Extending sleep to improve glycemia: The Family Routines Enhancing Adolescent Diabetes by Optimizing Management (FREADOM) randomized clinical trial protocol.

Sleep deficiencies amongst individuals with type 1 diabetes mellitus (T1DM) have been linked with dysregulated glycemic control and greater morbidities. Sleep extension (EXT) has been identified as a viable intervention target to improve adolescent outcomes. The intervention aims to emphasize collaborative work with families to engage in behaviors that increase the likelihood of the youth increasing their sleep duration consistently. This study will randomize up to 175 youth with T1DM and at least one caregiver to either an EXT intervention or a family routines support (FRS) consultation. It is hypothesized that the EXT condition will lead to improvements in sleep, which in turn, will contribute to improved glycemic control. The primary endpoint is improved glycemic control assessed via a continuous glucose monitor (CGM) to ascertain average glucose levels across a week, glycemic variability, and percent time in the target range at one month and HbA1c at three months. Analyses will control for co-morbid conditions, including sleep-disordered breathing and obesity. This study will provide the needed data to support addressing sleep as part of the standards of care in youth with T1DM.

Sleep-related disorders in patients with type 1 diabetes mellitus: current insights.

Type 1 diabetes mellitus (T1DM) is an autoimmune condition that results from destruction of beta cells in the pancreas. Several reviews have concluded that sleep contributes to poor glycemic control, diabetes management, and diabetes-related complications in individuals with T1DM and represents an untapped opportunity for intervention. However, at the current juncture, the American Diabetes Association's Standards of Medical Care are devoid of recommendations about how to address sleep in the management of T1DM. This article summarizes reviews of sleep in youth and adults with T1DM and empirical studies that have examined various sleep parameters ranging from sleep disturbances (general, perceived sleep quality, sleepiness, awakenings, and sleep efficiency), sleep duration, sleep consistency, sleep-disordered breathing (SDB), and sleep architecture. The data show that many individuals with T1DM sleep less than recommendations; individuals with the poorest sleep have difficulties with diabetes management; and sleep deficiency including SDB often corresponds to several disease morbidities (neuropathy, nephropathy, etc). Mixed findings exist regarding direct associations of various sleep parameters and glycemic control. SDB appears to be just as prevalent, if not more, than other conditions that have been recommended for universal screening in individuals with T1DM. The article concludes with recommendations for collaborative research efforts to further elucidate the role of sleep in diabetes-related outcomes; investigations to test behavioral strategies to increase sleep quantity and consistency; and considerations for clinical care to address sleep.

Sleep patterns and sleep deprivation recorded by actigraphy in 4th-grade and 5th-grade students.

OBJECTIVE: This study investigates sleep patterns of fourth- and fifth-grade students using actigraphy. METHODS: The study included 257 students enrolled in a Southwestern US school district who participated in a novel sleep science curriculum during the Spring 2016-17 and Fall 2017-18 semesters and met the study inclusion criteria. As part of this curriculum, participants underwent 5-7 days of continuous wrist actigraphy and completed an online sleep diary. RESULTS: Approximately two-thirds of the 9-11-year-old fourth- and fifth-grade students slept less than the minimum 9 h per night recommended by both the American Academy of Sleep Medicine/Sleep Research Society and the National Sleep Foundation. The sleep midpoint time on weekends was about 1 h later than on weekdays. There was a significant effect of age on sleep duration. Compared to 9-year old students, a larger proportion of 10-year old students had a sleep duration less than 8.5 h. Boys had shorter sleep duration than girls, and a larger percentage of boys obtained less than 9 h of sleep compared to girls. CONCLUSIONS: Insufficient sleep is a highly prevalent condition among 9-11-year-old fourth- and fifth-grade elementary students. Importantly, there is a difference between sleep patterns on weekdays and weekends which may portend greater problems with sleep in adolescence and young adulthood.

Introduction to special issue on the history of the future of proactive school psychology: Transcending the past, excelling in the present, and transforming the future.

This Special Issue celebrates the 75th anniversary of the formation of the Division of School Psychology of the American Psychological Association. As part of this milestone celebration, we envisioned a field that could be changed by transcending the past, excelling in the present, and transforming the future. We identified a seminal article written by Conoley and Gutkin (1995) that advocated for the implementation of a systemic, prevention-oriented, ecological framework that would allow school psychology to realize its promise. Conoley, Powers, and Gutkin (2020) provided a synopsis of progress and stagnation in a new paper that served as the nexus from which invited authors were asked to respond, each representing a different aspect of school psychology practice, science, and training. In light of the division anniversary, authors described the historical context of their domain, reflected on the present, and shared recommendations for the future of school psychology. Collectively these contributions discussed school psychology's achievement to date, identify its shortfalls, and offer actionable suggestions for future school psychologists. Transformation is critical now more than ever in light of current health and world concerns and school psychology training and practice issues related to social justice and psychological and educational change. School psychologists are called to become proactive agents of change if we are to help heal our fractured and wounded world. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Differences in sleep architecture according to body mass index in children with type 1 diabetes.

Slow wave sleep (SWS), or deep sleep, is thought to be the most restorative stage of sleep and may be of a particular interest in the pathophysiology of obesity. The aim of this study was to investigate differences in sleep architecture based on body mass index (BMI) among a pediatric population with type 1 diabetes mellitus (T1DM). We hypothesized that children with T1DM who are obese would have less SWS than those who are not obese. Of 105 children with T1DM (mean age 13.54 years, 49.5% females) in this study, 19% were obese, 22% were overweight, and 59% had a normal BMI (81% non-obese). The overall SWS% among the participants was 13.2%. In contrast to our hypothesis, there was no significant difference in SWS% between obese and non-obese participants. However, the percent of time spent in rapid eye movement (REM) sleep among obese participants was significantly lower than those who were not obese (P = .022), which remained after adjusting the result for multiple covariates. While we found no significant association between the SWS time and BMI, obese adolescents with T1DM spent less time in REM sleep than those who were not obese. This study adds to the growing body of evidence supporting the importance of addressing sleep in clinical care of youth with T1DM.

Introduction to the special section on school-related outcomes and success for youth with chronic medical conditions.

Chronic medical conditions permeate our schools with estimates showing that between 15% and 25% of students present with an ongoing illness or disease. Treatments for the most prevalent of these conditions (e.g., diabetes, epilepsy, cancer, juvenile arthritis, and asthma) include hospitalizations, home treatments, and frequent physician appointments-all of which are highly disruptive to children and families. Given the potential medical, cognitive/academic, social-emotional, and behavioral challenges encountered by students with chronic medical conditions, school psychologists are in a unique position to both identify and support the educational experiences of these students. Further, schools provide an ideal forum for outcomes research and intervention programs. This Introduction to the Special Issue on School-Related Outcomes and Success for Youth With Chronic Medical Conditions addresses definitional issues, identifies challenges, reviews the 7 empirical articles in this issue, and discusses areas for future research. This special issue includes scientifically rigorous papers, which feature innovative studies that emphasize real-time, momentary assessments; positive psychology frameworks; and intervention approaches. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Glycemic control influences on academic performance in youth with Type 1 diabetes.

This study examined how children's and adolescents' with Type 1 diabetes mellitus glucose levels during and prior to academic assessment contributed to performance on reading, writing, and mathematics tasks. Participants had a mean age of 13.69 (SD = 2.10); 44.6% were female and 58.1% reported their ethnicity to be Hispanic, Latino, or Mexican. They wore a continuous glucose monitor for approximately 6 days and completed a neurobehavioral evaluation that consisted of tasks assessing basic reading skills, reading fluency, reading comprehension, math fact fluency, math calculation, spelling, and writing fluency. Results indicated that individuals whose glucose levels were suboptimal (>140 mg/dL) or hyperglycemic (>180 mg/dL) had significantly lower scores on reading fluency (ηp2 = .16) and writing fluency (ηp2 = .28) subtests than those in the target range (70-140 mg/dL). Moreover, more time spent hypoglycemic (<70 mg/dL) within the 12 hr prior to the evaluation increased the risk for impaired performance on academic tasks. These findings support the need to move beyond considering only overall glycemic control to review temporal influences of glucose levels on academic performance. By tracking how fluctuations impact academic performance, school based practitioners can better determine necessary accommodations to buffer glycemic dysregulation effects. In particular, individuals whose glucose levels are frequently outside of the target range are at greatest risk for performing below their true academic potential. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Diabetes management mediates the association between sleep duration and glycemic control in youth with type 1 diabetes mellitus.

OBJECTIVE/BACKGROUND: The purpose of this study was to examine the associations of diabetes management and sleep duration with glycemic control in youth with type 1 diabetes mellitus. PATIENTS/METHODS: 111 participants (mean age = 13.59 ± 2.11 years, 52.3% male, 50.5% non-white) wore actigraphy (average duration = 5.5 nights) and completed self-reported daily sleep diaries (average duration = 5.3 nights). Parents and participants each completed the Diabetes Management Scale (DMS) as part of a neurobehavioral evaluation. Glycated hemoglobin (HbA1c) and daily frequency of self-monitored blood glucose (SMBG) were collected from patient medical records. RESULTS: Youth with T1DM slept below the recommended amount of sleep for this age group (M = 7.45, SD = 0.74), which is approximately 9 h for school aged youth. They were in poor glycemic control with an average HbA1c of 9.11% (SD = 1.95) and their SMBG frequency was 4.9 (SD = 2.71). Average sleep duration from actigraphy was significantly correlated with average SMBG frequency and inversely related to HbA1c, indicating that less sleep was associated with worse management and glycemic control. When entered into a mediation model, diabetes management (SMBG frequency) completely mediated the relationship between sleep duration and glycemic control (HbA1c). Different sleep parameters of sleep quality, time to sleep, and sleep consistency also significantly correlated with HbA1c, SMBG, and parent and child-reports of various aspects of diabetes management. In particular, later bedtimes and a greater social jetlag predicted worse glycemic control. CONCLUSIONS: In a sample of sleep deprived and poorly controlled youth with T1DM, diabetes management was an intermediary factor between sleep duration and glycemic control. Additional analyses of data supported circadian influences on glycemic control. These results highlight the importance of addressing sleep duration, quality, and consistency as part of routine diabetes management in this population.

A Novel Artificial Neural Network Based Sleep-Disordered Breathing Screening Tool.

STUDY OBJECTIVES: This study evaluated a novel artificial neural network (ANN) based sleep-disordered breathing (SDB) screening tool incorporating nocturnal pulse oximetry with demographic, anatomic, and clinical data. The tool was compatible with 6 categories of apnea-hypopnea index (AHI) with 4% oxyhemoglobin desaturation threshold, ≥ 5, 10, 15, 20, 25, and 30 events/h. METHODS: Using a general population dataset, the training set included 2,280 subjects, whereas the test set included 470 subjects. The input of this tool was a set of 22 variables. The tool had six neural network models for each AHI threshold. Several metrics were explored to evaluate the performance of the tool: area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value, negative predictive value, and 95% confidence interval (CI). RESULTS: The AUC was 0.904, 0.912, 0.913, 0.926, 0.930, and 0.954, respectively, with models of AHI ≥ 5, 10, 15, 20, 25, and 30 events/h thresholds. The sensitivities of all neural network models were higher than 95%. The AHI ≥ 30 events/h model had the maximum sensitivity: 98.31% (95% CI: 95.01%-100%). CONCLUSIONS: The results of this study suggested that the ANN based SDB screening tool can be used to identify the presence or absence of SDB. Future validation should be performed in other populations to determine the practicability of this screening tool in sleep clinics and other at-risk populations.

The Development of a Clinically Relevant Sleep Modification Protocol for Youth with Type 1 Diabetes.

Findings from type 2 diabetes research indicate that sleep is both a predictor of onset and a correlate of disease progression. However, the role sleep plays in glucose regulation and daytime functioning in youth with type 1 diabetes mellitus (T1DM) has not been systematically investigated. Nonetheless, preliminary findings have supported that various sleep parameters are strongly correlated to health-related and neurobehavioral outcomes in youth with T1DM. This suggests that improving sleep might reduce morbidity. A critical step in developing evidence-based guidelines regarding sleep in diabetes management is to first determine that sleep modification in natural settings is possible (i.e., instructing youth to have a healthy sleep opportunity leads to more total sleep time) and that an increased sleep duration impacts disease and psychosocial outcomes in these youth. This article describes the background, design, and feasibility of an ongoing randomized clinical trial that aims to examine if increasing sleep relative to youth's own sleep routines affects glucose control and daytime functioning.

Sleep characteristics in type 1 diabetes and associations with glycemic control: systematic review and meta-analysis.

OBJECTIVES: The association between inadequate sleep and type 2 diabetes has garnered much attention, but little is known about sleep and type 1 diabetes (T1D). Our objectives were to conduct a systematic review and meta-analysis comparing sleep in persons with and without T1D, and to explore relationships between sleep and glycemic control in T1D. METHODS: Studies were identified from Medline and Scopus. Studies reporting measures of sleep in T1D patients and controls, and/or associations between sleep and glycemic control, were selected. RESULTS: A total of 22 studies were eligible for the meta-analysis. Children with T1D had shorter sleep duration (mean difference [MD] = -26.4 minutes; 95% confidence interval [CI] = -35.4, -17.7) than controls. Adults with T1D reported poorer sleep quality (MD in standardized sleep quality score = 0.51; 95% CI = 0.33, 0.70), with higher scores reflecting worse sleep quality) than controls, but there was no difference in self-reported sleep duration. Adults with TID who reported sleeping >6 hours had lower hemoglobin A1c (HbA1c) levels than those sleeping ≤6 hours (MD = -0.24%; 95% CI = -0.47, -0.02), and participants reporting good sleep quality had lower HbA1c than those with poor sleep quality (MD = -0.19%; 95% CI = -0.30, -0.08). The estimated prevalence of obstructive sleep apnea (OSA) in adults with TID was 51.9% (95% CI = 31.2, 72.6). Patients with moderate-to-severe OSA had a trend toward higher HbA1c (MD = 0.39%, 95% CI = -0.08, 0.87). CONCLUSION: T1D was associated with poorer sleep and high prevalence of OSA. Poor sleep quality, shorter sleep duration, and OSA were associated with suboptimal glycemic control in T1D patients.

Risk of behavioral and adaptive functioning difficulties in youth with previous and current sleep disordered breathing.

OBJECTIVES: To examine the rates of behavioral and adaptive functioning difficulties among youth who never had sleep disordered breathing (SDB), had remitted SDB, had incident SDB, or had persistent SDB; and to determine if there were increased odds of behavioral difficulties among youth with varying SDB histories relative to those who never had SDB. METHODS: 263 youth had valid polysomnography and neurobehavioral data at two time points approximately 5 years apart from the prospective Tucson Children's Assessment of Sleep Apnea study. Primary outcomes were the behavior assessment scale for children-2(nd) Edition parent report form (BASC-PRF) and Self-Report of Personality (SRP), and the Adaptive Behavior Assessment System-2(nd) Edition (ABAS-2). RESULTS: Compared to those who never had SDB, individuals with persistent SDB had significant odds and met more cutoff scores on the BASC-2-PRF externalizing problems composite (odds ratio [OR] 3.29; 8.92% vs. 35.3%), behavioral symptoms index (OR 6.82; 7.4% vs. 35.3%) and Hyperactivity subscale (OR 6.82; 11.1% vs. 41.2%). Similarly, greater difficulties was seen for the group with persistent SDB (relative to never) on the ABAS-2 social domain (OR 3.39; 22% vs. 50%), and Communication (OR 4.26; 15% vs. 42.9%) and Self-Care subscales (OR = 2.97; 25.2% vs. 50%). Relative to youth who never had SDB, youth who developed SDB at Time 2 had compromised adaptive skills as evidenced by the BASC-2 PRF adaptive behavior composite (OR 3.34; 15.6% vs. 38.1%) and the ABAS-2 general adaptive composite (OR 2.83; 20.5% vs. 42.1%). CONCLUSIONS: Youth with current SDB exhibited hyperactivity, attention problems, aggressivity, lower social competency, poorer communication, and/or diminished adaptive skills.

Relations between resiliency, diabetes-related quality of life, and disease markers to school-related outcomes in adolescents with diabetes.

The current study examined the role that resiliency and diabetes quality of life play in school functioning and glucose control among adolescents with diabetes. Participants included 45 adolescents with diabetes who participated in a larger study evaluating the feasibility of a model of mental health screening, assessment, and referral/service coordination. We hypothesized that aspects of resiliency (e.g., self-mastery, optimism, interpersonal relations, emotional control) would be related to self-reported grades and glucose control Hemoglobin A1c (HbA1c). We also hypothesized that the relation between resiliency and HbA1c would be mediated by blood glucose monitoring. We found that self-mastery (i.e., the perception that one has the ability to overcome challenges and solve problems) predicted self-reported school grades. Fewer diabetes-related worries and parental reports of less school-related problems (e.g., absences, problems with teacher) also predicted better grades. Females and youth with less disruptive behaviors and higher levels of self-mastery were less likely to be viewed by parents as having problems in school. Self-mastery, in addition to later age of onset and more frequent blood glucose monitoring, predicted lower HbA1c. The mediational model could not be tested because the same components of resiliency that related to blood glucose monitoring did not relate to HbA1c. This study suggests that evaluation of positive attributes of adolescents, particularly the self-mastery component of resiliency, and consideration to the adolescents' perceptions of how diabetes affects their lives, may assist in understanding how these adolescents perform in school and manage their diabetes.

Relationship between sleep quality and quantity and weight loss in women participating in a weight-loss intervention trial.

Evidence suggests that individuals who report fewer total hours of sleep are more likely to be overweight or obese. Few studies have prospectively evaluated weight-loss success in relation to reported sleep quality and quantity. This analysis sought to determine the association between sleep characteristics and weight loss in overweight or obese women enrolled in a randomized clinical trial of a weight-loss program. We hypothesized that in overweight/obese women, significant weight loss would be demonstrated more frequently in women who report a better Pittsburgh Sleep Quality Index (PSQI) Global Score or sleep >7 h/night as compared to women who report a worse PSQI score or sleep ≤7 h/night. Women of ages 45.5 ± 10.4 (mean ± SD) years and BMI of 33.9 ± 3.3 (n = 245) were randomized and completed PSQI at baseline and 6 months; 198 had weight change assessed through 24 months. At baseline, 52.7% reported PSQI scores above the clinical cutoff of 5. Better subjective sleep quality increased the likelihood of weight-loss success by 33% (relative risk (RR), 0.67; 95% confidence interval (CI), 0.52-0.86), as did sleeping >7 h/night. A worse Global Score at 6 months was associated with a 28% lower likelihood of continued successful weight loss at 18 months, but unassociated by 24 months. These results suggest that sleep quality and quantity may contribute to weight loss in intervention-based studies designed to promote weight control in overweight/obese adult women.

Mothers' depressive symptoms and children's facial emotions: examining the depression-inhibition hypothesis.

Vibrant expression of emotion is the principal means infants and young children use to elicit appropriate and timely caregiving, stimulation, and support. This study examined the depression-inhibition hypothesis: that declines in mothers' support as their depressive symptoms increase inhibit children's emotional communication. Ninety-four mothers and their 14- to 27-month-olds interacted in a university playroom. Based on microanalytic coding of discrete facial displays, results supported three components of the hypothesis. (a) As mothers' depressive symptoms increased, children displayed less facial emotion (more flat affect, less joy, less sadness, less negative). (b) Mothers' low emotional and behavioral support predicted children's low facial communication and mediated relations between mothers' depressive symptoms and children's infrequent emotion. (c) Children who were passive with mothers behaviorally expressed emotion infrequently. Children's passivity mediated relations between mothers' depressive symptoms and children's infrequent emotion displays. Contrary to modeling and contagion theories, mothers' facial displays did not mediate relations between their depressive symptoms and children's facial displays. Nor were the outcomes children experienced regulating their facial displays. Rather, findings suggest that, even when depressive symptoms are modest, young children inhibit emotion as mothers' depressive symptoms increase to withdraw from unresponsive mothers, which may adversely affect children's subsequent relationships and competencies.

Sleep, glucose, and daytime functioning in youth with type 1 diabetes.

UNLABELLED: STUDY HYPOTHESES: 1) Youth with evidence of SDB (total apnea-hypopnea index [Total-AHI] ≥ 1.5) would have significantly worse glucose control than those without SDB; 2) Elevated self-reported sleepiness in youth with T1DM would be related to compromised psychosocial functioning; and 3) Youth with T1DM would have significantly less slow wave sleep (SWS) than controls. DESIGN: The study utilized home-based polysomnography, actigraphy, and questionnaires to assess sleep, and continuous glucose monitors and hemoglobin A1C (HbA1C) values to assess glucose control in youth with T1DM. We compared sleep of youth with T1DM to sleep of a matched control sample. SETTING: Diabetic participants were recruited in a pediatric endocrinology clinic. PARTICIPANTS: Participants were youth (10 through 16 years) with T1DM. Controls, matched for sex, age, and BMI percentile, were from the Tucson Children's Assessment of Sleep Apnea study. RESULTS: Participants with a Total-AHI ≥ 1.5 had higher glucose levels. Sleepiness and/or poor sleep habits correlated with reduced quality of life, depressed mood, lower grades, and lower state standardized reading scores. Diabetic youth spent more time (%) in stage N2 and less time in stage N3. Findings related to sleep architecture included associations between reduced SWS and higher HbA1C, worse quality of life, and sleepiness. More time (%) spent in stage N2 related to higher glucose levels/hyperglycemia, behavioral difficulties, reduced quality of life, lower grades, depression, sleep-wake behavior problems, poor sleep quality, sleepiness, and lower state standardized math scores.

Relations between Minnesota Multiphasic Personality Inventory-A scales and Rorschach variables with the scope and severity of maltreatment among adolescents.

This study examined preexisting Rorschach (Exner, 2001) and Minnesota Multiphasic Personality Inventory-A (MMPI-A; Butcher et al., 1992) profiles to determine if selected MMPI-A scales and Rorschach variables would jointly associate with the number and severity of maltreatment subtypes (physical abuse, sexual abuse, neglect, and emotional maltreatment) of 157 adolescents (ages 14-17) with documented maltreatment histories. The Maltreatment Classification System was used to systematically code the maltreatment attributes. Six Rorschach variables (MOR, PER, Afr, SumY, SumC', Human Content) were significantly correlated with the number of maltreatment subtypes, but none of the anticipated MMPI-A scales were related. MMPI-A Scale 7 and Rorschach variables Ego, MOR, and PER were jointly associated with physical abuse severity. MMPI-A Scale 0 and Rorschach variables MOR, PER, SumY, SumC', PTI, Human Content, and Texture jointly associated with sexual abuse severity. This study supports the potential for certain MMPI-A scales and Rorschach variables to reflect the impact of adolescents' maltreatment experiences in terms of the number and severity of types of maltreatment experienced. Because both instruments captured different aspects of adolescents' maltreatment experiences, clinicians should consider using both when evaluating the impact of maltreatment on adolescents.

Adolescents with diabetes and their parents' perceptions of mental health screening, assessment, and feedback.

This study examined adolescents with diabetes and their parents' reactions to mental health screenings, assessments, and feedback. Most parents and adolescents did not report negative affect, but 15- and 16-year olds and referred adolescents showed greater levels of concern with assessment outcomes. Among those referred to mental health services, parents anticipated barriers in costs, insurance, and lack of qualified providers. Adolescents reported scheduling conflicts, time, and confidentiality concerns. Respondents perceived feedback as an important component of the clinical process and findings indicated a need for clinicians to incorporate psychosocial screenings and feedback in healthcare visits for adolescents with diabetes.

Cognitive-behavioral therapy and hypnotic relaxation to treat sleep problems in an adolescent with diabetes.

Inadequate sleep among adolescents frequently contributes to obesity and reduced academic performance, along with symptoms of anxiety, depression, fatigue, and attention deficits. The etiological bases of sleep quality has been associated with both stress and sleep habits. These problems tend to be especially important for adolescents with diabetes as the effects of poor sleep complicate health outcomes. This case example concerns a 14-year-old adolescent girl with a history of type I diabetes and stress-related sleep difficulties. Treatment included cognitive-behavioral methods and hypnotic relaxation therapy. Results of this case example and other controlled research suggest that hypnotic relaxation therapy is well accepted, results in good compliance, and serves as a useful adjunctive to cognitive-behavioral intervention for sleep problems.