Longitudinal Evaluation of Cognitive Functioning in Young Children with Type 1 Diabetes over 18 Months.

OBJECTIVES: Decrements in cognitive function may already be evident in young children with type 1 diabetes (T1D). Here we report prospectively acquired cognitive results over 18 months in a large cohort of young children with and without T1D. METHODS: A total of 144 children with T1D (mean HbA1c: 7.9%) and 70 age-matched healthy controls (mean age both groups 8.5 years; median diabetes duration 3.9 years; mean age of onset 4.1 years) underwent neuropsychological testing at baseline and after 18-months of follow-up. We hypothesized that group differences observed at baseline would be more pronounced after 18 months, particularly in those T1D patients with greatest exposure to glycemic extremes. RESULTS: Cognitive domain scores did not differ between groups at the 18 month testing session and did not change differently between groups over the follow-up period. However, within the T1D group, a history of diabetic ketoacidosis (DKA) was correlated with lower Verbal IQ and greater hyperglycemia exposure (HbA1c area under the curve) was inversely correlated to executive functions test performance. In addition, those with a history of both types of exposure performed most poorly on measures of executive function. CONCLUSIONS: The subtle cognitive differences between T1D children and nondiabetic controls observed at baseline were not observed 18 months later. Within the T1D group, as at baseline, relationships between cognition (Verbal IQ and executive functions) and glycemic variables (chronic hyperglycemia and DKA history) were evident. Continued longitudinal study of this T1D cohort and their carefully matched healthy comparison group is planned.

UTILITY OF PSYCHOLOGICAL SCREENING OF YOUNG ADULTS WITH TYPE 1 DIABETES TRANSITIONING TO ADULT PROVIDERS.

OBJECTIVE: Screening for depression, diabetes distress, and disordered eating in youth with type 1 diabetes (T1D) is recommended, as these comorbidities contribute to poor glycemic control. No consensus exists on which measures are optimal, and most previous studies have used nondisease-specific measures. We examined the utility of screening for these disorders using two disease-specific and one general measure at the time of transition from pediatric to adult care. METHODS: Forty-three young adults from a T1D transition clinic completed the Patient Health Questionnaire, the Diabetes Distress Scale, and the Diabetes Eating Problem Survey-Revised. Chart review determined if clinicians noted similar symptoms during the year prior to transition. Metabolic data were also recorded. RESULTS: Chart review identified 5 patients with depressive symptoms and 8 patients with diabetes distress. Screening identified 2 additional patients with depressive symptoms and 1 additional patient with diabetes distress. Of those noted to have symptomatic depression or diabetes distress on chart review, several subsequently screened negative on transition. Disordered eating was not detected by chart review, but 23.5% screened positive on transition. While depression, diabetes distress, and disordered eating positively correlated with glycated hemoglobin (HbA1c) (r = 0.31, P = .05; r = 0.40, P = .009; r = 0.63, P<.001, respectively), disordered eating accounted for the majority of observed variance (df = 1; F = 18.6; P<.001). Even though HbA1c was higher in patients with versus without disordered eating (P<.001), body mass index did not differ between the 2 groups (P = .51). CONCLUSION: In young adults with T1D, formal screening provides an opportunity to detect psychological problems, which, when treated, may help optimize metabolic control during the transition process. ABBREVIATIONS: T1D = type 1 diabetes HbA1C = hemoglobin A1c YCDP = Yale Children's Diabetes Program PHQ-8 = Patient Health Questionnaire-8 DDS = Diabetes Distress Scale DEPS-R = Diabetes Eating Problem Survey-Revised.

Cognitive functioning in young children with type 1 diabetes.

The aim of this study was to assess cognitive functioning in children with type 1 diabetes (T1D) and examine whether glycemic history influences cognitive function. Neuropsychological evaluation of 216 children (healthy controls, n = 72; T1D, n = 144) ages 4-10 years across five DirecNet sites. Cognitive domains included IQ, Executive Functions, Learning and Memory, and Processing Speed. Behavioral, mood, parental IQ data, and T1D glycemic history since diagnosis were collected. The cohorts did not differ in age, gender or parent IQ. Median T1D duration was 2.5 years and average onset age was 4 years. After covarying age, gender, and parental IQ, the IQ and the Executive Functions domain scores trended lower (both p = .02, not statistically significant adjusting for multiple comparisons) with T1D relative to controls. Children with T1D were rated by parents as having more depressive and somatic symptoms (p < .001). Learning and memory (p = .46) and processing speed (p = .25) were similar. Trends in the data supported that the degree of hyperglycemia was associated with Executive Functions, and to a lesser extent, Child IQ and Learning and Memory. Differences in cognition are subtle in young children with T1D within 2 years of onset. Longitudinal evaluations will help determine whether these findings change or become more pronounced with time.

Pediatric psychologist use of adherence assessments and interventions.

OBJECTIVE: To document current clinical practices for medical regimen adherence assessment and intervention in the field of pediatric psychology. METHODS: 113 members of the Society of Pediatric Psychology completed an anonymous online survey that assessed use of adherence assessments and interventions in clinical practice, barriers and facilitators to their use, and preferred resources for obtaining information on adherence assessments and interventions. RESULTS: Respondents reported using a range of adherence assessment and intervention strategies, some of which are evidence-based. Barriers to implementing these clinical strategies included time constraints and lack of familiarity with available clinical tools. Respondents reported that education about effective clinical tools would facilitate their use of adherence assessments and interventions. CONCLUSIONS: Future research and clinical efforts in adherence should consider developing practical tools for clinical practice, making accessible resources to promote dissemination of these tools, and increase understanding of clinician implementation of adherence assessments and interventions.

Development of an Internet coping skills training program for teenagers with type 1 diabetes.

The purpose of this study was to develop an Internet coping skills training program and to evaluate its feasibility and acceptability compared with an Internet education intervention for teenagers with type 1 diabetes. A multiphase mixed-methods design with focus groups, a randomized pilot study, and a program evaluation was used. Teenagers with type 1 diabetes, parents, and health professionals were included in the development and evaluative phases along with the research and information technology team. The pilot study included 12 teenagers with type 1 diabetes (mean [SD] age, 14.4 [.90] years; 58% female; mean [SD] duration of diabetes, 5.9 [3.0] years). Psychosocial data and HbA1c levels were collected at baseline and at 3 and 6 months. Results indicate that the development of a psychosocial Internet intervention was complex and required multiple iterations of development and evaluation. Results of this study also indicate the feasibility and acceptability of translating a group-based intervention for teenagers with type 1 diabetes to the Internet. Thus, this study demonstrates a systematic approach to Internet intervention development. Including teenagers with type 1 diabetes and a multidisciplinary professional team into the intervention design was critical to the success of this project.

Trust in hybrid closed loop among people with diabetes: Perspectives of experienced system users.

Automated closed loop systems will greatly change type 1 diabetes management; user trust will be essential for acceptance of this new technology. This qualitative study explored trust in 32 individuals following a hybrid closed loop trial. Participants described how context-, system-, and person-level factors influenced their trust in the system. Participants attempted to override the system when they lacked trust, while trusting the system decreased self-management burdens and decreased stress. Findings highlight considerations for fostering trust in closed loop systems. Systems may be able to engage users by offering varying levels of controls to match trust preferences.

Effects of coping skills training in school-age children with type 1 diabetes.

Children with type 1 diabetes are at risk for negative psychosocial and physiological outcomes, particularly as they enter adolescence. The purpose of this randomized trial (n = 82) was to determine the effects, mediators, and moderators of a coping skills training intervention (n = 53) for school-aged children compared to general diabetes education (n = 29). Both groups improved over time, reporting lower impact of diabetes, better coping with diabetes, better diabetes self-efficacy, fewer depressive symptoms, and less parental control. Treatment modality (pump vs. injections) moderated intervention efficacy on select outcomes. Findings suggest that group-based interventions may be beneficial for this age group.

Short-term effects of coping skills training in school-age children with type 1 diabetes.

OBJECTIVE: Little is known about the use of psychosocial interventions in children younger than adolescence with type 1 diabetes (T1D) and their parents. We report preliminary short-term outcomes of a randomized controlled trial of coping skills training (CST) compared with group education (GE) in school-aged children with T1D and their parents. METHODS: One hundred and eleven children (range = 8-12 yr) with T1D for at least 6 months (3.71 +/- 2.91 yr) were randomized to CST (55.6% female (F); 81.5% white (W)) or GE (69.7% F; 90.9% W). Children and parents (n = 87) who completed the intervention, baseline, 1- and 3-month data are included. Children completed measures of self-efficacy, coping, and quality of life; parents completed measures of family functioning (adaptability and cohesion), diabetes-related conflict, parent depression, and parent coping. Metabolic control was assessed with glycosylated hemoglobin A1c. Mixed-model repeated measures anova was used to analyze the data. RESULTS: CST and GE group composition was generally comparable. Children had good psychosocial adaptation and metabolic status. CST parents reported significantly more improvement in family adaptability compared with GE parents, and a trend was seen indicating that CST children showed greater improvement in life satisfaction than GE children. Effect sizes for this short-term follow-up period were small, but group participants were receptive to the intervention and reported positive gains. CONCLUSIONS: In these preliminary results, CST and GE were more similar than different across multiple measure of psychosocial adaptation, although CST showed promising statistical trends for more adaptive family functioning and greater life satisfaction. Longer term follow-up is underway.

Mediators of depressive symptoms in children with type 1 diabetes and their mothers.

OBJECTIVE: To examine the relationships among maternal and child depressive symptoms and child and family psychosocial factors. METHOD: Secondary analysis of baseline data for a coping skills intervention for school-age children (ages 8-12) with type 1 diabetes (T1D) and their mothers. Children and mothers completed measures of depressive symptoms, coping, quality of life, and family functioning. RESULTS: There was a strong relationship between maternal and child depressive symptoms (r = .44, p < .001). Maternal depressive symptoms were negatively related to child quality of life, perceptions of coping, and family functioning. Impact of diabetes on quality of life, finding coping with diabetes upsetting, and family warmth mediated the relationship between maternal and child depressive symptoms. CONCLUSIONS: Maternal depression may negatively affect child adjustment through its influence on quality of life, coping, and family functioning. Implications for interventions to improve psychosocial adjustment in children with T1D are discussed.

Positive Health Benefits of Peer Support and Connections for College Students With Type 1 Diabetes Mellitus.

Purpose The purpose of this study is to examine the characteristics and health outcomes of college students with type 1 diabetes mellitus (T1DM) as it relates to membership in a local university-based diabetes student organization. Methods This descriptive, correlational research design is a secondary analysis of data. The sample consisted of nationally representative young adults in college (n = 317) between 18 and 30 years of age who were diagnosed with T1DM. Data were collected during April 2017 using a secure electronic diabetes management survey to inquire about self-reported barriers to diabetes management, hypoglycemia, and diabetic ketoacidosis of members of a diabetes organization. Results Students were evenly distributed from freshman to senior year of college with a slight decrease at the graduate level. Students who were affiliated members of a student-led diabetes student organization were less likely to report increased levels of isolation, depressive symptoms, and anxiety related to their diabetes than were general members. Conclusion Participation in a university-based diabetes student organization on campus and connecting with other college students with diabetes may have health benefits. In conclusion, the current study underscores the potential importance of peer-led, diabetes-specific support for adolescents emerging into adulthood.

Psychosocial and Human Factors During a Trial of a Hybrid Closed Loop System for Type 1 Diabetes Management.

BACKGROUND: Hybrid closed loop (HCL) systems are designed to automate insulin delivery to improve type 1 diabetes (T1D) outcomes and reduce user burden and distress. Because the systems only automate some aspects of diabetes care, psychosocial and human factors remain an important consideration in their use. Thus, we examined whether psychosocial and human factors (i.e., distress related to diabetes management, fear of hypoglycemia, and technology attitudes) would (1) change after using the system and (2) predict glycemic outcomes during the trial. SUBJECTS AND METHODS: Fourteen adults and 15 adolescents with T1D participated in a multisite clinical trial of an investigational version of the MiniMed™ 670G system (Medtronic, Northridge, CA) over 4 to 5 days in a semisupervised outpatient setting. Users completed surveys assessing psychosocial and human factors before beginning the HCL system and at the conclusion of the study. t-Tests and regression analyses were conducted to examine whether these factors changed following trial exposure to the HCL system and predicted glycemic outcomes during the trial. RESULTS: Diabetes management distress decreased and diabetes technology attitudes became more positive over the trial period. Fear of hypoglycemia did not change over the trial period. There was a trend toward greater pretrial management distress predicting less time in range during the trial, controlling for time in range before the trial. CONCLUSIONS: Results suggest that this system is promising for enhancing technology attitudes and reducing management distress. Psychosocial factors, such as management distress, may negatively impact glycemic outcomes and should be a priority area for further investigation.

Disordered Eating Behaviors in Emerging Adults With Type 1 Diabetes: A Common Problem for Both Men and Women.

INTRODUCTION: Emerging adults (EA) with disordered eating behaviors (DEBs) and Type 1 diabetes (T1D) are at increased risk for severe complications of T1D, and these behaviors have been reported in EA women with T1D. Few studies, though, have included men. This study assessed the prevalence of DEB in both EA men and women with T1D. METHODS: DEB was measured with the diabetes-specific Diabetes Eating Problem Survey-Revised (DEPS-R); scores of 20 or greater indicate need for further evaluation for DEB. RESULTS: A total of 27 women and 33 men (age range = 21 ± 2.5 years) completed the DEPS-R; 27% of women and 18% of men had scores of 20 or greater (p = .23). Hemoglobin A1c level was significantly higher in subjects with elevated DEPS-R scores (10.4 ± 2.1% vs. 7.8 ± 1.3%; p < .001), and DEPS-R scores correlated with increased body mass index values (r = 0.27, p < .05). DISCUSSION: Clinicians should assess for DEB in both male and female emerging adults with T1D, especially overweight patients with poor glycemic control.

Expectations and Attitudes of Individuals With Type 1 Diabetes After Using a Hybrid Closed Loop System.

Purpose The first hybrid closed loop (HCL) system, which automates insulin delivery but requires user inputs, was approved for treatment of type 1 diabetes (T1D) by the US Food and Drug Administration in September 2016. The purpose of this study was to explore the benefits, expectations, and attitudes of individuals with T1D following a clinical trial of an HCL system. Methods Thirty-two individuals with T1D (17 adults, 15 adolescents) participated in focus groups after 4 to 5 days of system use. Content analysis generated themes regarding perceived benefits, hassles, and limitations. Results Some participants felt misled by terms such as "closed loop" and "artificial pancreas," which seemed to imply a more "hands-off" experience. Perceived benefits were improved glycemic control, anticipated reduction of long-term complications, better quality of life, and reduced mental burden of diabetes. Hassles and limitations included unexpected tasks for the user, difficulties wearing the system, concerns about controlling highs, and being reminded of diabetes. Conclusion Users are willing to accept some hassles and limitations if they also perceive health and quality-of-life benefits beyond current self-management. It is important for clinicians to provide a balanced view of positives and negatives to help manage expectations.