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Objective The purpose of the study was to determine whether resilience, defined by cognitive adaptation theory, predicted emerging adulthood outcomes among youth with and without type 1 diabetes. Methods Youth with ( n = 118) and without type 1 diabetes ( n = 122), who were part of a previous longitudinal study during adolescence, completed on-line questionnaires during their senior year of high school and one and two years later. They were average age 18, 53% female, and 93% white. Questionnaires assessed cognitive adaptation theory (CAT) indicators (self-esteem, mastery, optimism) and psychological, relationship, behavioral, vocational, and, for those with diabetes, diabetes outcomes. Results The CAT index at baseline predicted reduced psychological distress, enhanced psychological well-being, increased friend support, reduced friend conflict, the presence of romantic relationships, reduced likelihood of romantic breakups, higher GPA, higher work satisfaction, and lower work stress during the transition to emerging adulthood. Among those with diabetes, the CAT index predicted better self-care behavior and revealed a marginal relation to better glycemic control. Analyses controlled for baseline levels when appropriate. Findings were stronger one year than two years post high school graduation, and findings were stronger for those with than without diabetes. Youth with diabetes also scored lower on the CAT index than youth without diabetes. Conclusions These findings suggest that the implications of CAT include not only psychological health but also relationship, vocational, and diabetes outcomes. Those who score lower on CAT indicators should be identified as children so that interventions designed to enhance resilience can be implemented.

Objective To examine whether friendship and romantic relationships of emerging adults with type 1 diabetes differed from those of a comparison group, and to determine whether these relationships were associated with psychological and diabetes health outcomes. Methods High school seniors with (n = 122) and without (n = 118) type 1 diabetes were assessed annually for 3 years. Friend and romantic relationship variables, psychological distress, life satisfaction, eating disturbances, and, for those with diabetes, diabetes outcomes were assessed. Results Those with diabetes reported less friend support but similar friend conflict compared with controls. Aspects of romantic relationships and friend relationships were associated with health outcomes, but there were more effects involving romantic relationships. On some indices, romantic support was more beneficial for controls and romantic conflict was more troublesome for those with diabetes. Conclusions Both friendship and romantic relationships were associated with psychological and diabetes outcomes among emerging adults.

Objective To examine the relation of behavioral autonomy to psychological, behavioral, and physical health among emerging adults with and without type 1 diabetes. Methods High school seniors with (n = 118) and without type 1 diabetes (n = 122) completed online questionnaires for three consecutive years. Behavioral autonomy, psychological health, risk behaviors, and diabetes outcomes were assessed. Regression analyses were conducted to predict Time 2 and 3 outcomes, controlling for Time 1 outcomes. Results There were no group differences in behavioral autonomy. Behavioral autonomy predicted better psychological health but only for emerging adults without diabetes. Behavioral autonomy was related to increased risk behavior for both groups. Behavioral autonomy was unrelated to self-care but predicted better glycemic control for females. Conclusions Behavioral autonomy may be beneficial for psychological health, but is related to increased risk behavior. The implications of behavioral autonomy for emerging adults with type 1 diabetes require careful consideration.

There is a need to better understand the posttreatment concerns of the nearly 14 million survivors of cancer alive in the United States today and their receipt of care. Using data from 2,910 posttreatment survivors of cancer from the 2006 or 2010 LIVESTRONG Surveys, the authors examined physical, emotional, and practical concerns, receipt of care, and trends in these outcomes at the population level.89% of respondents reported at least one physical concern (67% received associated posttreatment care), 90% reported at least one emotional concern (47% received care), and 45% reported at least one practical concern (36% received care). Female survivors, younger survivors, those who received more intensive treatment, and survivors without health insurance often reported a higher burden of posttreatment concerns though were less likely to have received posttreatment care. These results reinforce the importance of posttreatment survivorship and underscore the need for continued progress in meeting the needs of this population. Efforts to increase the availability of survivorship care are extremely important to improve the chances of people affected by cancer living as well as possible in the posttreatment period.

Aims The goals of the study were to describe the transition of youth with Type 1 diabetes from paediatric to adult healthcare services, examine the link of this transition with self care and glycaemic control, and distinguish youth who received medical treatment from different physicians in terms of demographic and parent relationship variables. Methods Youth with Type 1 diabetes (n = 118) were enrolled in a prospective study that examined the transition from the paediatric to adult healthcare systems and were evaluated during their senior year of high school (time 1) and 1 year later (time 2). Data on self care, glycaemic control and parent relationship were collected. Results The majority of youth saw a paediatric endocrinologist at both assessments (n = 64); others saw an adult care physician at both assessments (n = 26) or transitioned from a paediatric endocrinologist to an adult care physician (n = 19). Nine youth saw no physician between time 1 and time 2. There were group differences in demographic and parent relationship variables and self-care behaviour and glycaemic control related to the transition of care. Youth who remained in the paediatric healthcare system had the best self care and did not experience declines in glycaemic control over time. Conclusions Early transition from the paediatric healthcare system to the adult healthcare system is associated with psychosocial variables and worse glycaemic control. Future research should identify factors that determine optimal timing and strategies to avoid deterioration of care and control during this transition.

Objective To examine the relation of adolescent and parent responsibility distribution for diabetes self-care to psychological and physical health. Methods We interviewed children (mean age 12 years) annually for 3 years and asked parents to complete a questionnaire. Both reported how diabetes self-care was distributed in the family. Amount of responsibility held by the child only, the parent only, and shared between child and parent was calculated. Psychological distress, competence, and diabetes outcomes were assessed at each wave. Results In both cross-sectional and longitudinal (lagged) analyses, multilevel modeling showed that shared responsibility was consistently associated with better psychological health, good self-care behavior, and good metabolic control, whereas child and parent responsibility were not. In some cases, links of shared responsibility to health outcomes were stronger among older adolescents. Conclusions These findings highlight the importance of shared responsibility for diabetes self-care through early to middle adolescence.

Objective To understand how primary care providers (PCPs) perceive barriers to adolescent depression care to inform strategies to increase treatment engagement. Study design We conducted semistructured interviews with 15 PCPs recruited from community pediatric offices with access to integrated behavioral health services (ie, low system-level barriers to care) who participated in a larger study on treating adolescent depression. Interviews addressed PCP perceptions of barriers to adolescents' uptake of care for depression. Interviews were audiorecorded, transcribed, and coded for key themes. Results Although PCPs mentioned several adolescent barriers to care, they thought parents played a critical role in assisting adolescents in accessing mental health services. Important aspects of the parental role in accessing treatment included transportation, financial support, and social support. PCPs perceived that parental unwillingness to accept the depression diagnosis, family dysfunction, and trauma were common barriers. PCPs contrasted this with examples of good family support they believed would enable adolescents to attend follow-up appointments and have a "life coach" at home to help monitor for side effects and watch for increased suicidality when starting antidepressants. Conclusions In this PCP population, which had enhanced access to mental health specialists, PCPs primarily reported attitudinal barriers to adolescent depression treatment, focusing mainly on perceived parent barriers. The results of these qualitative interviews provide a framework for understanding PCP perceptions of parental barriers to care, identifying that addressing complex parental barriers to care may be important for future interventions.

Adolescent depression is an under-recognized public health problem in the United States with serious consequences.1, 2 While almost 12% of all adolescents are diagnosed with major depression or dysthymia,3 only one-third of depressed adolescents receive mental health care.4 Although screening in primary care settings provides one route to identify and offer treatment for adolescents with depression,2, 5 other barriers may intervene to prevent successful treatment initiation, sufficient treatment engagement, and improved outcomes.6, 7 For primary care providers (PCPs) to effectively address adolescent depression and increase the likelihood for treatment initiation and engagement, strategies to better identify and address barriers to care are needed. Teens and parents in primary care settings identify a wide range of both external (e.g. transportation or access) and internal barriers (e.g. negative beliefs and attitudes) to depression care.8, 9 Depressed teens endorse internal barriers including fear of being identified as abnormal or a belief that they do not have a problem.8, 10 Parents may also face internal barriers such as not acknowledging that depression is a problem for the teen7, 9 or feeling guilty that the diagnosis is a result of poor parenting. Barriers most salient for parents differ from barriers identified by teens.9 A study on barriers to depression care among adolescents in primary care found that the top three barriers for parents of depressed teens were trouble making an appointment, high costs, and not wanting care.9 The top three barriers for depressed teens were personal responsibilities at school, home, or work, worry about family’s perceptions, and trouble making an appointment. Both parent and teen barriers predict poor uptake of depression care.7, 9 This study concluded that for PCPs to increase treatment uptake, they should identify and address teen and parent barriers to care. While several studies have investigated barriers to depression care for teens and parents,9–11 we are unaware of studies examining PCPs’ perceptions of these teen and parent barriers. Better understanding PCPs’ perceptions will assist in designing primary care interventions directed toward assisting PCPs in considering teen and parent needs, values, and preferences, thereby increasing initiation of and engagement with mental health care for adolescent depression. This exploratory study examined how PCPs perceive adolescents’ and parents’ beliefs about barriers to care, which may be important to improving the quality of shared decision-making in adolescent depression treatment decisions.

Adolescent depression is a serious public health problem which is under-recognized as well as undertreated.1 The primary care setting may be a key place where adolescent mental health concerns can be addressed. Most adolescents have a usual place of health care,2 and up to one-third of adolescents presenting to primary care have an emotional problem, with 14% screening positive for depression.3, 4 Furthermore adolescents with mental health problems more frequently visit their primary care provider (PCP) than do adolescents without mental health problems.5 Understanding how PCPs make treatment decisions for depressed adolescents and identifying the factors that influence these decisions may help increase the initiation of depression treatment in the primary care setting. Current PCP guidelines for adolescent depression recommend active support and monitoring (or watchful waiting) for mild depression, and cognitive behavioral therapy (CBT) and/or selective serotonin reuptake inhibitors (SSRIs) for moderate or severe depression.6-8 CBT is recommended for first-line treatment in the primary care setting,9 especially for moderate depression which may respond to CBT alone.7, 8 SSRIs, which show a greater benefit for lowering depressive symptoms for severely depressed teens compared with moderate or mildly depressed teens, are the first-line treatment for patients with a severe major depressive disorder diagnosis with or without psychotherapy.7, 10 A mental health consultation is also strongly encouraged for severely depressed teens.7 Of note, a recent systematic review and meta-analysis found limited evidence for the effectiveness of antidepressants in children and adolescents, especially at follow-up,11 and there are a small number of trials with positive findings.12 However, many factors beyond treatment guidelines influence PCPs’ treatment decisions for adolescent depression, such as structural barriers to care including poor access to mental health specialists, insurance barriers, and insufficient training in depression management.13 For families in many parts of the United States, access to specialty pediatric mental health care is characterized by long waits for appointments associated with an insufficient and poorly distributed mental health workforce, particularly child psychiatrists.14-16 Many pediatric PCPs lack training in the treatment of depression, and therefore, may lack confidence to prescribe antidepressants independently.17-19 Indeed, studies suggest that only one quarter of pediatric PCPs had recently independently prescribed an SSRI for an adolescent.17, 19 PCPs are particularly likely to refer patients to mental health specialists when symptoms are severe,20, 21 and due to discomfort with prescribing antidepressants,17, 18, 22 may prefer to refer a more severely depressed adolescent to child psychiatry for medication management as opposed to initiating medication themselves. While prior studies have examined PCP treatment decisions for adolescent depression, in many cases structural barriers may have dominated PCP decision-making, reducing the ability to study other PCP-level factors that influence treatment decisions for depressed adolescents. For this reason, we sought to examine this issue in a practice environment with fewer structural barriers due to frequent access to on-site mental health therapists, PCP training in depression diagnosis and management, and communication between PCPs and mental health providers through an integrated electronic health record. The current work addresses this gap by examining PCP beliefs about adolescent depression treatment in a setting with few structural barriers, allowing a clearer perspective on the impact of PCP characteristics and beliefs on their intentions. We examined PCPs’ initial treatment decisions using adolescent depression scenarios, assessing the impact of depression severity and other related factors on these treatment decisions. These other factors were exploratory due to limited research in this area. We hypothesized that PCPs would be sensitive to the severity of adolescent depression, and would alter treatment decisions based on the clinical information available in structured vignettes. We also hypothesized that PCPs with better knowledge of depression and more positive attitudes toward managing psychosocial problems would be more likely to prescribe antidepressants.

Objective This longitudinal study compared emerging adults with and without type 1 diabetes on life path decisions, health behaviors, and psychological well-being during the transition out of high school. Methods Administered questionnaires during the senior year of high school and 1 year later to 117 emerging adults with diabetes and 122 emerging adults without diabetes. Comparisons were conducted with respect to health status, sex, and school status. Results Those with and without diabetes chose similar life paths and engaged in similar levels of risky behaviors, but disturbed sleep increased for males with diabetes only. Having diabetes was not associated with depressive symptoms, loneliness, or bulimic symptoms, but was associated with lower life satisfaction and lower life purpose over time. Conclusions Emerging adults with and without diabetes fare similarly on most dimensions studied during the first year out of high school.

Purpose We examined differences in the nature of friendship between adolescents with diabetes and healthy adolescents. We also examined whether friend support and negative relations with friends were related to health for both groups. Method We interviewed 127 adolescents with diabetes and 129 healthy adolescents on two occasions, separated by one year. We measured aspects of friendship and psychological health among both groups as well as self-care behavior and metabolic control among adolescents with diabetes. We used logistic regression analysis to predict the presence of friends, repeated measures analysis of covariance to predict changes in friendship over time, and hierarchical multiple regression analysis to examine the relations of friendship to psychological health, self-care behavior, and metabolic control. Results Both groups of adolescents were equally likely to have a best friend and boyfriend/girlfriend, but healthy adolescents were more likely to have an other-gender friend. Adolescents with diabetes and healthy adolescents reported similar levels of friend support, but support increased over the year for healthy girls only. Boys with diabetes had the lowest levels of friend support. Negative relations with friends were inversely related to psychological health and predicted a decline in psychological health over time. Negative relations also predicted poor metabolic control and a deterioration of metabolic control over time. Conclusion There are similarities and differences in the nature of friendship for adolescents with diabetes compared with healthy adolescents. Friendship serves a protective function for psychological health for both groups and has implications for physical health among those with diabetes.

Background Friendships of adolescents with chronic illness have been rarely studied. Objective To compare the friendships of boys and girls with diabetes with those between healthy adolescents. Methods One hundred and thirty-eight adolescents were interviewed at summer camps. Participants indicated their number of close friends and rated friendships for support and conflict. Participants described aspects of their same-sex and other-sex friendships that they liked and disliked. Results Adolescents with diabetes have friendships that are similar to those between healthy adolescents, with a few exceptions. Conclusions Emotional support may be especially valued by girls with diabetes, whereas differences among friends may be less valued among adolescents with diabetes.