Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for youth with Type 2 diabetes: reliability and validity.

AIM: To test the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module originally developed in Type 1 diabetes in youth with Type 2 diabetes. METHODS: The PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were administered in a field test study to 100 young people aged 9-25 years with Type 2 diabetes. Factor analysis was conducted to determine the factor structure of the items. RESULTS: The 15-item Diabetes Symptoms Summary Score and 12-item Type 2-specific Diabetes Management Summary Score were empirically derived through factor analysis. The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores showed acceptable to excellent reliability across the age groups tested (α = 0.85-0.94). The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores evidenced construct validity through large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.67 and 0.57, respectively). HbA1c was correlated with the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores (r = -0.13 and -0.22). Minimal clinically important difference (MCID) scores were 5.91 and 7.39 for the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores. CONCLUSIONS: The PedsQL 3.2 Diabetes Module Diabetes Symptoms Summary Score and Type 2-specific Diabetes Management Summary Score exhibited satisfactory measurement properties for use as youth self-reported diabetes symptoms and diabetes management outcomes for clinical research and clinical practice for young people with Type 2 diabetes.

Targeting risk factors for type 2 diabetes in American Indian youth: the Tribal Turning Point pilot study.

BACKGROUND: American Indian (AI) youth are at high risk for type 2 diabetes. OBJECTIVES: To partner with Eastern Band of Cherokee Indians and Navajo Nation to develop a culturally sensitive behavioural intervention for youth (Tribal Turning Point; TTP) and assess feasibility in an 8-month randomized pilot study. METHODS: We enrolled 62 overweight/obese AI children (7-10 years) who participated with ≥1 parent/primary caregiver. Intervention participants (n = 29) attended 12 group classes and five individual sessions. Control participants (n = 33) attended three health and safety group sessions. We analysed group differences for changes in anthropometrics (BMI, BMI z-score, waist circumference), cardiometabolic (insulin, glucose, blood pressure) and behavioural (physical activity and dietary self-efficacy) outcomes. RESULTS: Study retention was 97%, and intervention group attendance averaged 84%. We observed significant treatment effects (p = 0.02) for BMI and BMI z-score: BMI increased in control (+1.0 kg m-2 , p < 0.001) but not intervention participants (+0.3 kg m-2 , p = 0.13); BMI z-score decreased in intervention (-0.17, p = 0.004) but not control participants (0.01, p = 0.82). There were no treatment effects for cardiometabolic or behavioural outcomes. CONCLUSIONS: We demonstrated that a behavioural intervention is feasible to deliver and improved obesity measures in AI youth. Future work should evaluate TTP for effectiveness, sustainability and long-term impact in expanded tribal settings.

Psychosocial therapies in diabetes: report of the Psychosocial Therapies Working Group.

OBJECTIVE: To review key advances in the behavioral science literature related to psychosocial issues and therapies for persons with diabetes, to discuss barriers to research progress, and to make recommendations for future research. RESEARCH DESIGN AND METHODS: Key findings from the literature on psychosocial research in diabetes are reviewed separately for children and adults. Specific issues covered include psychosocial adjustment and psychiatric disorders, neurocognitive functioning, quality of life, and psychosocial therapies. Barriers that must be addressed to allow research in this area to progress are discussed. Recommendations are then made concerning high-priority areas for advancing research in the field. CONCLUSIONS: A substantial amount of behavioral science research has demonstrated that psychosocial factors play an integral role in the management of diabetes in both children and adults. Research has also shown the efficacy of a number of psychosocial therapies that can improve regimen adherence, glycemic control, psychosocial functioning, and quality of life. More research in this area is needed to develop psychosocial intervention programs for specific patient populations and to demonstrate the cost-effectiveness of these approaches.

Parenting styles, regimen adherence, and glycemic control in 4- to 10-year-old children with diabetes.

OBJECTIVE: To examine relationships among parenting styles, regimen adherence, and glycemic control for preschool and elementary school children who have Type I diabetes. METHODS: Parents of 55 children with diabetes completed parenting style and regimen adherence questionnaires. Glycosylated hemoglobin results were collected by chart review. RESULTS: Parental warmth was associated with better adherence ratings. Regression analyses showed that parental warmth explained 27% of the variance in adherence ratings. Parental restrictiveness was associated with worse glycemic control in univariate analyses. However, only Black ethnicity, not adherence or parenting variables, predicted glycemic control. Black ethnicity and lower socioeconomic status (SES) were associated with more parental restrictiveness and worse glycemic control. CONCLUSIONS: These results suggest that authoritative parenting, characterized by support and affection, may be advantageous for the regimen adherence and glycemic control of school-age and younger children with diabetes. Demographic characteristics are important and require further study in this context.

School-based identification of asthma in a low-income population.

The increase in the prevalence, morbidity, and mortality of asthma among children over the last decade has been well documented, especially among low-income minority children. Hypotheses for the increases in morbidity and mortality include limited access to primary care services and the failure to recognize the presence and severity of asthma. The University of Miami Pediatric Mobile Clinic (Mobile Clinic) Asthma Intervention Program is designed to identify underserved asthmatic children at school and offer them culturally sensitive care. Nine elementary schools with low income, predominantly Hispanic and African-American populations regularly served by the Mobile Clinic, were chosen for study participation. All 5,800 students who were enrolled in kindergarten through third grade were given letters at the time of registration by their homeroom teachers about the asthma program. Caretakers who returned the questionnaire and reported that the student had asthma symptoms were invited to have the student undergo a medical evaluation in the Mobile Clinic. Over a 2-year period, caretakers of 423 students (7.3% of all students) expressed an interest in further evaluating their child's respiratory health. Of these, we enrolled and evaluated 154 in the Mobile Clinic's Asthma Intervention Program. The Mobile Clinic physicians identified 145 of the enrollees as having asthma. These results indicate that in elementary schools serving predominantly low-income minority populations, a large fraction of the asthmatic population (estimated prevalence, 6-10%) can be identified by a school-based letter. Further, in a subset of asthmatic students (children of interested caretakers), there is good agreement between caretaker responses and physician diagnosis of asthma. Since school attendance is mandatory, school-based methods may be an effective method for identifying low-income children with asthma.

Risk for metabolic control problems in minority youth with diabetes.

OBJECTIVE: We examined and quantified the degree of risk for poor glycemic control and hospitalizations for diabetic ketoacidosis (DKA) among black, Hispanic, and white children and adolescents with diabetes. RESEARCH DESIGN AND METHODS: We examined ethnic differences in metabolic control among 68 black, 145 Hispanic, and 44 white children and adolescents with type 1 diabetes (mean age 12.9 [range 1-21] years), who were primarily of low socioeconomic status. Clinical and demographic data were obtained by medical chart review. Glycohemoglobins were standardized and compared across ethnic groups. Odds ratios among the ethnic groups for poor glycemic control and hospitalizations for DKA were also calculated. RESULTS: The ethnic groups were not different with respect to age, BMI, insulin dose, or hospitalizations for DKA, but black children were older at the time of diagnosis than Hispanics (P < 0.05) and were less likely to have private health insurance than white and Hispanic children (P < 0.001). Black youths had higher glycohemoglobin levels than white and Hispanic youths (P < 0.001 after controlling for age at diagnosis). Black youths were also at greatest risk for poor glycemic control (OR = 3.9, relative to whites; OR = 2.5, relative to Hispanics). CONCLUSIONS: These results underscore and quantify the increased risk for glycemic control problems of lower-income, black children with diabetes. In the absence of effective intervention, these youths are likely to be overrepresented in the health care system as a result of increased health complications related to diabetes.

Self- and spouse ratings of anger and hostility as predictors of coronary heart disease.

Self- and spouse ratings of anger and hostility were examined as predictors of coronary heart disease (CHD) in 185 cardiac patients. Patients completed the Multidimensional Anger Inventory (MAI) and the Marlowe-Crowne Social Desirability (MCSD) Scale; the MAI (rewritten to 3rd person) was completed by patients' spouses or by a peer. Thallium scans were used to measure CHD status. Results showed that patient-rated MAI scores were inversely correlated with MCSD. There were no gender differences for patient-rated MAI scores, but spouse ratings showed gender effects for Anger-Arousal and Hostile Outlook: Women rated their husband higher than men rated their wife. Patients with positive thallium scans were no different from those without CHD on patient-rated MAI scores; however, spouse ratings indicated that those with CHD had higher Hostile Outlook and Anger-In scores. After accounting for the effects of traditional CHD risk factors, only spouse-rated hostility contributed significant incremental variance to the prediction of CHD status.

Stress management training for adolescents with diabetes.

Evaluated the effects of stress management training (SMT) for adolescents with diabetes in a 9-month controlled treatment-outcome study. Nine patients were randomly assigned to a stress management group while another 10 patients served as controls and received standard outpatient treatment. The treatment program consisted of 10 sessions over 3 months, 3 additional sessions over 3 months, and a 3-month follow-up without treatment. Diabetes-specific stress decreased significantly for patients in the SMT group over the course of the intervention and follow-up. However, metabolic control, regimen adherence, coping styles, and self-efficacy about diabetes were unchanged. These findings suggest a SMT program for adolescents with diabetes may be helpful in reducing diabetes-specific stress, but additional procedures are necessary to improve adherence, coping styles, and metabolic control.

Compliance with dietary prescriptions in children and adolescents with insulin-dependent diabetes mellitus.

This study investigated the relationship between compliance with a prescribed diabetic diet and metabolic control of insulin-dependent diabetes mellitus (IDDM). The study sought to determine the degree to which patients translated food exchange prescriptions into appropriate food choices and to identify correlations between metabolic control (as measured by glycosylated hemoglobin level) and compliance with prescribed food exchanges, body mass index (BMI), and intake of energy and fat. Subjects were 40 inpatients and 29 outpatients aged 4 to 18 years with IDDM. Records of the inpatients' food selections for 3 days and 3-day food records collected from the outpatients (or their parents) were analyzed. For all 69 subjects, the mean daily deviation from the prescribed food exchanges was 23.8%, which indicates that subjects added or deleted approximately one of four prescribed exchanges. Records of actual food intake revealed that both patient groups had greater mean energy intakes than had been prescribed: 196 additional kcal for inpatients and 372 additional kcal for outpatients; fat sources accounted for 92% and 68% of the greater energy intake, respectively. No correlation was found between glycosylated hemoglobin level and BMI, energy intake, or fat intake.

Racial differences in metabolic control of children and adolescents with type I diabetes mellitus.

OBJECTIVE: This study evaluated racial differences in the metabolic control of children and adolescents with insulin-dependent (type I) diabetes mellitus and examined the interactive effects of race with age and sex. RESEARCH DESIGN AND METHODS: Data on several demographic and clinical variables were obtained for 102 black and 108 white children, including the percentage of total HbA1, age, age at diagnosis, duration of diabetes, pubertal status, insulin dose (U.kg-1.day-1), body mass index, number of clinic visits kept and missed, number of hospitalizations for diabetic ketoacidosis (DKA) for the year, and socioeconomic status (SES). RESULTS: Black children had higher insulin dosages (P less than 0.05) and lower SESs (P less than 0.001) than white children. HbA1 was higher in black than white children (P less than 0.01) after statistically adjusting for the effects of insulin dose, diabetes duration, and SES. With HbA1-based criteria, more black than white children were in poor and fewer in good metabolic control (P less than 0.001). Older children (greater than or equal to 13 yr) had higher HbA1 levels than younger (less than 13 yr) children (P less than 0.002), but there were no differences in HbA1 between males and females nor were there interactive effects of race, sex, and age-group. Black children were hospitalized for DKA more frequently than white children (P less than 0.04). More black than white children missed clinic visits (P less than 0.01), but they did not differ in number of visits kept. CONCLUSIONS: Black youths with type I diabetes mellitus are in poorer metabolic control than white youths.

Learned helplessness in diabetic youths.

Determined the relationships among the learned helplessness attributional style, depression, regimen adherence, and metabolic control in a sample of diabetic youth. Fifty children (20 male and 30 female) between the ages of 10 and 16 completed the Children's Attributional Style Questionnaire and the Children's Depression Inventory. Regimen adherence was assessed with three 24-hr recall interviews conducted separately with patients and their mothers over a 1-week period. Metabolic control was measured by glycosylated hemoglobin A1 (HbA1). Learned helplessness was significantly associated with depression (p less than .001) and HbA1 (p less than .02), but was not associated with regimen adherence. Depression was unrelated to regimen adherence and metabolic control. The adherence measures together accounted for 24% of the variance of HbA1. Significant correlations were obtained between HbA1 and the exercise (p less than .05) and eating/testing frequency (p less than .05) adherence factors, indicating that lower levels of adherence were associated with worse metabolic control. Age, pubertal status, sex, disease duration, and SES were unrelated to regimen adherence and metabolic control. These results support the notion that the learned helplessness attributional style for negative events is related to both depression and long-term metabolic control problems in diabetic youths.

Randomized prospective study of self-management training with newly diagnosed diabetic children.

This study was designed to evaluate the effects of a self-management training (SMT) program on metabolic control of children with insulin-dependent diabetes mellitus (IDDM) in the first 2 yr after diagnosis. After standard in-hospital diabetes education, 36 children (mean age 9.3 yr, range 3-16 yr) were randomized to conventional follow-up, conventional and supportive counseling (SC), or conventional and SMT, which emphasized use of data obtained from self-monitoring of blood glucose. SC and SMT interventions consisted of seven outpatient sessions with a medical social worker during the first 4 mo after diagnosis and booster sessions at 6 and 12 mo postdiagnosis. Groups were similar with respect to age, sex, body mass index, socioeconomic status, C-peptide, and severity of illness at diagnosis. Metabolic control, measured quarterly by glycosylated hemoglobin (HbA1), improved substantially in all three treatment groups during the first 6 mo. SMT patients had significantly lower HbA1 levels than conventional patients at 1 yr (P less than 0.01) and 2 yr (P less than 0.05) postdiagnosis. SMT patients also had lower HbA1 levels than SC patients, but this did not reach statistical significance. The lower HbA1 levels of SMT patients were not explained by severity of illness at diagnosis, or insulin dose, body mass index, and C-peptide levels at 2 yr. These results suggest that an SMT program during the first few months after diagnosis helps avoid the deterioration in metabolic control often seen in children with IDDM between 6 and 24 mo after diagnosis.

Cardiovascular correlates of type A behavior components during social interaction.

This study examined the cardiovascular (CV) correlates of the primary Type A behavior components during social interactions. Brief dialogues were created to role-play (RP) stereotypic Type A and Type B ways of responding to three common social situations designed to elicit hostility (H), time-urgency (T), and competition (C). Situations and dialogues were validated by independent raters. Thirty undergraduate students were identified as Type A and 30 as Type B, with 15 males and 15 females in each group. Subjects were provided scripts for each of the six experimental RPs and rehearsed them prior to the CV assessment. Measures of systolic and diastolic blood pressure (SBP, DBP) and heart-rate (HR) were obtained during an adaptation period and during each RP. Analyses of the "A" (i.e. H, T, C) versus "B" (i.e. non-H, non-T, non-C) RPs indicated that DBP (p less than 0.03) and HR (p less than 0.002) were higher during the H as compared with non-H RP. Significantly higher SBP was observed in the T as compared with the non-T RP (p less than 0.04). No CV differences were observed in the comparison of the C and non-C RPs. Analyses comparing the three "Type A" RPs revealed higher SBP during H and T RPs, as compared with the C RP (p less than 0.003). Effects of subject Type (i.e. A/B) were not obtained in any analysis. These findings indicate that hostile and time-urgent social interactions are associated with significant increases in CV arousal which are independent of overall Type status.

Self-monitoring of blood glucose by adolescents with diabetes: technical skills and utilization of data.

Two studies of adolescent patients were conducted to determine their technical skills and utilization of data obtained by self-monitoring of blood glucose (SMBG). In Study 1, direct observations of 58 adolescents revealed an overall SMBG technical accuracy score of 82%. Most frequent errors were not cleaning fingers (45%), not placing blood on strips correctly (21%), and wiping strip at wrong time (14%). Technical performance was inversely correlated with blood glucose concentration, but was unrelated to other variables. In Study 2, a questionnaire was used to determine SMBG practices among 64 adolescents. Although the majority of patients reported doing daily SMBG, most did not record results in logbooks every time or utilize such data for self-management. No significant relationships were found between SMBG behaviors and other variables. We conclude that periodic evaluation and retraining are required for maintenance of SMBG skills and that methods to enhance utilization of SMBG data be developed for this patient population.

Interpersonal behavior and cardiovascular reactivity in pharmacologically-treated hypertensives.

This study examined the interpersonal behavior and concomitant cardiovascular reactivity (CVR) of hypertensive patients whose resting blood pressure was controlled by antihypertensive medication. Thirty hypertensive and 30 normotensive subjects matched for age, sex and occupational status were recruited from an industrial setting. The groups were compared on measures of interpersonal behavior, blood pressure and heart rate while they engaged in both role-played (RP) and naturalistic interactions (NI) requiring positive and negative assertion. Interpersonal behavior of the groups was generally similar, with two exceptions: hypertensives made fewer requests for new behavior in the negative RP and verbalized more praise statements in the positive NI. There were no differences between the groups on measures of CVR during interpersonal interactions. Overall effectiveness during scenes requiring negative assertion was associated with increased cardiovascular reactivity, especially for hypertensives. The interpersonal behavior and cardiovascular responses of patients taking beta-blocker medication did not differ from those taking diuretics. These findings are discussed with regard to methodological considerations pertinent to the assessment of interpersonal behavior and the issue of heterogeneity among hypertensives.

Stress and coping in relation to metabolic control of adolescents with type 1 diabetes.

The purpose of this study was to determine whether measures of anxiety, stress, and means of coping with stress differ in diabetic adolescents in good, fair, and poor metabolic control. Trait anxiety, perceived daily stress, and coping responses to a recent stressful event were assessed in 27 adolescents with Type 1 diabetes mellitus. Information also was obtained regarding the type of stressful events that subjects referred to in completing the coping measure, as well as their appraisals of the events. Hemoglobin A1 (HbA1) obtained at the time of the study was used as a measure of antecedent metabolic control. Based upon their HbA1, patients were divided into three metabolic control subgroups: good control (M = 8.4%; n = 8), fair control (M = 10.9%; n = 9), and poor control (M = 13.3%; n = 10). Patients in these subgroups were similar with regard to age, disease duration, and socioeconomic status. Results indicated that the subgroups did not differ on the anxiety and stress measures; however, analyses of the coping data indicated that patients in poor control employed significantly more wishful thinking and avoidance/help-seeking than did patients in good metabolic control. Furthermore, the metabolic control subgroups differed in the type of stressful events reported and their appraisals of the stressful events. These results support the hypothesis that the ways in which individuals with diabetes appraise and cope with stress is related to their metabolic control. The findings are discussed in relation to methodological issues and treatment implications.

Physiological correlates of conduct problems and anxiety in hyperactive and learning-disabled children.

Thirty-six learning disabled children (21 of whom were also classified as hyperactive) were subgrouped according to teacher ratings of tension-anxiety and conduct problems and then compared on measures of tonic and phasic autonomic arousal. The results indicated that children rated high on the conduct problem dimension evidenced smaller amplitude specific skin conductance responses, and that anxiety appeared to exert a moderating effect on physiological responses. When the hyperactive sample was considered separately, lower skin conductance levels were observed in children rated high on conduct problems than in hyperactive children rated low in conduct problems. These findings support the notion that hyperactive and learning-disabled children are heterogeneous at a physiological level and suggest that physiological differences previously attributed to hyperactivity may actually be correlates of the conduct problem dimension.