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There are few detailed workforce studies of specialty fields within professional psychology, and none have been reported for pediatric psychology since 2006. Availability of such data could facilitate more-informed decision making by students and trainees, psychologists pursuing employment opportunities, and psychologists involved in employment or compensation negotiations. This article describes the work of a task force of the American Psychological Association (APA) Division 54 (Society of Pediatric Psychology) in the design, construction, pretesting, distribution, and data management for the Society of Pediatric Psychology (SPP) Workforce Survey. The 18-member task force was established to design and implement a workforce survey that balanced needs for breadth, clarity, brevity, and protection of confidentiality. The survey solicits information about demographic characteristics; training, licensure and certifications; employment settings, responsibilities, and productivity metrics; compensation; and employment satisfaction. A survey link was distributed via e-mail to full members of the SPP in June 2015. A total of 404 members (32.3% return rate) completed the survey. This article focuses on the development, methodology, and respondent characteristics for this 1st administration of the workforce survey. Separate articles will report detailed analyses of the survey results such as compensation and work satisfaction. Future distributions of the survey will enable compilation of a longitudinal database to track changes in the profession. SPP members and others may propose additional analyses of these data. This work may provide guidance to other groups of specialized psychologists who may wish to implement similar initiatives.

OBJECTIVE This study assessed longitudinal change in depression symptoms over ≥4 years in adults with type 1 diabetes and examined the association between change in depression symptom status and glycemia. RESEARCH DESIGN AND METHODS Adults in the T1D Exchange registry with HbA1c and Patient Health Questionnaire (PHQ-8) at 1 year (baseline) and 5 years post-enrollment (follow-up; n = 2,744, mean age, 42 years; 57% female, 92% white; mean HbA1c, 7.6% [58 mmol/mol]) were included. Depression status was defined as Persistent Elevated Depression Symptoms (EDS) (EDS at baseline and follow-up), Resolved EDS (EDS at baseline, no EDS at follow-up), New Onset EDS (no EDS at baseline, EDS at follow-up), and Not Depressed (no EDS at baseline or follow-up). RESULTS Overall, 131 (5%) had Persistent EDS, 122 (4%) had Resolved EDS, 168 (6%) had New Onset EDS, and 2,323 (85%) were Not Depressed. Of those with EDS (PHQ ≥ 10) at baseline, 53% had EDS at follow-up; of those not depressed at baseline, 7% had EDS at follow-up. An increase in PHQ-8 was associated with an increase in HbA1c (P < 0.001). Although HbA1c increased in all groups, the increase was less in the Resolved EDS and Not Depressed groups (P = 0.001). Persistent EDS and New Onset EDS groups were more likely to experience diabetic ketoacidosis (DKA) (P < 0.001). CONCLUSIONS T1D Exchange registry data provide evidence for relationships over time between persistently, and newly developing EDSs and worsening glycemic control, and suggest relationships between depression symptoms and the occurrence of severe hypoglycemia and DKA. Successful treatment of depression symptoms may lead to better long-term diabetes outcomes.

Developmental shifts during early adolescence relate to type 1 diabetes (T1D) self-management, increased risk of emotional distress, and worsening health status. Less is known about positive experiences related to T1D. This study evaluated associations of positive well-being (PWB) with diabetes burden, self-management, and glycemic control. Youth ( N = 55, age = 12-13 years; [Formula: see text] age = 12.75 + 0.56 years, 50.9% male, 38.2% non-Caucasian) reported PWB, depressive symptoms, and diabetes burden. Parents reported on overall T1D adherence. Adherence behaviors and glycemic control were assessed objectively. Higher PWB correlated with lower depressive symptoms ( rs = −.45), less diabetes burden ( rs = −.48), and better glycemic control ( rs = −.43), all p < .01. When controlling for diabetes duration, higher PWB correlated with lower depressive symptoms and better glycemic control. PWB was not related to demographics or adherence. Initial exploration suggests PWB is related to key diabetes constructs, and maybe valuable to consider along with efforts to support youth with T1D during a vulnerable developmental period.

OBJECTIVE: Children with type 1 diabetes and their parents face daily self-care demands, leading to diabetes-specific emotional distress. A standardized measure of diabetes distress can guide clinical care and prevent negative outcomes. METHODS: This study evaluated the psychometric properties of child- and parent-report measures of the Problem Areas in Diabetes Scale, adapted for children ages 8–12 (PAID-C) and their parents (P-PAID-C). Participants were from 42 diabetes camps in the United States. Children (N = 804; mean age = 10.3 ± 1.1) and parents (N = 968) completed measures of diabetes distress, diabetes-related strengths, and self-care skills. Half of the sample was used for exploratory factor analyses (EFA) with direct oblimin rotation and the other half for confirmatory factor analyses (CFAs). RESULTS: For the PAID-C, EFA and CFAs supported an 11-item two-factor measure, Cronbach’s α = .91, accounting for 54.6% of the variance. For the P-PAID-C, analyses resulted in a 16-item measure, Cronbach’s α = .92, accounting for 51.9% of the variance. PAID-C and P-PAID-C scores were positively correlated with HbA1c (r(child) = .08, p = .04; r(parent) = .18, p

This review summarizes the literature on care and outcome disparities in young adults (YA) with type 1 and type 2 diabetes, and outlines remaining needs and suggestions to reduce disparities and improve care. Despite well-documented disparities and data from large national and international diabetes populations, the role that social determinants of health play in disease management is largely unstudied. Further, mechanisms of how these risk factors interact with the unique developmental needs of racial-ethnic minority and economically vulnerable young adults with diabetes remain unknown. Little intervention research has focused on improving outcomes in this vulnerable population. More research needs to focus on identifying and addressing risk factors in racial-ethnic minority and economically vulnerable young adults with diabetes. Interventions need to be adapted and developed to meet the unique needs of this high-risk population. Clinicians and healthcare systems must recognize the inequity in care and outcomes for this group and structure clinical programs and policies to promote their optimal care.

Background: While health-related quality of life (HRQoL) is gaining recognition as an important patient-reported outcome, little is known about how diabetes care providers define or apply HRQoL in practice. The purpose of this study was to identify how diabetes care providers conceptualize HRQoL for youth and adults with type 1 diabetes (T1D) to help guide efforts to more routinely assess and intervene to improve HRQoL. Methods: As part of a larger qualitative study on T1D-specific HRQoL, semi-structured qualitative interviews were conducted with 8 diabetes care providers (5 pediatric providers, 3 adult providers, 62.5% male) via focus groups or individually. Sessions were audio-recorded, transcribed, and coded to derive common themes. Results: Providers identified three key components of T1D-specific HRQoL: (1) their patients’ day-to-day functioning, including the ability to engage in everyday activities and its impact on their emotional well-being; (2) their patients’ medical management, including diabetes self-management behaviors and presence of complications and hypo/hyperglycemia; and (3) the impact of T1D on their patients’ personal relationships, including the impact on the HRQoL of their parents/partners. Conclusion: Providers described three aspects of T1D-specific HRQoL: everyday functioning, medical considerations, and interpersonal relationships. This extends the HRQoL literature from other chronic condition populations, which has not emphasized provider perceptions of HRQoL, has primarily identified medical domains such as disease-specific symptoms/complications, and provides little understanding of HRQoL of other family members. Together with findings about patient/family perspectives on HRQoL from the larger study, the current findings about how diabetes care providers conceptualize diabetes-specific HRQoL are necessary to help guide clinical processes to routinely assess and enhance HRQoL across the lifespan. Disclosure V.T. Cao: None. S.S. Eshtehardi: None. B.M. McKinney: None. B. Anderson: Advisory Panel; Self; Sanofi-Aventis. D.G. Marrero: None. D. Thompson: None. M.E. Hilliard: None.

To assess change in depression over ≥4 years in adults with type 1 diabetes (T1D) and the association between change in depression and glycemic outcomes, we examined PHQ-8 data in adults in the T1D Exchange Clinic Registry with T1D duration ≥ 1 year (N= 2547; 57% female, 92% non-Hispanic white, year 1 age 43±16 years). PHQ-8 score ≥10 defined “depressed.” Linear regression was used to assess association of continuous outcomes and depression; logistic regression was used for categorical outcomes. At year 1/year 5, 9%/11% were depressed. In this sample, 126 (5%) had Persistent Depression (depressed at year 1 and year 5), 112 (4%) Resolved Depression (depressed at year 1, not at year 5), 148 (6%) New Year 5 Depression (not depressed at year 1, depressed at year 5), and 2161 (85%) Not Depressed at year 1/year 5. Of those depressed at year 1, 53% were depressed at year 5; of those not depressed at year 1, 6% were depressed at year 5. Participants with persistent depression/new year 5 depression had a significant increase (↑) in A1c [adj mean ↑ 0.5± 0.2/0.5± 0.2; adj mean 8.1±0.1 for both; adj P’s=0.001]; those not depressed at year 1/year 5 showed a trend in ↑A1c [0.3±0.1; adj mean 7.8±0.1; adj P=0.04]. Those with resolved depression did not show change in A1c [0.2±0.2; adj mean 7.7±0.2; adj P=0.28]. Those with persistent depression/new year 5 depression were more likely to report new year 5 DKA (DKA year 5 | no DKA year 1) than those not depressed at year 1/year 5 (adj P’s=0.03/0.04). There were trends for those with persistent depression to be more likely to report new year 5 severe hypoglycemia (SH) than those not depressed (11.1% vs. 4.8%); and for those with resolved depression to be less likely to report new year 5 SH (3.6 vs. 4.8%, adj P’s=0.09/0.11). Depression category was not associated with change in BMI (adj P=0.80). As a continuous variable, ↑in PHQ-8 was associated with ↑ in A1c (adj P0.50). Depression (persistent or new year 5) has a negative impact on glycemic control over time. Adults with T1D should be screened and treated for depression. Disclosure P.M. Trief: Research Support; Self; National Institute of Diabetes and Digestive and Kidney Diseases. N.C. Foster: None. N. Chaytor: None. M.E. Hilliard: None. J. Kittelsrud: None. S. Jaser: None. S. Majidi: None. S. Corathers: None. S. Bzdick: None. D. Adkins: None. R.S. Weinstock: Research Support; Self; Medtronic MiniMed, Inc., Mylan, Kowa Pharmaceuticals America, Inc., Diasome Pharmaceuticals, Inc., Calibra Medical, Dexcom, Inc., Ultradian Diagnostics LLC., JAEB Center For Health Research, JDRF, National Institute of Diabetes and Digestive and Kidney Diseases.

Aims Adolescent girls with diabetes are at risk for adverse pregnancy outcomes due to age, risk-taking behavior, poor glycemic control, and lack of knowledge. Our aims were to assess attitudes and behaviors related to reproductive health education (RHE) among diabetes healthcare providers and adolescent girls with diabetes, and to pilot a brief clinic-based RHE intervention. Methods We surveyed 29 providers and 50 adolescent girls with type 1 diabetes about RHE experiences, attitudes, and behaviors. We piloted the RHE intervention with 9 adolescent-parent dyads. Results 50% of providers were very uncomfortable discussing pregnancy or contraception. Most (72%) did not proactively initiate RHE; common barriers included insufficient time and subject knowledge. Fewer than 10% recommended long-acting reversible contraceptives. A minority (10%) of adolescents had discussed pregnancy or contraception with a provider. RHE sessions lasted a median of 16 (range 13–24) minutes, and there were promising trends for changes in adolescents’ self-efficacy and intentions to use contraception and seek preconception counseling and in their knowledge of reproductive health. Conclusion Adolescent girls with diabetes rarely receive education on pregnancy and contraception due to provider discomfort, limited knowledge, and limited time. RHE using easily-accessible materials with an educator may help address this gap in care.

Background: Supportive parent involvement for adolescents’ type 1 diabetes (T1D) self-management promotes optimal diabetes outcomes. However, family conflict is common and can interfere with collaborative family teamwork. Few interventions have used explicitly strengths-based approaches to help reinforce desired management behaviors and promote positive family interactions around diabetes care. Objective: The aim of this protocol was to describe the development of a new, strengths-based behavioral intervention for parents of adolescents with T1D delivered via a mobile-friendly Web app called Type 1 Doing Well. Methods: Ten adolescent-parent dyads and 5 diabetes care providers participated in a series of qualitative interviews to inform the design of the app. The 3- to 4-month pilot intervention will involve 82 parents receiving daily prompts to use the app, in which they will mark the diabetes-related strength behaviors (ie, positive attitudes or behaviors related to living with or managing T1D) their teen engaged in that day. Parents will also receive training on how to observe diabetes strengths and how to offer teen-friendly praise via the app. Each week, the app will generate a summary of the teen’s most frequent strengths from the previous week based on parent reports, and parents will be encouraged to praise their teen either in person or from a library of reinforcing text messages (short message service, SMS). Results: The major outcomes of this pilot study will include intervention feasibility and satisfaction data. Clinical and behavioral outcomes will include glycemic control, regimen adherence, family relationships and conflict, diabetes burden, and health-related quality of life. Conclusions: This strengths-based, mobile health (mHealth) intervention aims to help parents increase their awareness of and efforts to support their adolescents’ engagement in positive diabetes-related behaviors. If efficacious, this intervention has the potential to reduce the risk of family conflict, enhance collaborative family teamwork, and ultimately improve diabetes outcomes. Trial Registration: ClinicalTrials.gov NCT02877680; https://clinicaltrials.gov/ct2/show/NCT02877680 (Archived by WebCite at http://www.webcitation.org/6xTAMN5k2) [JMIR Res Protoc 2018;7(3):e77]

Background Diabetes self-management is complex and demanding, and isolation and burnout are common experiences. The Internet provides opportunities for people with diabetes to connect with one another to address these challenges. The aims of this paper are to introduce readers to the platforms on which Diabetes Online Community (DOC) participants interact, to discuss reasons for and risks associated with diabetes-related online activity, and to review research related to the potential impact of DOC participation on diabetes outcomes. Methods Research and online content related to diabetes online activity is reviewed, and DOC writing excerpts are used to illustrate key themes. Guidelines for meaningful participation in DOC activities for people with diabetes, families, health care providers, and industry are provided. Results Common themes around DOC participation include peer support, advocacy, self-expression, seeking and sharing diabetes information, improving approaches to diabetes data management, and humor. Potential risks include access to misinformation and threats to individuals’ privacy, though there are limited data on negative outcomes resulting from such activities. Likewise, few data are available regarding the impact of DOC involvement on glycemic outcomes, but initial research suggests a positive impact on emotional experiences, attitudes toward diabetes, and engagement in diabetes management behaviors. Conclusion The range of DOC participants, activities, and platforms is growing rapidly. The Internet provides opportunities to strengthen communication and support among individuals with diabetes, their families, health care providers, the health care industry, policy makers, and the general public. Research is needed to investigate the impact of DOC participation on self-management, quality of life, and glycemic control, and to design and evaluate strategies to maximize its positive impact.

Suboptimal adherence remains a significant concern for adolescents with Type 1 diabetes, the treatment regimen for which is complex and includes numerous behaviors. Accurate assessment of adherence is critical for effective healthcare and to measure trial outcomes. Without a valid biomarker of adherence, assessment strategies must rely on measuring management behaviors. This paper provides an overview of approaches to measure adherence, with an emphasis on contemporary, validated measures that are appropriate for current diabetes care. Objective measures include electronic data from diabetes management devices. Subjective measures include self/parent-report questionnaires, structured interviews and diaries/logbooks. Practical strategies for selecting measurement approaches for clinical and research purposes are reviewed, and implications of adherence assessment for clinical care delivery and adherence-promotion are discussed.

Behavioral management of diabetes leads to better health outcomes. This paper reviews the available literature on facilitators of behavior change in people with diabetes and highlights approaches and strategies diabetes care providers can utilize. The research and clinical evidence points to the critical nature of considering the content and structure of recommendations, and utilizing problem solving and teamwork approaches. Furthermore, close attention to individual and community factors will optimize behavior change. These factors include health literacy, community infrastructure, support within the family, and whether there are co-occurring eating and mood issues. Recommendations are provided to optimize communication and embed behavior change approaches in clinical and community encounters.

Health-related quality of life (HRQOL) is a critical diabetes outcome, yet differences between youth and parent-proxy ratings can make interpretation difficult. This study aims to explore potential differences between self- and parent-reports of Pediatric Quality of Life Inventory (PedsQL) scores from youth with type 1 (T1D) or type 2 diabetes (T2D) and to evaluate associations between discrepancies, PedsQL scores, and glycemic control (HbA1c). Youth and parents in the SEARCH for Diabetes in Youth Study (T1D: age 5–18, n = 3402; T2D: age 8–18, n = 353) completed the PedsQL Generic and Diabetes Modules, and youth provided a blood sample to assess HbA1c. Discrepancies (youth minus parent PedsQL ratings) were calculated and examined by age and diabetes type, and associations with youth PedsQL scores and HbA1c were evaluated. Discrepancies existed between youth and parent-proxy reports of generic and diabetes PedsQL scores in T1D and T2D (all p values

An electronic medical record (EMR)-based transition planning tool (TPT) designed to facilitate transition from pediatric to adult-based health care for youth (16-25 years) with special health care needs was introduced at a large children's hospital. Activities to increase provider use were implemented in five plan-do-study-act cycles. Overall, 22 of 25 (88%) consenting providers in four pediatric subspecialty services used the TPT during 303 patient encounters, with nurses and case-managers the top users and physicians the least likely users. Use was highest with intensive technical assistance and following the introduction of an upgraded tool. Provider satisfaction with the TPT and self-reported transition planning activities notably increased across the PDSA cycles.

This special issue of the Journal of Pediatric Psychology showcases a growing area of research with a collection of 16 contemporary studies of resilience in youth with chronic medical or developmental conditions and their families. The research reported in this special issue covers a broad range of pediatric populations, including cancer, type 1 diabetes, and chronic pain, among others, ranging in age from early childhood through early adulthood. This introduction to the special issue reviews the various ways the articles' authors conceptualize and define risk and resilience; most analyze protective processes in relation to resilient outcomes, including both achievement of explicitly positive experiences and avoidance of dysfunction or disruption. Challenges with measurement of resilience-related constructs is reviewed. Finally, the special issue editors offer a definition of resilience in the context of pediatric and health psychology.

Medication adherence plays an important role in optimizing the outcomes of many treatment and preventive regimens in chronic illness. Self-report is the most common method for assessing adherence behavior in research and clinical care, but there are questions about its validity and precision. The NIH Adherence Network assembled a panel of adherence research experts working across various chronic illnesses to review self-report medication adherence measures and research on their validity. Self-report medication adherence measures vary substantially in their question phrasing, recall periods, and response items. Self-reports tend to overestimate adherence behavior compared with other assessment methods and generally have high specificity but low sensitivity. Most evidence indicates that self-report adherence measures show moderate correspondence to other adherence measures and can significantly predict clinical outcomes. The quality of self-report adherence measures may be enhanced through efforts to use validated scales, assess the proper construct, improve estimation, facilitate recall, reduce social desirability bias, and employ technologic delivery. Self-report medication adherence measures can provide actionable information despite their limitations. They are preferred when speed, efficiency, and low-cost measures are required, as is often the case in clinical care.

Objective To characterize protective factors in young children with type 1 diabetes, and evaluate associations among child protective factors and indicators of diabetes resilience, including better child and parent psychosocial functioning and glycemic control. Methods Parents of 78 young children with type 1 diabetes reported on child protective factors, child quality of life, parent depressive symptoms, and disease-specific parenting stress. A1c values were collected from medical records. Results Young children with type 1 diabetes were rated as having similar levels of protective factors as normative samples. Greater child protective factors were associated with indicators of diabetes resilience, including higher child quality of life and lower parent depressive symptoms and parenting stress. Regression analyses demonstrated that child protective factors were associated with 16% of the variance in parent-reported depressive symptoms. Conclusions Attention to child protective factors can enhance understanding of adjustment to type 1 diabetes and may have implications for intervention.

Type 1 diabetes (T1D) incidence in youth is growing across all racial/ethnic backgrounds, with the most marked increase in African-American youth under 5. Underrepresented racial/ethnic minorities are at an increased risk for health complications. This review focuses on the reported disparities, demographics of samples in behavioral interventions, and study design considerations. Recruitment data from two ongoing behavioral intervention trials for young children with T1D are presented to compare enrolled/non-enrolled individuals and to discuss culturally appropriate study design considerations. Data were compared to the demographics of children (ages 1–6) with T1D in the clinic populations from the recruitment sites. Enrolling a representative sample and designing culturally appropriate behavioral interventions are important for generalizability, yet there is a gap between the individuals participating in T1D research and those who are most negatively affected by T1D. Suggestions are offered for ways to expand inclusion of diverse samples in behavioral intervention research in T1D.

BACKGROUND Supportive parent involvement for adolescents’ type 1 diabetes (T1D) self-management promotes optimal diabetes outcomes. However, family conflict is common and can interfere with collaborative family teamwork. Few interventions have used explicitly strengths-based approaches to help reinforce desired management behaviors and promote positive family interactions around diabetes care. OBJECTIVE The aim of this protocol was to describe the development of a new, strengths-based behavioral intervention for parents of adolescents with T1D delivered via a mobile-friendly Web app called Type 1 Doing Well. METHODS Ten adolescent-parent dyads and 5 diabetes care providers participated in a series of qualitative interviews to inform the design of the app. The 3- to 4-month pilot intervention will involve 82 parents receiving daily prompts to use the app, in which they will mark the diabetes-related strength behaviors (ie, positive attitudes or behaviors related to living with or managing T1D) their teen engaged in that day. Parents will also receive training on how to observe diabetes strengths and how to offer teen-friendly praise via the app. Each week, the app will generate a summary of the teen’s most frequent strengths from the previous week based on parent reports, and parents will be encouraged to praise their teen either in person or from a library of reinforcing text messages (short message service, SMS). RESULTS The major outcomes of this pilot study will include intervention feasibility and satisfaction data. Clinical and behavioral outcomes will include glycemic control, regimen adherence, family relationships and conflict, diabetes burden, and health-related quality of life. CONCLUSIONS This strengths-based, mobile health (mHealth) intervention aims to help parents increase their awareness of and efforts to support their adolescents’ engagement in positive diabetes-related behaviors. If efficacious, this intervention has the potential to reduce the risk of family conflict, enhance collaborative family teamwork, and ultimately improve diabetes outcomes. CLINICALTRIAL ClinicalTrials.gov NCT02877680; https://clinicaltrials.gov/ct2/show/NCT02877680 (Archived by WebCite at http://www.webcitation.org/6xTAMN5k2)

One of the most common chronic conditions of childhood, the prevalence of type 1 diabetes (T1D) in young children is increasing. Early childhood development complicates optimal T1D management and glycemic outcomes. Parents are at risk for elevated psychological distress, especially immediately following diagnosis. Few empirically supported interventions are available to support parents and promote optimal T1D management during this vulnerable period. This paper reports on the development and study design of First STEPS: Study of Type 1 in Early childhood and Parenting Support. The aim of this trial is to evaluate the efficacy of a stepped care behavioral intervention for parents of young children over the first year following a new T1D diagnosis. The stepped care design provides participants with up to three intensity levels, or steps, of clinical behavioral intervention support based on need, compared to usual care. Intervention steps include peer parent coaching, telephone-based behavioral support, personalized psychological assessment and recommendations, and intensive assessment of T1D glycemic management with recommendations. Primary outcomes include children's glycemic control and parents' psychosocial functioning. Secondary outcomes include children's behavioral and psychosocial functioning. Exploratory analyses will evaluate demographic, disease-specific, and psychosocial factors related to progression in and response to each step of the intervention.

This study investigated unique burdens experienced by parents of young children with type 1 diabetes in the context of contemporary diabetes management.Self-report surveys and medical record information from the T1D Exchange clinic registry were used. Parental burden and family impact scores were tabulated across demographic and clinical characteristics, overall and according to age group (4, 4-6, and 6-7 years).The mean age of the 597 children was 5.2 ± 1.2 years (n = 1114 years, n = 291 4-6 years, and n = 195 6-7 years) and mean duration of diabetes was 2.4 ± 1.1 years. Mean hemoglobin A1c was 8.2% ± 1.1%. Approximately one-third (31%) reported their child was currently using CGM and over half (58%) reported using insulin pumps. The most frequently endorsed parent-reported burdens of diabetes were worrying about child having a low blood sugar (74%), about the future and possibility of serious complications (70%), and feeling upset when their child's diabetes management is "off track" (61%). Areas endorsed for negative family impact were diminished amount or quality of sleep for family members (59%) and need for flexible working arrangements to help care for their child (55%).Substantial burdens remain for parents of young children with type 1 diabetes, despite the availability of advanced technologies for diabetes management.

Peer support is a promising model of providing psychosocial support to parents of children with type 1 diabetes. This review seeks to discuss the findings of the existing literature in peer coaching as it relates to parents and diabetes as well as to identify gaps in knowledge for future intervention development and implementation. Peer support programs vary widely with regard to recruitment, training, and delivery protocols. Across most programs, ongoing support and supervision are provided to peer coaches. Despite inconsistent effects on psychosocial and child health outcomes, parent coaching is consistently a highly acceptable and feasible intervention with parents of children with T1D. Current evidence supports use of parent coaching as part of a multicomponent intervention or program to increase patient satisfaction, but more research is needed to determine if it can stand alone as an active mechanism for behavior change. The use of peer coach interventions for parents of young children with diabetes is feasible to implement and highly acceptable. However, more research is needed to understand the enduring impact for target parents and peer coaches alike, as well as impact on child outcomes.

The purpose of this study is to evaluate the mediating role of perceptions of primary care (PC) on the association between depression and PC clinic attendance among caregivers of children with asthma. In adults, depression is associated with lower PC clinic attendance and ∼25% of mothers presenting to a pediatric PC clinic will screen positive for depression. Adults' perceptions about their medical care mediate the depression-clinic attendance relation, but this has not been tested in children or in an asthma population.This is a secondary prospective data analysis of 141 caregivers of Head Start children diagnosed with asthma, offered an intervention to reduce barriers to PC. Caregivers rated their depressive symptoms and perceptions of PC (access, provider contextual knowledge, and continuity of care) at baseline. PC clinic attendance was tracked prospectively for 6-months.At baseline, 26% of caregivers screened positive for depression. Within 6-months, 66% of children attended a PC appointment. A positive depression screen was not associated with PC attendance (p = 0.07) or continuity of care (p = 0.98) but was inversely associated with perceptions of both access (p = 0.03) and provider contextual knowledge (p = 0.02). Though the total indirect effect was not significant, the specific indirect effect of depression on PC attendance through access was significant (95% CI: 0.01, 0.68).Providing tangible resources to reduce barriers to PC without addressing perceptions of access may not sufficiently improve PC clinic attendance in pediatric asthma. Screening caregivers for depression may identify families requiring targeted interventions to improve their perceptions of access.

Practice-based psychological intervention research that is conducted by practitioners in pediatric clinical settings raises special challenges that need to be met to maximize opportunity for success. Based on our experiences in intervention research conducted in clinical settings by practicing pediatric psychologists and health care providers, we consider issues in designing and implementing intervention research, resource development, interdisciplinary collaboration, ethical issues, data analysis, and application of findings in clinical practice. Recommendations to enhance the implementation of psychological intervention research in pediatric clinical settings include balancing feasibility versus validity in study design, considering multiple approaches to study designs and data analyses, identifying and managing ethical issues, facilitating interdisciplinary collaborations, developing resources, and enhancing opportunities for research training.

OBJECTIVE Among the many milestones of adolescence and young adulthood, transferring from pediatric to adult care is a significant transition for those with type 1 diabetes. The aim of this study was to understand the concerns, expectations, preferences, and experiences of pretransition adolescents and parents and posttransition young adults. RESEARCH DESIGN AND METHODS Participants completed questionnaires and responded to open-ended qualitative questions regarding self-management, self-efficacy, and their expectations and experiences with pediatric and adult care providers across the transition process. RESULTS At a mean age of 16.1 years, most pretransition adolescents had not yet discussed transferring care with their parents or doctors. Although many posttransition young adults reported positive, supportive interactions, several described challenges locating or establishing a relationship with an adult diabetes care provider. Qualitative themes emerged related to the anticipated timing of transfer, early preparation for transition, the desire for developmentally appropriate interactions with providers, the maintenance of family and social support, and strategies for coordinating care between pediatric and adult care providers. CONCLUSIONS Standardizing transition preparation programs in pediatric care and introducing transition-oriented clinics for late adolescents and young adults prior to adult care may help address patients’ preferences and common transfer-related challenges.

OBJECTIVE To establish minimal clinically important difference (MCID) scores representing the smallest detectable change in quality of life (QOL), using the Pediatric Quality of Life Inventory (PedsQL) Generic Core and Diabetes Module among youth with diabetes and their parents, and to identify demographic and clinical correlates of QOL change over 1 year. RESEARCH DESIGN AND METHODS Participants in the SEARCH for Diabetes in Youth Study aged >5 years and parents of youth aged RESULTS The sample comprised 5,004 youth (mean age, 12.5 ± 4.7 years; mean diabetes duration, 3.4 ± 3.7 years). Of 100 possible points, PedsQL total score MCIDs for youth with type 1 and type 2 diabetes, respectively, were Generic Core, 4.88, 6.27 (parent) and 4.72, 5.41 (youth); Diabetes Module, 4.54, 6.06 (parent) and 5.27, 5.96 (youth). Among 1,402 youth with a follow-up visit, lower baseline QOL, male sex, private insurance, having type 1 diabetes, longer diabetes duration, and better glycemic control predicted improvements in youth- and parent-reported PedsQL total scores over 1 year. Clinically meaningful (≥1 MCID) improvements in total score for at least one PedsQL module were predicted by private insurance, lower BMI, and lower A1C at baseline. CONCLUSIONS These diabetes-specific reference points to interpret clinically meaningful change in PedsQL scores can be used in clinical care and research for youth with type 1 and type 2 diabetes.

Cough is a pervasive and disabling symptom of idiopathic pulmonary fibrosis (IPF) and is an independent predictor of disease progression. The Cough Quality-of-Life Questionnaire (CQLQ) is a validated measure of cough-specific quality of life that could be used as an outcome measure in therapeutic trials for IPF. This study aimed to assess the reliability and validity of the CQLQ in individuals with IPF.The CQLQ was administered as an outcome within a previously published 27-week, placebo-controlled, crossover trial of thalidomide for cough in IPF. Participants were adults with IPF and chronic cough. A cough visual analog scale (VAS) and the St. George's Respiratory Questionnaire (SGRQ) were administered to establish concurrent validity of the CQLQ.Internal consistency was high (Cronbach αgt; .70) for the CQLQ total and four of six subscale scores. The CQLQ total score demonstrated concurrent validity through significant correlations with scores on the cough VAS and SGRQ total and subscale scores (r range, 0.63-0.81; Plt; .05). The intraclass correlation coefficient for the CQLQ completed at baseline and after a therapeutic washout period at week 15 was 0.87, indicating very good test-retest reliability.This study supports the use of the CQLQ as a valid and reliable instrument in IPF and should be used to assess cough-specific quality of life in therapeutic trials.

Type 1 diabetes is a chronic condition that impacts two of every 1000 youth in the United States (Liese et al., 2006). The complex, demanding regimen for diabetes self-care requires frequent blood glucose (BG) monitoring and management of insulin, nutritional intake, and physical activity (Silverstein et al., 2005). Common declines in adolescents’ self-care and disease control (Helgeson, Siminerio, Escobar, & Becker, 2009; Luyckx, Seiffge-Krenke, & Hampson, 2010) elevate the risk for complications, lead to greater healthcare utilization, and result in higher medical costs (Menzin, Langley-Hawthorne, Friedman, Boulanger, & Cavanaugh, 2001; Wagner et al., 2001). Ideally, youth with diabetes and their parents complete diabetes management jointly (Anderson, 2004; Silverstein et al., 2005), and family interactions related to diabetes can impact youths’ diabetes self-care and glycemic outcomes (Anderson, Ho, Brackett, Finkelstein, & Laffel, 1997). Parental involvement in diabetes management can take the form of parental responsibility, in which parents complete particular tasks for youth, or of parental monitoring, in which parents supervise youths’ independent completion of self-care tasks. Both forms of involvement are associated with better glycemic control via their beneficial impact on adolescents’ self-care (Anderson et al., 1997; Ellis et al., 2007). In early adolescence, increasing autonomy is typical (Beyers, Goossens, Vansant, & Moors, 2003) and parents’ expectations for teens’ diabetes self-care tend to increase while their direct participation in diabetes management often decreases (Palmer et al., 2004; Wysocki et al., 1996). During this period, parental involvement may begin to transition from responsibility to monitoring. The shift in disease management responsibility from parents to youth is one factor associated with the common deterioration in diabetes outcomes in adolescence (Holmes et al., 2006; Grey, Boland, Yu, Sullivan-Bolyai, & Tamborlane, 1998; Palmer et al., 2004), although greater parental monitoring appears to minimize this risk (Ellis et al., 2007). Conflict between teens and their parents about diabetes is another factor associated with worsening diabetes outcomes in adolescence. Diabetes-related conflict is of significant concern given that even minimally elevated conflict can negatively impact glycemic control (Hood, Anderson, Butler, & Laffel, 2007), in part by detracting from diabetes self-care (Hilliard, Guilfoyle, Dolan, & Hood, 2011). For example, some adolescents who are distressed, angry, or frustrated about family conflict may be less inclined or less able to complete diabetes tasks. Others might limit their completion of diabetes self-care tasks to avoid arguments (e.g., related to BG values). While previous studies have identified family conflict and lower parental monitoring as independent risk factors for suboptimal self-care and ultimately poorer glycemic outcomes (Ellis et al., 2007; Hilliard et al., 2011), it remains unclear how these two important family characteristics are related to one another in the context of diabetes management and glycemic control. There are likely reciprocal relations between them, such that the amount and nature of parental monitoring may impact family conflict, and family conflict may impact how much and in what ways parents are involved in adolescents’ daily diabetes self-care. Greater parental responsibility for and monitoring of diabetes self-care often are encouraged to improve adolescents’ diabetes management and glycemic outcomes (Anderson et al., 1997; Ellis et al., 2007). Yet, clinically it is apparent that some aspects of parent involvement in adolescents’ diabetes self-care, including parental monitoring, may inadvertently foster conflict. For example, frequent reminders or questions about diabetes self-care might irritate teens and lead to or exacerbate conflict. Among youth without diabetes, those with more family conflict want less parental supervision (Laird, Pettit, Dodge, & Bates, 2003) and this preference likely is mirrored in teens with diabetes, who often want less frequent or less intrusive parental involvement in their diabetes self-care (Hanna & Guthrie, 2001; Weinger, O’Donnell, & Ritholz, 2001). Conflict also may detract from diabetes management and glycemic control through its impact on the amount and ways that parents participate in their adolescents’ self-care (Weinger et al., 2001). For example, in order to avoid conflict some parents might decrease their monitoring or oversight of diabetes management (Palmer et al., 2004). Parents who argue frequently with their teens about diabetes may refrain from asking questions or be hesitant to offer assistance with diabetes tasks. Other parents may increase or become more persistent in their monitoring to ensure their teens follow directions. Additionally, adolescents themselves may avoid discussions about diabetes with their parents as a means to avoid conflict. Any of these scenarios could detract from self-care and negatively impact glycemic control. Given the developmentally normative changes in parent-youth relationships at the entry to adolescence and their potential impact on diabetes self-care and glycemic control, a better understanding of how family conflict and parental monitoring relate to each other and to diabetes self-care and glycemic outcomes is valuable. Thus, this paper aims to examine the associations among family conflict, parental monitoring, diabetes self-care, and glycemic control. More family conflict and less parental monitoring were hypothesized to be correlated and to each have a direct association with poorer glycemic control. Given previous evidence of self-care as a mediator of the separate relations of parental monitoring (Ellis et al., 2007) and family conflict (Hilliard et al., 2011) with glycemic control, poorer self-care was hypothesized to mediate these associations. Confirmation of this model would indicate that interventions to improve adolescents’ glycemic control should address multiple aspects of the parent-adolescent relationship related to diabetes and directly address teens’ diabetes self-care behaviors.

Fear of hypoglycemia is common in parents of young children with type 1 diabetes (T1D), but little is known about the specific fears that parents most often experience. Hypoglycemia fear has been associated with poorer glycemic control in older children, though not yet studied in a large cohort of very young children.Parents of 549 children7 years (mean 5.2 ± 1.2 years [19%3 years]) with a mean diabetes duration of 2.4 ± 1.0 years (range 1-6 years) and mean HbA1c 8.2% ± 1.1% (66 ± 12 mmol/mol) registered in the T1D Exchange completed the worry scale of the Hypoglycemia Fear Survey modified for parents (HFS-P).Mean parental fear of hypoglycemia worry score was 36.1 ± 23.1 (possible range 0-100), with most frequent worries related to the child having a low while asleep and the child not recognizing a low. The mean worry score was not associated with the child's age, glycemic control, or recent severe hypoglycemic event. Parental worries about lows while sleeping were significantly higher in pump users than non-users (61% vs. 45%; P .001), and tended to be higher in CGM users than non-users (62% vs 51%; P = .02).The greatest worries of parents of young children with T1D were related to hypoglycemia during sleep and other times/circumstances during which it would be difficult to detect hypoglycemia. Using advanced diabetes technologies may be an effort to temper fears about hypoglycemia during sleep, though the directionality of this relationship is undetermined. Additional studies can clarify this association and leverage use of diabetes technologies to improve glycemic control.

Objective This study examines whether race/ethnicity moderates relationships of (a) diabetes stress and general life stressors with (b) diabetes outcomes of glycemic control and diabetic ketoacidosis (DKA) among emerging adults (aged 18-25 years) with type 1 diabetes (T1D). Method Using a T1D Exchange Registry sample of non-Hispanic White, African American, and Hispanic emerging adults (N = 3,440), multiple group analyses were used to determine whether race/ethnicity moderates the relationships between stress and diabetes outcomes. Results The relationships between the two stress types and glycemic control did not differ between African American and non-Hispanic Whites. However, as compared with non-Hispanic Whites, the association between higher diabetes-specific stress and poorer glycemic control was significantly stronger for Hispanics, and Hispanics had poorer glycemic control when they experienced a relatively fewer number of general life stressors than non-Hispanic Whites. The relationships between the type of stress (diabetes-specific and general stress) and DKA did not differ across racial/ethnic groups. Conclusions Future research should evaluate possible mechanisms that contribute to the different relationships of stress with glycemic control among Hispanics compared with non-Hispanic Whites.

Stress is known to negatively affect health and is a potentially serious barrier to diabetes-related health outcomes. This paper synthesizes what is known about stress and glycemic control among people with type 1 and type 2 diabetes across the lifespan. Chronic stress-especially in relation to living with diabetes-was most strongly associated with A1c, particularly among subgroups that face disproportionate stress, such as minority groups or adolescents/young adults. Mechanisms of the stress-A1c association include physiological, psychological, behavioral, and environmental links. Understanding the dimensions of stress as they relate to health in diabetes can be of significant clinical importance, and interventions targeting mechanisms that either exacerbate or buffer stress have reported modest improvements in A1c.

Declining diabetes management and control are common as children progress through adolescence, yet many youths with diabetes do remarkably well. Risk factors for poor diabetes outcomes are well-researched, but fewer data describe processes that lead to positive outcomes such as engaging in effective diabetes self-management, experiencing high quality of life, and achieving in-range glycemic control. Resilience theory posits that protective processes buffer the impact of risk factors on an individual's development and functioning. We review recent conceptualizations of resilience theory in the context of type 1 diabetes management and control and present a theoretical model of pediatric diabetes resilience. Applications to clinical care and research include the development of preventive interventions to build or strengthen protective skills and processes related to diabetes and its management. The ultimate goal is to equip youths with diabetes and their families with the tools to promote both behavioral and health-related resilience in diabetes.

Background: Due to the intensive treatment requirements needed to maintain diabetes control, optimal diabetes outcomes can be difficult to achieve for individuals with type 1 or type 2 diabetes from child- hood through adulthood. While risk factors related to individual differences in outcomes have been studied in depth, there is a growing body of research that has revealed the effects of positive personal and environmental characteristics on diabetes management and glycemic control. The goal of this review is to summarize the existent literature on the role of positive characteristics in diabetes outcomes. Method: Extensive literature searches were conducted using Medline, PsychInfo, and CINAHL to identify studies assessing positive personal and environmental characteristics and diabetes outcomes. Included articles were published between 1989 and 2012. Results: Across the lifespan, positive personal characteristics such as self-efficacy, self-esteem, and adaptive coping were associated with diabetes management and glycemic control. Positive environmental factors such as parental monitoring and support were also important predictors of good outcomes, particularly for adolescents. Conclusions: Positive personal and environmental factors have been shown to be associated with diabetes outcomes and should be addressed in efforts to improve outcomes at all life stages. Clinical research and practice may be enhanced through efforts to evaluate and promote positive personal and environmental factors with the ultimate goal of reducing barriers to optimal diabetes management and control.

OBJECTIVE: Pediatric psychologists are increasingly called upon to treat children from non-Western countries, whose cultures may contrast with a Western medical setting. Research on cultural adaptations of evidence-based treatments (EBTs), particularly for individuals from the Middle East, is sparse. To address this need, we discuss clinical issues encountered when working with patients from the Middle East. METHODS: Synthesis of the literature regarding culturally adapted EBTs and common themes in Middle Eastern culture. Case vignettes illustrate possible EBT adaptations. RESULTS: Integrating cultural values in treatment is an opportunity to join with patients and families to optimize care. Expectations for medical and psychological treatment vary, and collaborations with cultural liaisons are beneficial. CONCLUSIONS: Critical next steps include systematic development, testing, and training in culturally adapting EBTs in pediatric medical settings. Increased dialogue between clinicians, researchers, and cultural liaisons is needed to share knowledge and experiences to enhance patient care. Language: en

Adolescents with type 1 diabetes are at increased risk for depression and anxiety, which can adversely affect diabetes management, glycemic control, and quality of life (QOL). However, systematic psychological screening is rarely employed. We hypothesized that higher depression and anxiety screener scores would predict higher HbA1c, less frequent blood glucose monitoring (BGM), and poorer QOL one year later. Raw screener scores were expected to be more robust predictors than cutoff scores.150 adolescents age 13-18 with type 1 diabetes completed depression and anxiety screeners. One year later, blood glucose meters were downloaded to assess BGM frequency, HbA1c values were obtained, and caregivers rated the participants' QOL. Separate regressions were conducted for each outcome, including demographic and medical covariates.Higher depression scores predicted less frequent BGM (b=-0.05, p.05) and poorer QOL (b=-0.71, p.01), and higher state anxiety scores predicted higher HbA1c (b=0.07, p.05). Continuous screener scores identified risk for 12-month outcomes more robustly than clinical cut-off scores.Psychological screeners predict diabetes outcomes one year later. Future clinical research studies should explore whether psychological screening and referral for appropriate intervention can prevent deteriorations in diabetes management and control commonly seen during adolescence.

OBJECTIVE This report describes an intervention to promote medication adherence and treat comorbid psychological symptoms in a 17 year-old female with Fanconi Anemia. The patient presented with a typical adherence rate estimated at 25% and self-reported symptoms of depressed mood and anxiety. METHOD Our comprehensive treatment approach integrated electronic monitoring (EM), an emerging strategy for adherence promotion, and motivational interviewing (MI) within an evidence-based cognitive-behavioral therapy (CBT) framework. We used EM data to assess and track medication adherence. The therapist reviewed these data with the patient and family in session and used MI techniques to promote health behavior change. We analyzed changes in adherence rates over time using a time series analysis (Auto-Regressive Moving Average [ARIMA]). In addition, the patient and her mother reported on depression, anxiety, and quality of life at intake and after 12 months, and the therapist treated psychological symptoms with CBT. RESULTS The average adherence rate during the baseline EM phase was ~53%. The mean adherence rate across treatment was ~77%, and after 17 months, the final weekly adherence rate was 82%. Adherence rates significantly improved over the treatment period, ARIMA t = 36.16, p < .01. CONCLUSIONS EM feedback and MI are viable additions to CBT to promote medication adherence in adolescence. This approach has the potential to effectively treat adolescents with adherence problems and psychological symptoms across multiple chronic illness diagnoses, and ultimately to improve health and quality of life outcomes.

We examined the association of youths' positive qualities, family cohesion, disease management, and metabolic control in Type 1 diabetes. Two-hundred fifty-seven youth-parent dyads completed the Family Cohesion subscale of the Family Environment Scale, the Diabetes Behavior Rating Scale, 24-hour diabetes interview, and youth completed the Positive Qualities subscale of the Youth Self Report (YSR-PQ). Structural equation modeling demonstrated that YSR-PQ scores were associated with metabolic control mediated by associations with more family cohesion and better disease management. That is, youth with higher YSR-PQ scores had more cohesive families, better disease management, and, indirectly, better metabolic control. Family cohesion was indirectly associated with better metabolic control mediated by its association with better disease management, but not mediated by its association with YSR-PQ scores. Youth who reported more positive qualities, as measured by the YSR-PQ subscale, had better disease management and metabolic control through the association with more family cohesion. However, the current results did not support an alternative hypothesis that cohesive families display better diabetes management mediated by higher YSR-PQ scores.

Background Parents of young children with type 1 diabetes (T1D) are responsible for executing a complex daily management regimen and are at risk for elevated levels of stress. Normative misbehaviour during the preschool years can complicate T1D management, and interpretation of behavioural concerns may vary because of child health status and parent stress. Within a paediatric transactional model framework, child characteristics (e.g. behaviour problems, metabolic control) and parent functioning (e.g. parenting stress, anxiety) likely impact one another. Methods Parents of 2- to 6-year-old children with T1D completed self-report measures, including the Pediatric Inventory for Parents (PIP), State-Trait Anxiety Inventory (STAI), Eyberg Child Behavior Inventory (ECBI), and 24-h Recall Interviews. Medical data were obtained by parent report and medical record review. It was hypothesized that greater parent stress and child blood glucose variability would be significantly associated with greater parent-reported child behaviour concerns. Results Moderate levels of parent stress and child behaviour problems were endorsed; however, parents perceived children's misbehaviour as problematic, particularly with relation to tasks relevant to diabetes management (e.g. bedtimes and mealtimes). Structural equation modelling indicated that greater general anxiety and paediatric parenting stress was associated with parent report of more problematic child behaviour. Blood glucose variability did not significantly contribute to this relationship. Conclusions The stress experienced by parents of young children with chronic illness appears to relate to their perception of their children's behaviour problems. Parents' experiences with developmentally normative misbehaviour may interfere with disease management and exacerbate parents' stress and the subsequent impact on well-being. Implications for supporting parents and children with T1D are discussed.

Parents of young children with Type 1 diabetes describe daily management as relentless. Nighttime caregiving, including nocturnal blood glucose monitoring (NBGM), occurs and may increase parents' anxiety and stress. The goal of this study was to examine the frequency of NBGM among parents of young children with Type 1 diabetes, and to identify children's illness characteristics and parents' fear of hypoglycemia, anxiety, and parenting stress associated with nighttime monitoring. Parents (N = 71) of children with Type 1 diabetes ages 2 to 6 completed questionnaires to assess frequency of NBGM, illness characteristics and health outcomes, and parent concern. Approximately one third of parents reported regularly monitoring their child's blood glucose level after their child was asleep. Frequency of NBGM was positively associated with basal-bolus regimen, longer illness duration, and increased parent-reported anxiety and parenting stress (p < .05). NBGM is prevalent among parents of young children with Type 1 diabetes, suggesting that parents' nighttime caregiving practices and resulting sleep disruption should be routinely addressed in clinical practice. Further investigations of NBGM, child health outcomes, and parent quality of life are warranted.

Objective To examine family and individual psychosocial, medical, and demographic factors associated with improved diabetes-related quality of life (QOL) after transitioning to the insulin pump among youth with type 1 diabetes. Method Fifty-three parent–child dyads completed questionnaires on four occasions prior to and following this medical regimen change, assessing QOL, family environment, depressive and anxiety symptoms, and medical and demographic information. Trajectories of change in QOL were analyzed using multilevel modeling. Result Psychosocial, medical, and demographic characteristics were associated with QOL prior to pump-start. Elements of children's QOL significantly improved after the transition, and improvement was predicted by psychosocial, medical, and demographic characteristics. Conclusion Results indicate that individual and contextual factors may play a role in QOL as children transition to the insulin pump. Findings may guide efforts to support families through this challenging time and potentially inform candidacy for transition to the pump.

Diabetes impacts tens of millions of people in the United States of America and 9 % of the worldwide population. Given the public health implications and economic burden of diabetes, the needs of people with diabetes must be addressed through strategic and effective advocacy efforts. Diabetes advocacy aims to increase public awareness about diabetes, raise funds for research and care, influence policy impacting people with diabetes, and promote optimal individual outcomes. We present a framework for diabetes advocacy activities by individuals and at the community, national, and international levels and identify challenges and gaps in current diabetes advocacy. Various groups have organized successful diabetes advocacy campaigns toward these goals, and lessons for further advancing diabetes advocacy can be learned from other health-related populations. Finally, we discuss the role of healthcare providers and mental/behavioral health professionals in advocacy efforts that can benefit their patients and the broader population of people with diabetes.

Only in recent years has a large enough body of research on adherence-promoting interventions been amassed so that systematic reviews and meta-analyses of their impact can reliably be evaluated. Overall, these reviews indicate that interventions tend to result in modest improvements in adherence to treatment recommendations and medications, with effect sizes typically in the small to medium range across various chronic condition populations and intervention types. Positive effects on health outcomes have also been reported. This chapter reviews the literature on interventions for pediatric nonadherence, paying special attention to recent innovations that have the potential to expand interventions’ reach and effectiveness.

Contributors to a person’s adherence or non-adherence are complex, varied, and highly individual. Yet common themes have emerged and show that barriers to and facilitators of adherence occur on multiple levels: individual, family, healthcare systems, and cultural issues. Some predictors of adherence are stable or fixed and must be considered in clinical care delivery, research, and policy, while other contributors have the potential to be modified through targeted clinical intervention strategies. This chapter will review predictors of adherence in youth with chronic conditions across these multiple levels.

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.

Suboptimal regimen adherence among youth with type 1 diabetes (T1D) is a common challenge for patients, families, and providers. Motivational interviewing (MI) is a brief communication style designed to elicit intrinsic motivation and strengthen commitment to behavior change goals. As pediatric MI research expands, a critical review of its evidence base and applicability to promote adherence behaviors for youth with T1D is needed. This review introduces the core tenets of MI and clinical applications in T1D, synthesizes the existing MI research in T1D, and discusses the next steps in MI research. Overall, mixed results for MI interventions in T1D reflect variations in research study design and clinical implementation. Targeting adherence rather than glycemic outcomes typically demonstrates greater results, highlighting the promise of MI to facilitate meaningful and enduring improvements in youths’ T1D adherence behaviors.

People with chronic medical conditions are at increased risk for depression and depressive symptoms (Clarke & Currie, 2009). This poses a threat to disease management and symptom control, with evidence from a range of chronic conditions spanning pediatrics through adulthood demonstrating that elevated depressive symptoms increase the risk for nonadherence approximately two-to threefold (DiMatteo Lepper, & Croghan, 2000; Grenard et al., 2011). Specific symptoms of depression, such as negative mood, low self-esteem, feelings of ineffectiveness, deficits in memory or energy, and more perceived barriers to adherence, may detract from adherence (Katon & Ciechanowski, 2002; McGrady & Hood, 2010). Ultimately, the association between depression and poor adherence translates to increases in disease symptoms, medical costs, morbidity, and mortality (Barth, Schumacher, & Herrmann-Lingen, 2004; Katon & Ciechanowski, 2002). The link between depressive symptoms and treatment adherence is well established, yet the mechanisms of this association are not well understood. Clarifying the processes by which depressive symptoms influence adherence would provide valuable direction for interventions to buffer the negative impact of depressive symptoms and ultimately improve health outcomes. Negative beliefs about prescribed medications (e.g., low self-efficacy to take medications, expectation of medications having null or negative outcomes, low motivation or intention to take medications) are possible mechanisms by which depressive symptoms could impede adherence. It is plausible that individuals’ depressive symptoms could influence their medication beliefs to be more negative, which may reduce the likelihood of adhering to prescribed medications. Individuals’ beliefs about medications are related to medication adherence. In a recent meta-analysis, Horne and colleagues (2013) reported that higher perceived need for treatment and fewer perceived concerns about treatments are significantly associated with better adherence. This holds across many conditions: Negative beliefs about treatments or medications have demonstrated associations with poorer adherence among individuals with HIV (Barclay et al., 2007), diabetes (Gherman et al., 2011), sleep apnea (Olsen, Smith, Oei, & Douglas, 2008), hypertension (Quine, Steadman, Thompson, & Rutter, 2012), and those recovering from stroke (Robinson-Smith, Johnston, & Allen, 2000) and chronic back pain (Glattacker, Heyduck, & Meffert, 2013). Studies evaluating medication beliefs as a potential mechanism linking depression and adherence have focused almost exclusively on one specific belief, self-efficacy; results indicate that medication self-efficacy mediates the links between depression and medication adherence for hypertension (Schoenthaler, Ogedegbe, & Allegrante, 2009) and HIV (Cha, Erlen, Kim, Sereika, & Caruthers, 2008) and between depression and glycemic control in Type 2 diabetes (Cherrington, Wallston, & Rothman, 2010). Few studies have examined the roles that other medication beliefs aside from self-efficacy play in the link between depressive symptoms and medication adherence. One exception demonstrated that not only lower self-efficacy but also more perceived barriers to taking medications were mediators of the indirect link between depressive symptoms and self-reported adherence in adults with diabetes (Chao, Nau, Aikens, & Taylor, 2005). More research examining a broader range of medication beliefs, including motivation, perceived importance, and outcome expectancies related to taking medications, is needed to fully understand the cognitive mechanisms by which depressive symptoms relate to adherence. Understanding the role that a comprehensive set of relevant medication beliefs plays in depressive symptoms and medication adherence has the potential to inform and guide clinical interventions to reduce depressive symptoms, support adaptive health-promoting beliefs, and facilitate optimal disease management. Cystic fibrosis (CF) is a chronic, progressive, obstructive lung disease with a complicated and demanding treatment regimen that includes multiple medications, nutritional guidelines, and chest physiotherapy, and can take several hours a day to complete (Sawicki, Sellers, & Robinson, 2009). In 1986, the median life expectancy was 27 years and less than 29% of individuals with CF were ≥18 years old in the United States, but with advances in drug therapies, this has changed dramatically (Cystic Fibrosis Foundation, 2013). In 2012, 49% of individuals with CF were adults and the median life expectancy was 41 years (Cystic Fibrosis Foundation, 2013). As adolescents and adults now account for over half of the CF population, there is growing attention to their health status and psychological and behavioral needs (Quon & Aitken, 2012). Depressive symptoms and medication nonadherence are emerging as significant risks for adolescents and adults with CF. Like other chronic conditions, the risk for depressive symptoms is elevated (Goldbeck, Besier, Hinz, Singer, & Quittner, 2010; Latchford & Duff, 2013; Riekert, Bartlett, Boyle, Krishnan, & Rand, 2007) and adherence to medications and other treatments is notably low (Briesacher et al., 2011; Eakin, Bilderback, Boyle, Mogayzel, & Riekert, 2011; Nasr, Chou, Villa, Chang, & Broder, 2013; Quittner et al., 2014). Despite these documented risks among people with CF and the known challenges to self-management, little is known about whether or how depressive symptoms relate to adherence to pulmonary medications for CF. One small study of adolescents with CF suggested that youths’ perceptions about their illness and treatments were related to self-reported adherence rates (Bucks et al., 2009), suggesting that beliefs about medications may be related to adherence to CF treatments. However, the role that CF-related medication beliefs play in depressive symptoms and adherence has not been explored, yet is a plausible mediator, given evidence suggesting such associations in other disease groups. No studies have examined a comprehensive set of disease-specific medication beliefs as a potential mechanism indirectly linking depressive symptoms with objectively measured medication adherence in adolescents and adults with CF or in any other chronic condition. Therefore, the aim of this study was to evaluate whether CF-related medication beliefs mediate the relationship between depressive symptoms and adherence to pulmonary medications. It was hypothesized that lower levels of positive medication beliefs, including lower self-efficacy, motivation, and perceived importance of and less optimistic outcome expectancies related to taking medications, would mediate the association between elevated depressive symptoms and suboptimal adherence as measured by 1 year of pharmacy refill data in individuals with CF.