated with worse glycemic control. CONCLUSION: Our results objectively describe differences in patterns of self-management in youth with type 1 diabetes, that relate to glycemic control. Interventions based on these specific patterns of self-management may improve diabetes management and enhance glycemic control in children and adolescents with type 1 diabetes.

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.

Implementation of effective treatments of preschool behavior problems in a clinic setting.

Epidemiological data indicate that nearly 20% of preschool aged children have significant behavioral problems. Parents typically consult their child's primary care provider, who frequently refers to child psychologists for treatment regarding these difficulties. Psychologists skilled in providing effective services for young children are in short supply, limiting accessibility, and parents often are reluctant to follow up with a mental health specialist, suggesting low acceptability. The Behavior Consultation Clinic is a structured clinic for preschool children designed to address these issues of effectiveness, accessibility and acceptability. A retrospective review of 550 patients seen over a 5-year period found that half were seen for one therapy session. Review of the remaining patients found that slightly more than half showed improvement (32% successful discharge with improvement, 24% premature discharge with improvement) with a typical range of two to seven half-hour sessions, about a quarter did not improve, and the remaining patients were referred to a higher level of service. These data indicate that a structured, brief clinic that focuses on the needs of preschool children utilizing evidence-based approaches can be effective, acceptable, and accessible. The Behavior Consultation Clinic also serves as a training clinic for psychology interns and pediatric medical residents.

When distraction fails: parental anxiety and children's responses to distraction during cancer procedures.

OBJECTIVE: To examine parental anxiety in the context of successful and unsuccessful distraction treatment of preschool aged children undergoing chemotherapy procedures. METHODS: Twenty-nine children (M age = 42 months) experiencing intramuscular or portacatheter injections participated in the study. Parents and children were shown how to use a portable electronic toy as a distractor during chemotherapy injections. Parental anxiety was assessed at baseline and child distress was coded during each procedure. RESULTS: Parents' baseline state anxiety accounted for 17% of the variance in changes in children's distress following distraction intervention. Parents of children who did not benefit from distraction reported significantly higher state anxiety at baseline than parents of the other participants. CONCLUSIONS: Results highlight the importance of examining individual outcomes in intervention studies and suggest that parents' emotional states may moderate distraction treatment outcome in young children. Future research formally testing parent anxiety as a moderator is recommended.

Peer and family support in children and adolescents with type 1 diabetes.

OBJECTIVE: To examine social support and peer and family involvement in relation to diabetes management within a developmental context. METHODS: Sixty-eight youths ages 8 to 17 diagnosed with type 1 diabetes participated. This study represents the phase 1 data from a multisystemic, home-based intervention. Data included parent and youth report of disease management and conflict, youth-reported perceptions of support, peer participation in the intervention, and HbA1c. RESULTS: Adolescents perceived greater diabetes-related peer support than did school-age children. Perceived peer and family support were not correlated with metabolic control. Peer participation in the intervention was correlated with metabolic control. CONCLUSIONS: There is a developmental shift in perceptions of peer support. Increased perceptions of peer and family support overall may not result in improved metabolic control. Social support interventions should focus on the types of support that are most highly associated with positive health outcomes.

Distraction intervention for preschoolers undergoing intramuscular injections and subcutaneous port access.

This study evaluated a distraction intervention designed to reduce the distress of preschool children undergoing repeated chemotherapy injections. Twenty-nine children aged 2-5 years were randomly assigned either to distraction by a developmentally appropriate electronic toy or to a wait-list control. Children who received the distraction intervention demonstrated lower overt behavioral distress and were rated by parents and nurses as less anxious than children in the control condition. The improvements were maintained over the 8-week intervention. The results suggest that a developmentally appropriate, multisensory, variable-distracting activity that requires active cognitive processing and active motor responses may be a viable cost-effective alternative to more time-intensive parent-training programs for preschool-age children.