Engaging Preschool and Early Elementary School-Aged Children in Exposure and Response Prevention (ERP).

Engaging children and caregivers in exposure and response-prevention (ERP) is a critical element in effective treatment of obsessive-compulsive disorder (OCD) in young children. Several clinical challenges pose barriers to participation and implementation of successful treatment such as specific parenting behaviors (e.g., accommodation of obsessions and compulsions) and child motivation for treatment. The authors offer strategies to address common clinical challenges in engaging young children with OCD and to promote effective implementation of ERP with children and caregivers.

Distal technologies and type 1 diabetes management.

Type 1 diabetes requires intensive self-management to avoid acute and long-term health complications. In the past two decades, substantial advances in technology have enabled more effective and convenient self-management of type 1 diabetes. Although proximal technologies (eg, insulin pumps, continuous glucose monitors, closed-loop and artificial pancreas systems) have been the subject of frequent systematic and narrative reviews, distal technologies have received scant attention. Distal technologies refer to electronic systems designed to provide a service remotely and include heterogeneous systems such as telehealth, mobile health applications, game-based support, social platforms, and patient portals. In this Review, we summarise the empirical literature to provide current information about the effectiveness of available distal technologies to improve type 1 diabetes management. We also discuss privacy, ethics, and regulatory considerations, issues of global adoption, knowledge gaps in distal technology, and recommendations for future directions.

Executive functioning and diabetes: The role of anxious arousal and inflammation.

Individuals who perform poorly on measures of the executive function of inhibition have higher anxious arousal in comparison to those with better performance. High anxious arousal is associated with a pro-inflammatory response. Chronically high anxious arousal and inflammation increase one's risk of developing type 2 diabetes. We sought to evaluate anxious arousal and inflammation as underlying mechanisms linking inhibition with diabetes incidence. Participants (N=835) completed measures of cognitive abilities, a self-report measure of anxious arousal, and donated blood to assess interleukin-6 (IL-6) and glycated hemoglobin (HbA1c). Individuals with low inhibition were more likely to have diabetes than those with high inhibition due to the serial pathway from high anxious arousal to IL-6. Findings remained when entering other indicators of cognitive abilities as covariates, suggesting that inhibition is a unique cognitive ability associated with diabetes incidence. On the basis of our results, we propose several avenues to explore for improved prevention and treatment efforts for type 2 diabetes.

Texting Adolescents in Repeat DKA and Their Caregivers.

BACKGROUND: Text message interventions are feasible, preferable, and sometimes effective for youth with diabetes. However, few, if any studies, have examined the personalized use of text messages with youth repeatedly hospitalized for diabetic ketoacidosis (DKA) and their caregivers. This study characterizes the use of personalized text messages in Novel Interventions in Children's Healthcare (NICH). METHODS: Approximately 2 months of text messages sent to youth with repeat DKA and their caregivers were logged regarding the following text characteristics: (1) content, (2) intervention type, (3) timing, and (4) recipient characteristics. RESULTS: NICH interventionists sent 2.3 and 1.5 texts per day to patients and caregivers, respectively. Approximately 59% of outgoing texts occurred outside of typical business hours, and roughly 68% of texts contained some form of support and/or encouragement. The relation between type of intended intervention and day/time of text was significant, χ(2)(2, N = 5,808) = 266.93, P < .001. Interventionists were more likely to send behavioral intervention text messages outside of business hours, whereas they were more likely to send care coordination and case management text messages during business hours. CONCLUSIONS: To our knowledge, this is the first study to specifically categorize and describe the personalized use of text messages with youth repeatedly hospitalized for DKA and their caregivers. Findings indicate that a promising treatment program for these youth frequently used text interventions to deliver praise and encouragement to patients and caregivers alike, often outside of typical business hours, and tailored text content based on patient and caregiver characteristics.

Videoconferencing for Teens With Diabetes: Family Matters.

BACKGROUND: Adolescence is a developmental period associated with increased difficulty managing diabetes. During adolescence family functioning, including miscarried helping, family conflict, and acceptance of illness, is an important predictor of adherence to treatment recommendations. Multiple barriers exist to receiving behavioral health interventions to address suboptimal adherence. We hypothesized that behavioral family systems therapy-diabetes (BFST-D) delivered via telehealth would yield changes in family functioning that were not significantly different than changes in clinic-based treatment. Furthermore, that BFST-D would significantly improve overall family functioning. METHODS: Ninety adolescent participants and their parents were randomized to receive BFST-D via telehealth or traditional (Clinic) treatment conditions. Repeated measures ANOVAs were used to assess changes in mean scores across pre, post, and follow-up assessments. Mediation analyses were conducted using methods outlined by Sobel and were confirmed by bootstrapping. RESULTS: Changes in miscarried helping, family conflict and adjustment to illness were not significantly different across groups. Overall, clinically significant improvements were identified in youth- and parent-reported miscarried helping, family conflict, and acceptance of illness. Reductions in family conflict mediated the relationship between changes in miscarried helping and acceptance of illness. In addition, improvements in family functioning were associated with changes in adherence and glycemic control. CONCLUSIONS: Results provide strong support for BFST-D (and similar interventions) delivered via telehealth as yielding outcomes no different than clinic-based treatment. In addition, further support was provided for the effectiveness of BFST-D.

Seeing Is Believing: Using Skype to Improve Diabetes Outcomes in Youth.

OBJECTIVE: The objective of this study was to compare the relative effectiveness of two modes of delivering Behavioral Family Systems Therapy for Diabetes (BFST-D) to improve adherence and glycemic control among adolescents with type 1 diabetes with suboptimal glycemic control (HbA(1c) ≥9.0% [≥74.9 mmol/mol]): face to face in clinic (Clinic) and Internet videoconferencing (Skype) conditions. RESEARCH DESIGN AND METHODS: Adolescents aged 12 to 18 years and at least one adult caregiver were randomized to receive BFST-D via the Clinic or Skype condition. Participants completed up to 10 therapy sessions within a 12-week period. Changes in youth- and parent-reported adherence and glycemic control were compared before and after the intervention and at follow-up assessment. RESULTS: Using an intent-to-treat analytic approach, no significant between-group differences were identified between the before, after, and follow-up assessments. Groups were collapsed to examine the overall effects of BFST-D on adherence and glycemic control. Results identified that statistically significant improvements in adherence and glycemic control occurred from before to after the intervention; improvements were maintained at 3-month follow-up. CONCLUSIONS: Delivery of BFST-D via Internet-based videoconferencing is viable for addressing nonadherence and suboptimal glycemic control in adolescents with type 1 diabetes, potentially reducing important barriers to care for youth and families.

Depressive Symptoms in a Trial Behavioral Family Systems Therapy for Diabetes: A Post Hoc Analysis of Change.

OBJECTIVE: The objective was to test whether Behavioral Family Systems Therapy for Diabetes (BFST-D), an evidence-based family therapy, produces individual changes in depressive symptoms for adolescents with type 1 diabetes in suboptimal glycemic control (HbA(1c) ≥9.0% [≥74.9 mmol/mol]). RESEARCH DESIGN AND METHODS: Data were from a randomized controlled trial (RCT) comparing two modes of BFST-D delivery: in clinic versus Internet videoconferencing. There were no significant differences between groups in the RCT, so groups were collapsed into a within-group prepost design for secondary analyses. A multiple regression analysis was performed to test for mediation of treatment outcomes by changes in family processes. RESULTS: Significant improvements in glycemic control, depressive symptoms, and family functioning were found from pre- to posttreatment. A multiple regression analysis for within-subject mediation indicated that improvements in depressive symptoms were partially mediated by improvements in parent-youth conflict; however, family process changes did not mediate diabetes health outcomes. CONCLUSIONS: In addition to improving treatment adherence and glycemic control, BFST-D has collateral benefits on depressive symptoms.

Executive function, adherence, and glycemic control in adolescents with type 1 diabetes: a literature review.

The aim of the present review was to examine and report findings from published research to date that has examined associations between executive function (EF), adherence, and glycemic control in youth with type 1 diabetes. A review of the published research is presented with the objectives of reporting the following: (1) the associations between EF and adherence, (2) the associations between EF and glycemic control, (3) proposed methodological considerations needed to advance related research, (4) recommendations for future research, and (5) clinical recommendations. The major conclusions of this review support the presence of an association between EF, adherence, and glycemic control. Additional prospective and controlled studies are necessary to fully understand the impact of EF on the ability of youth to independently manage type 1 diabetes.

Systematic review and meta-analysis of behavioral interventions for fecal incontinence with constipation.

BACKGROUND: Multiple treatments exist for fecal incontinence. However, the relative and additive influence of commonly used behavioral approaches remains unclear. OBJECTIVE: We conducted a systematic review of randomized controlled trials to synthesize the effects of behavioral treatment of fecal incontinence with constipation in children aged 4-18 years. Mixed treatment comparisons (MTCs) and random effects models were used to analyze outcomes. Risk of bias and quality of evidence were rated. RESULTS: Although 10 studies were identified for MTCs, results did not yield reliable or valid estimates. Four studies were retained for random effects pooled outcome analysis. Results indicated that behavioral intervention was more effective than control conditions for author-defined success and soiling frequency. CONCLUSION: Although evidence supports behavioral treatments for fecal incontinence with constipation in children, available evidence is limited. More and higher-quality trials are needed to better understand the relative effects of different treatments, including behavioral strategies.

Power of magic hands: parent-driven application of habit reversal to treat complex stereotypy in a 3-year-old.

OBJECTIVE: The authors assessed the effectiveness of habit reversal training (HRT) to treat a complex motor stereotypy in a healthy 3-year-old female. METHOD: This data-based case study involved training parents in HRT to deliver the parent-driven intervention to the child. The frequency of the child's behaviors was estimated daily in 30-min intervals by her parents. RESULTS: Outcomes supported the effectiveness of the intervention, with the estimated frequency of the stereotypy decreasing from occurring during approximately 85% of recorded intervals to less than 2% over a period of 4 weeks. Further record keeping over 19 weeks suggested treatment gains were generally maintained over time. CONCLUSIONS: The current case study provides preliminary evidence supporting the effectiveness of modified HRT to reduce stereotypies in young children. Further, data suggest that the intervention may be extended to younger ages by teaching parents how to facilitate treatment delivery.

Behavioral health care for adolescents with poorly controlled diabetes via Skype: does working alliance remain intact?

BACKGROUND: Increasingly various technologies are being tested to deliver behavioral health care. Delivering services via videoconferencing shows promise. Given that the patient-provider relationship is a strong predictor of patient adherence to medical regimens, addressing relationship quality when services are not delivered face-to-face is critical. To that end, we compared the therapeutic alliance when behavioral health care was delivered to youth with poorly controlled type 1 diabetes mellitus (T1DM) and their caregivers in-clinic with the same services delivered via Internet-based videoconferencing (i.e., Skype™). METHODS: Seventy-one adolescents with poorly controlled T1DM (hemoglobin A1c ≥9%) and one of their caregivers received up to 10 sessions of a family-based behavioral health intervention previously shown to improve adherence to diabetes regimens and family functioning; 32 were randomized to the Skype condition. Youth and caregivers completed the working alliance inventory (WAI), a 36-item measure of therapeutic alliance, at the end of treatment. Additionally, the number of behavioral health sessions completed was tracked. RESULTS: No significant differences in WAI scores were found for those receiving behavioral health care via Skype versus in-clinic. Youth WAI goal and total scores were significantly associated with the number of sessions completed for those in the clinic group. CONCLUSION: Behavioral health can be delivered to youth with T1DM via Internet-based videoconferencing without significantly impacting the therapeutic relationship. Thus, for those adolescents with T1DM who require specialized behavioral health care that targets T1DM management, Internet-based teleconferencing represents a viable alternative to clinic-based care.

Looking forward to transition: perspectives on transition from pediatric to adult diabetes care.

AIM: This study aimed to prospectively investigate transition beliefs, knowledge and needs of pediatric patients with diabetes and their parents. PATIENTS & METHODS: Parallel youth and parent questionnaires evaluating the transition process were distributed over a 6-month time period. Respondents included 123 pediatric patients with diabetes (11-19 years old) and their parents. RESULTS: Few families had discussed the transition of diabetes care (∼25%). Most had not established a transition plan (∼90%). Youth and parents agreed that seeing the doctor alone, discussions about transition and transition itself should occur at 17-18 years of age. CONCLUSION: Youth with diabetes and their parents are not prepared for transition to adult care. Transition discussions should begin at an earlier age. Additional research is needed to learn how and when to begin these discussions.

Gender differences in the relationship between parental report of self-regulation skills and adolescents' management of type 1 diabetes.

OBJECTIVE: To examine the extent to which self-regulation skills of adolescents with type 1 diabetes (T1D), including executive functioning and emotion regulation, relate to treatment adherence and glycemic control. METHOD: Participants were 109 adolescents aged 12-18 yr with TID and their primary caregiver who attended an outpatient appointment at a pediatric endocrinology clinic. Parents and adolescents completed a measure of treatment adherence. Parents completed a self-regulation measure while a glycemic control measure [i.e., hemoglobin A1c (HbA1c)] was collected. RESULTS: For boys, executive functioning and emotion regulation deficits were significantly associated with worse treatment adherence and glycemic control. Further analyses indicated that emotion regulation was the primary self-regulation measure related to treatment adherence and glycemic control. No significant associations were found for girls. CONCLUSION: For adolescent boys, the ability to cope with various stressors and emotions may be as important as higher-order thinking skills for maximizing treatment adherence and diabetes control. Clinical implications and potential mechanisms by which emotion regulation skills relate to adolescent boys' diabetes treatment management are discussed.

Getting (the most) out of the research business: interventions for youth with T1DM.

We review research on psychosocial interventions to improve outcomes for youth with type 1 diabetes mellitus. Specifically, we discuss individual- and small group-focused, family-focused, group-focused, and other interventions. After reviewing extant research in each area, we discuss how the current evidence base may be used to inform clinical practice. Finally, we conclude by discussing variations in effects of interventions on different outcomes (eg, glycemic control, family functioning) and how to consider this evidence when selecting treatments to transport into clinical settings.

Trichotillomania: A current review.

This review provides a broad and thorough synthesis of the Trichotillomania (TTM) literature as a resource for health professionals seeking the most current and complete information available. For the treatment provider, up to date information can help inform assessment, treatment, or referral decisions. For the student, this review provides a general overview and broad background information necessary to better understand hair-pulling and associated problems. For the researcher, information can help inform study planning. Prevalence, gender distributions, comorbidities, subtypes, and phenomenological characteristics are presented. Etiological theories are reviewed, and assessment and treatment options are offered. The validity of current DSM requirements is discussed and psychological and psychiatric treatment options are presented and evaluated for their strength of recommendation. Challenges to research and treatment are presented and directions for future research are suggested.

Brief report: normative data on a structured interview for diabetes adherence in childhood.

OBJECTIVE: This study provides normative data, divided by age and gender, for the Diabetes Self-Management Profile (DSMP), an empirically supported structured interview that assesses adherence with the type 1 diabetes treatment regimen. Despite wide use, normative data on the DSMP have yet to be reported. METHODS: The sample included 444 parents and 275 youth with type 1 diabetes. The DSMP was administered by a trained clinician. RESULTS: For both child and parent ratings of adherence, means and standard deviations for the overall sample and subdivision by gender and three age groups are presented for normative comparisons. Subscale data (e.g., glucose monitoring, diet, exercise) are similarly presented. Lower adherence scores were reported among older adolescents relative to preadolescents. CONCLUSIONS: The literature has lacked normative data on pediatric diabetes adherence. These data present means and standard deviations for parent and child ratings of regimen adherence from a relatively large sample of youth with diabetes that can be utilized for normative comparisons for clinical and research purposes.

The phenomenology of hairpulling in a community sample.

Assessment and treatment of trichotillomania (TTM) has evolved substantially over the past decade. However, standardized assessment and empirically supported treatment for TTM is still in early stages of development. We proposed that information important to the ongoing evolution of assessment and treatment could be obtained through the study of hairpulling across its range of severity. Hairpulling phenomenology was assessed in a large community sample across its range of presentation. Although the estimated prevalence rate of .6% for TTM is congruent with past studies, the 1.2% prevalence estimated for clinically significant hairpulling suggests that the current diagnostic criteria are overly restrictive. Overall, hairpulling occurred at a rate of 6.5%, while age of onset was 15.92 years. Symptoms of depression, anxiety, and history of teasing were positively associated with hairpulling, while self-esteem was negatively related to hairpulling. Cognitions most commonly associated with hairpulling were "feels coarse" (53.3%), "doesn't feel right" (30.0%), "is curly" (26.7%), and "doesn't look right" (23.3%). Environments most commonly associated with hairpulling included "while reading" (38.9%), "while watching television" (37.0%), and "in class" (35.25). Applications of findings to assessment and intervention formulation are suggested, and limitations and future directions are discussed.

Validity and reliability of an adolescent and parent rating scale of type 1 diabetes adherence behaviors: the Self-Care Inventory (SCI).

OBJECTIVE: Accurate assessment of diabetes regimen adherence behaviors in youth is a challenging endeavor and is limited by a paucity of empirically supported measures. The purpose of this research is to further demonstrate the validity and reliability of the Self-Care Inventory (SCI), a youth and parent report measure of adherence with diabetes self-care behaviors. The SCI was chosen given its ease of implementation, applicability to multiple diabetes regimens, and dual parent/youth formats. METHODS: Participants were 164 youth with type 1 diabetes and a parent. Measures were administered at regular office visits to a tertiary care diabetes clinic. RESULTS: The SCI has strong psychometric properties, including adequate internal consistency, parent-youth agreement, and test-retest agreement. Relations between the SCI and a structured interview of diabetes adherence (the Diabetes Self-Management Profile; DSMP) and hemoglobin A1c (HbA1c) were strong. CONCLUSIONS: In addition to demonstrating strong psychometrics, this research provides independent support for the SCI. Thus, the SCI is consistent with recent criteria proposed by Quittner et al. (Journal of Pediatric Psychology, 33, 916-936) for an empirically supported measure of regimen adherence. Although other methods of accessing adherence may provide more comprehensive assessments, the brevity, ease-of-implementation, and robustness for multiple regimens makes the SCI an ideal tool for clinicians and researchers.

Glycemic control in youth with type 1 diabetes: family predictors and mediators.

OBJECTIVE: This study examined predictive and mediated relationships among youth perception of critical parenting, Child Behavior Checklist Externalizing Subscale (CBCL) externalizing problem scores, adherence, and (hemoglobin A(1c) HbA(1c)), in youth with type 1 diabetes from low socioeconomic status families. METHODS: Caregiver/youth dyads (n = 120) completed diabetes specific measures of family functioning regarding diabetes management and structured adherence interviews. Parents completed the CBCL, while assays of youth HbA(1c) were performed. Analyses were conducted using hierarchical linear regression. RESULTS: Combined measures predicted 44% of the variance in HbA(1c). Adherence partially mediated critical parenting and HbA(1c), while critical parenting and adherence mediated CBCL externalizing problem scores and HbA(1c). CBCL externalizing problem scores did not mediate critical parenting and HbA1(c). CONCLUSIONS: The presence of youth perceptions of critical parenting and youth externalizing behavior problems may interfere with adherence, leading to increases in HbA(1c).