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Kara N Shah,1 Sandra Cortina,2,3 Michelle M Ernst,2 Jessica C Kichler2 1Division of Pediatric Dermatology, 2Division of Behavioral Medicine and Clinical Psychology, 3Center for Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA Abstract: Psoriasis is a relatively common chronic inflammatory skin disease in children for which there is no cure. Most children have mild disease that can be managed with topical therapy as opposed to phototherapy or systemic therapy. Despite the mild presentation of psoriasis in most children, the disease can have a significant impact on quality of life due to the need for ongoing treatment, the frequently visible nature of the cutaneous manifestations, and the social stigma that is associated with psoriasis. Adherence to treatment, in particular topical therapy, is often poor in adults and compromises response to therapy and medical provider management strategies. Multiple factors that may contribute to nonadherence in adults with psoriasis have been identified, including lack of education on the disease and expectations for management, issues related to ease of use and acceptability of topical medications, and anxiety regarding possible medication side effects. There is currently no published data on adherence in the pediatric psoriasis population; however, poor adherence is often suspected when patients fail to respond to appropriate therapy. General strategies used to assess adherence in other pediatric disease populations can be applied to children with psoriasis, and interventions that reflect experience in other chronic dermatologic disorders such as atopic dermatitis may also be helpful for medical providers caring for children with psoriasis. Keywords: adherence, psoriasis, children

Aims: This study investigates stigma predictors across ages and genders, addressing a critical gap in understanding diverse populations to reduce related suboptimal clinical and psychosocial outcomes., Methods: Cross-sectional analysis of self-reported data from BETTER, a Canadian registry of people with type 1 diabetes. Participants (n = 709) completed the 19-item-Diabetes-Stigma Assessment-Scale (DSAS-1) categorized into treated differently, blame and judgment, and identity concerns sub-scales. Associations with diabetes distress (DDS-17-score/102), depression (PHQ-9-score/27), social-support (ESSI-score/34), fear of hypoglycemia (HFS-II-score/132), and hyperglycemia-avoidance-behaviours (HAS-score/88) were computed., Results: Perceived stigma was highest in youth aged 14-24 years (46·0 ± 15·6, p < 0·001) and women (41·2 ± 15·7, p = 0·009), compared to other age groups and men. Blame and Judgment contributed to most of stigma perception. Youth perceived significantly more blame and judgment (p < 0·001) and identity concerns (p = 0·001) compared to middle-aged adults and seniors. Women perceive significantly more blame and judgment compared to men (p < 0·001). The perception of being treated differently was not reported to be an issue across ages and genders. Participants with higher scores of depression, diabetes-distress, fear of hypoglycemia, hyperglycemia-avoidance behaviours, and lesser social-support, reported increased stigma., Conclusions: Stigma varies by age and gender, underscoring the need for targeted interventions to reduce it. Challenging stereotypes and reducing stigma-related stressors are essential for better outcomes., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Anne-Sophie Brazeau reports financial support was provided by JDRF Canada. Anne-Sophie Brazeau reports financial support was provided by Canadian Institutes of Health Research., (Copyright © 2024 Research Trust of DiabetesIndia (DiabetesIndia) and National Diabetes Obesity and Cholesterol Foundation (N-DOC). Published by Elsevier Ltd. All rights reserved.)

Objectives: There are many educational resources for adolescents and young adults living with type 1 diabetes; however, it is unknown whether they address the breadth of topics related to transition to adult care. Our aim in this study was to collect educational resources relevant to Canadian youth and assess their quality and comprehensiveness in addressing the knowledge necessary for youth to prepare for interdependent management of their diabetes., Methods: We conducted an environmental scan, a systematic assessment and analysis, of online education resources in English and French relevant to Canadian youth living with type 1 diabetes. Resources were screened using an open education resource evaluation grid and relevant resources were mapped to the Readiness for Emerging Adults with Diabetes Diagnosed in Youth, a validated diabetes transition readiness assessment tool., Results: From 44 different sources, 1,245 resources were identified and, of these, 760 were retained for analysis. The majority were webpages (50.1%) and downloadable PDFs (42.4%), and 12.1% were interactive. Most resources covered Diabetes Knowledge (46.0%), Health Behaviour (23.8%), Insulin and Insulin Pump Management (11.8% and 8.6%, respectively), and Health-care System Navigation (9.7%). Topic areas with the fewest resources were disability accommodations (n=5), sexual health/function (n=4), and locating trustworthy diabetes resources (n=3)., Conclusions: There are many resources available for those living with type 1 diabetes preparing to transition to adult care, with the majority pertaining to diabetes knowledge and the least for navigation of the health system. Few resources were available on the topics of substance use, sexual health, and reproductive health. An interactive presentation of these resources, as well as a central repository to house these resources, would improve access for youth and diabetes care providers during transition preparation., (Copyright © 2024 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: The transition to adulthood is a challenging period for individuals with type 1 diabetes, especially those attending post-secondary education (PSE) at a university or college. In addition to balancing academic responsibilities and adapting to a novel environment, young adults (YAs) with type 1 diabetes must more independently manage the daily demands of diabetes care., Objective: The aim of this study was to collect qualitative data from multiple stakeholders addressing the transition of students with type 1 diabetes into a PSE setting., Methods: A total of 15 participants were interviewed, including three health care provider diabetes educators, four parents of YAs with type 1 diabetes, and eight YAs with type 1 diabetes. Reflexive thematic analysis of the qualitative interviews revealed four major themes and 11 subthemes., Results: The four major themes revealed included 1 ) inappropriateness of services available to support students with type 1 diabetes in PSE settings, 2 ) individuals with type 1 diabetes having to compensate for inadequate systems, 3 ) variability of social support effectiveness, and 4 ) the need for a more holistic approach to improve diabetes education and social support systemically., Conclusion: This study identified some key systemic barriers experienced by PSE students with type 1 diabetes. Future research needs to extend the sample populations to understand a wider range of PSE student experiences. The findings from this study provide initial recommendations to develop new PSE readiness interventions for YAs with type 1 diabetes., Competing Interests: No potential conflicts of interest relevant to this article were reported., (© 2023 by the American Diabetes Association.)

Background: Despite the widespread clinical perception that hypoglycemia may drive weight gain in youth with type 1 diabetes (T1D), there is an absence of published evidence supporting this hypothesis., Methods: We estimated the body fat percentage (eBFP) of 211 youth (HbA1c 8.0-13.0%, age 13-16) at baseline, 6, and 18 months of the Flexible Lifestyles Empowering Change trial using validated equations. Group-based trajectory modeling assigned adolescents to sex-specific eBFP groups. Using baseline 7-day blinded continuous glucose monitoring data, "more" vs. "less" percent time spent in hypoglycemia was defined by cut-points using sample median split and clinical guidelines. Adjusted logistic regression estimated the odds of membership in an increasing eBFP group comparing youth with more vs. less baseline hypoglycemia., Results: More time spent in clinical hypoglycemia (defined by median split) was associated with 0.29 the odds of increasing eBFP in females (95% CI: 0.12, 0.69; p = 0.005), and 0.33 the odds of stable/increasing eBFP in males (95% CI: 0.14, 0.78; p = 0.01)., Conclusions: Hypoglycemia may not be a major driver of weight gain in US youth with T1D and HbA1c ≥8.0. Further studies in different sub-groups are needed to clarify for whom hypoglycemia may drive weight gain and focus future etiological studies and interventions., Impact: We contribute epidemiological evidence that hypoglycemia may not be a major driver of weight gain in US youth with type 1 diabetes and HbA1c ≥8.0% and highlight the need for studies to prospectively test this hypothesis rooted in clinical perception. Future research should examine the relationship between hypoglycemia and adiposity together with psychosocial, behavioral, and other clinical factors among sub-groups of youth with type 1 diabetes (i.e., who meet glycemic targets or experience a frequency/severity of hypoglycemia above a threshold) to further clarify for whom hypoglycemia may drive weight gain and progress etiological understanding of and interventions for healthy weight maintenance., (© 2022. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Objective: To assess the relationship between mindfulness and glycemia among adolescents with type 1 diabetes (T1D) with suboptimal glycemia, and evaluate the potential mediation by ingestive behaviors, including disordered eating, and impulsivity., Research Design and Methods: We used linear mixed models for hemoglobin A1c (HbA1c) and linear regression for continuous glucose monitoring (CGM) to study the relationship of mindfulness [Child and Adolescent Mindfulness Measure (CAMM)] and glycemia in adolescents with T1D from the 18-month Flexible Lifestyles Empowering Change (FLEX) trial. We tested for mediation of the mindfulness-glycemia relationship by ingestive behaviors, including disordered eating (Diabetes Eating Problem Survey-Revised), restrained eating, and emotional eating (Dutch Eating Behavior Questionnaire); and impulsivity (total, attentional, and motor, Barrett Impulsiveness Scale)., Results: At baseline, participants (n = 152) had a mean age of 14.9 ± 1.1 years and HbA1c of 9.4 ± 1.2% [79 ± 13 mmol/mol]. The majority of adolescents were non-Hispanic white (83.6%), 50.7% were female, and 73.0% used insulin pumps. From adjusted mixed models, a 5-point increase in mindfulness scores was associated with a -0.19% (95%CI -0.29, -0.08, p = 0.0006) reduction in HbA1c. We did not find statistically significant associations between mindfulness and CGM metrics. Mediation of the relationship between mindfulness and HbA1c by ingestive behaviors and impulsivity was not found to be statistically significant., Conclusions: Among adolescents with T1D and suboptimal glycemia, increased mindfulness was associated with lower HbA1c levels. Future studies may consider mindfulness-based interventions as a component of treatment for improving glycemia among adolescents with T1D, though more data are needed to assess feasibility and efficacy., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Type 1 diabetes (T1D) is a lifelong and chronic condition that can cause severely compromised health. The T1D treatment regimen is complex, and is a particular challenge for adolescents, who frequently experience a number of treatment adherence barriers (e.g., forgetfulness, planning and organizational challenges, stress). Diabetes Journey is a gamified mHealth program designed to improve T1D self-management through a specific focus on decreasing adherence barriers and improving executive functioning skills for adolescents. Grounded in situativity theory and guided by a sociotechnical-pedagogical usability framework, Diabetes Journey was designed, developed, and evaluated using a learning experience design approach. This approach applied design thinking methods within a Successive Approximation Model design process. Iterative design and formative evaluation were conducted across three design phases, and improvements were implemented following each phase. Findings from the user testing phase indicate Diabetes Journey is a user-friendly mHealth program with high usability that holds promise for enhancing adolescents' T1D self-management. Implications for future designers and researchers are discussed regarding the social dimension of the sociotechnical-pedagogical usability framework. An extension to the framework is proposed to extend the social dimension to include socio-cultural and contextual considerations when designing mHealth applications. Consideration of the pedagogical and sociocultural dimensions of learning is imperative when developing psychoeducational interventions., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© Association for Educational Communications and Technology 2022, Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Objective: We sought to determine whether census tract poverty, race, and insurance status were associated with the likelihood and severity of diabetic ketoacidosis (DKA) hospitalization among youth with type 1 diabetes (T1D)., Methods: We conducted a retrospective population-based cohort study using Cincinnati Children's Hospital electronic medical record (EMR) data from January 1, 2011, to December 31, 2017, for T1D patients ≤18 years old. The primary outcome was admission for DKA. Secondary outcomes included DKA severity, defined by initial pH and bicarbonate, and length of stay. Exposures were the poverty rate for the youth's home census tract, parent-reported race, and insurance status. We used multivariable logistic regression to analyze effects on odds of admission., Results: We identified 439 patients with T1D; 152 were hospitalized. The cohort was 48% female, 25% Black, and 36% publicly insured; the median age was 14 years. For every 10% increase in a youth's census tract poverty rate, the adjusted odds of admission increased by 22% (95% CI, 1.03-1.47). Public insurance status was associated with DKA admission (adjusted odds ratio [AOR], 2.71, 95% CI, 1.62-4.55) while race was not. There were no clinically meaningful differences in pH or bicarbonate by census tract poverty, race, or insurance status; however, Black patients experienced differences in care (eg, longer length of stay)., Conclusion: Youth with T1D living in high poverty areas and on public insurance were significantly more likely to be admitted for DKA. Severity upon presentation was similar across exposures. Understanding contextual mechanisms by which disparities emerge will inform changes aimed at equitably improving care.

Objectives: Our aim was to evaluate self-reported depressive symptoms and clinical outcomes during routine screening for adolescents and young adults with type 2 diabetes (T2D), and examine associations among depressive symptoms and demographic and clinical characteristics., Methods: The Patient Health Questionnaire (PHQ) was administered to 197 adolescents and young adults with T2D using the PHQ-2 or PHQ-9 in routine pediatric diabetes care at 4 academic medical centres. Data from electronic health records were extracted from the screening date and 12 months earlier., Results: Adolescents and young adults with T2D (mean age, 16.85 years; 57% male; 77.2% non-Caucasian) completed the PHQ as part of routine diabetes care. On the PHQ, 19.3% of adolescents and young adults endorsed elevated depressive symptoms (PHQ score ≥10) and, among a subsample with item-level data (n=53), 18.9% endorsed thoughts of self-harm. Subsequently, 50.0% of those with depressive symptoms had a documented referral for mental health treatment in the electronic health record after the positive screening outcome. Older age, shorter diabetes duration, higher glycated hemoglobin level, being non-Hispanic white, more blood glucose checks per day and being prescribed oral medications were significantly associated with more depressive symptoms., Conclusions: Screening for depressive symptoms identifies individuals in need of referral for mental health treatment. A focus on self-harm assessment, standardized methods for documentation of symptoms and mental health referrals and increased referral resources are needed., (Copyright © 2021 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Psychosocial guidelines recommend routine screening of depressive symptoms in adolescents and young adults (AYA) with diabetes. Best practices for screening in routine care and patient characteristics associated with depressive symptoms require further investigation. The purpose of this study was to examine psychometric properties of the Patient Health Questionnaire (PHQ-2 and PHQ-9); document rates of depressive symptoms and related clinical actions; and evaluate associations with patient characteristics. The Patient Health Questionnaire (PHQ-2 or PHQ-9) was administered at five pediatric academic medical centers with 2,138 youth with type 1 diabetes. Screening was part of routine clinical care; retrospective data from electronic health records were collected for the first screening date as well as 12 months prior. The PHQ demonstrated good psychometric properties. Evaluation of item-level PHQ-9 data identified 5.0% of AYA with at least moderate depressive symptoms who would not have been flagged for further screening using the PHQ-2 only. On the PHQ-9, 10.0% of AYA with type 1 diabetes endorsed elevated depressive symptoms and 7.0% endorsed thoughts of self-harm. Patients with moderate or greater depressive symptoms had a 43.9% documented referral rate for mental health treatment. Higher BMI, older age, public insurance, shorter diabetes duration, higher HbA1C, and a diabetic ketoacidosis (DKA) event in the past year were associated with depressive symptoms. The PHQ-9 identified AYA with elevated depressive symptoms that would not have been identified using the PHQ-2. Depressive symptoms were associated with negative diabetes indicators. To improve referral rates, standardized methods for provision and documentation of referrals are needed., (© Society of Behavioral Medicine 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Youth with type 1 diabetes (T1D) commonly do not meet HbA1c targets. Youth-directed goal setting as a strategy to improve HbA1c has not been well characterized and associations between specific goal focus areas and glycemic control remain unexplored., Objective: To inform future trials, this analysis characterized intended focus areas of youth self-directed goals and examined associations with change in HbA1c over a 18 months., Methods: We inductively coded counseling session data from youth in the Flexible Lifestyle Empowering Change Intervention (n = 122, 13-16 years, T1D duration >1 year, HbA1c 8-13%) to categorize intended goal focus areas and examine associations between frequency of goal focus areas selected by youth and change in HbA1c between first and last study visit., Results: We identified 13 focus areas that categorized youth goal intentions. Each session where youth goal setting concurrently incorporated blood glucose monitoring (BGM), continuous glucose monitoring (CGM), and insulin dosing was associated with a 0.4% (95% CI: -0.77, -0.01; P = .03) lower HbA1c at the end of intervention participation. No association was observed between HbA1c and frequency of sessions where goal intentions focused on BG only (without addressing insulin or CGM) (β: 0.07; 95% CI: -0.07, 0.21; P = .33) nor insulin dosing only (without addressing BGM or CGM) (β: 0.00; 95% CI: -0.11, 0.10; P = .95)., Conclusions: Findings exemplify how guiding youth goal development and combining multiple behaviors proximally related to glycemic control into goal setting may benefit HbA1c among youth with T1D. More research characterizing optimal goal setting practices in youth with T1D is needed., (© 2020 John Wiley & Sons A/S . Published by John Wiley & Sons Ltd.)

Objectives Turner syndrome (TS) is a complex and chronic medical condition that requires lifelong subspecialty care. Effective transition preparation is needed for successful transfer from pediatric to adult care in order to avoid lapses in medical care, explore health issues such as fertility, and prepare caregivers as adolescents take over responsibility for their own care. The objective of this study was to evaluate accuracy of knowledge of personal medical history and screening guidelines in adolescents and young adults (AYA) with TS. Methods This was a prospective cross-sectional study of 35 AYA with TS of ages 13-22 years recruited from a tertiary care center. AYA completed questionnaires on personal medical history, knowledge of screening guidelines for TS, and the Transition Readiness Assessment Questionnaire (TRAQ). Results Eighty percent of AYA with TS were 100% accurate in reporting their personal medical history. Only one-third of AYA with TS were accurate about knowing screening guidelines for individuals with TS. Accuracy about knowing screening guidelines was significantly associated with TRAQ sum scores (r = 0.45, p < 0.05). However, there was no association between knowledge of personal medical history and TRAQ sum scores. Conclusions Transition readiness skills, TS-specific knowledge, and accurate awareness of health-care recommendations are related, yet distinct, constructs. Understanding of one's personal medical history is not an adequate surrogate for transition readiness. Validated tools for general transition, like the TRAQ, can be used but need to be complemented by TS-specific assessments and content. Providers are encouraged to identify opportunities for clinical and educational interventions well in advance of starting transfer to adult care.

BACKGROUND | Young adulthood is a vulnerable developmental period associated with increased risk for suboptimal health outcomes in youth with type 1 diabetes. Psychosocial factors have been associated with self-management and glycemic control in younger populations, but the extent to which these associations exist among young adults is poorly understood. This study aimed to examine the psychosocial functioning of young adults with type 1 diabetes and associated clinical outcomes. METHODS | Participants included young adults ( n = 44) between the ages of 18 and 23 years in a pediatric setting who were preparing to transition to adult care. All participants completed self-report measures of psychosocial functioning at baseline as part of this longitudinal observational study. Outcome data included glycemic control, frequency of blood glucose monitoring, and self-management ratings at baseline and 1-year follow-up. RESULTS | Young adults with type 1 diabetes reported higher levels of depressive symptoms, lower self-efficacy, and more risk behaviors compared with previously published scores for adolescents. Young adults also reported greater resilience and transition readiness than their younger counterparts. Psychosocial variables were differentially related to glycemic control and frequency of blood glucose monitoring both cross-sectionally and longitudinally. CONCLUSION | This study provides key information about the psychosocial functioning of young adults with type 1 diabetes. It identifies relevant psychosocial factors that are associated with meaningful health outcomes during the transition preparation period. These findings may inform the development of clinical programs aimed at promoting transition preparation and health outcomes in young adults with type 1 diabetes., (© 2020 by the American Diabetes Association.)

Objective: The 2017 Society of Pediatric Psychology (SPP) Workforce Survey provides self-reported compensation by pediatric psychologists, identifies predictors of compensation, and establishes a better understanding of compensation within the context of gender and race/ethnicity minority status., Methods: SPP members who attended the SPP Annual Conference (SPPAC; April 2017) were invited to complete the survey at the conference through electronic tablets provided on-site by the Workforce Survey Committee. The survey was subsequently distributed online to SPP members who did not complete the survey at SPPAC. The statistical analyses used for this salary data employed flexible semi-parametric models, cross-validation, and prediction models for both the overall sample and academic rank subgroups., Results: Of 27 potential demographic and employment-related predictors from the 2017 SPP Workforce Survey, significant predictors of salary emerged within this sample: academic rank, time since obtaining doctoral degree, managing internal and external funds (of at least $50,000), years in primary employment position, obtaining Fellowship status in the American Psychological Association (APA), and managing other employees (at least 10 people). Given low response rates for males and individuals who identify as belonging to racial and ethnic minority subgroups, only limited, exploratory results are reported for these subgroups., Conclusions: These findings suggest that not only is longevity in one's career important but managing funds/personnel and obtaining professional designations are also predictors of higher salaries for pediatric psychologists, in general. Specific implications of salary according to the psychologist's academic rank, gender, and racial/ethnicity group status are also explored., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To assess maintenance of improved weight outcomes in preschoolers with obesity 6 and 12 months following a randomized clinical trial comparing a home- and clinic-based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health [LAUNCH]) to motivational interviewing and standard care., Study Design: Randomized controlled trial with children between the ages of 2 and 5 years above the 95th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012, and June 8, 2015, were followed 6 and 12 months post-treatment. Child and caregiver weight, height, and caloric intake, child physical activity, and home environment were assessed. The primary outcome was maintenance of greater reduction of percent over the 50th percentile body mass index (BMI%50th) by LAUNCH compared with motivational interviewing and standard care at the 6- and 12-month follow-up., Results: Significantly lower child BMI%50th was maintained for LAUNCH compared with motivational interviewing at 12-month follow-up and to standard care at the 6-month follow-up; however, the effect sizes were maintained for comparison with standard care at 12-month follow-up. LAUNCH had significantly lower daily caloric intake compared with motivational interviewing and standard care at both follow-ups and maintained significantly fewer high-calorie foods in the home compared with standard care at 6 and 12 months and compared with motivational interviewing at 12 months. However, caloric intake increased by 12% from post-treatment. LAUNCH caregivers did not maintain improved BMI at follow-up., Conclusions: LAUNCH showed success in reducing weight in preschoolers. However, maintaining treatment gains post-treatment is more difficult. Treatment may need to last longer than 6 months to achieve optimal results., Trial Registration: Clinicaltrials.gov: NCT01546727., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: The Flexible Lifestyles Empowering Change (FLEX) trial, an 18-month randomized clinical trial testing an adaptive behavioral intervention in adolescents with type 1 diabetes, showed no overall treatment effect for its primary outcome, change in hemoglobin A1c (HbA1c) percentage of total hemoglobin, but demonstrated benefit for quality of life (QoL) as a prespecified secondary outcome., Objective: To apply a novel statistical method for post hoc analysis that derives an individualized treatment rule (ITR) to identify FLEX participants who may benefit from intervention based on changes in HbA1c percentage (primary outcome), QoL, and body mass index z score (BMIz) (secondary outcomes) during 18 months., Design, Setting, and Participants: This multisite clinical trial enrolled 258 adolescents aged 13 to 16 years with type 1 diabetes for 1 or more years, who had literacy in English, HbA1c percentage of total hemoglobin from 8.0% to 13.0%, a participating caregiver, and no other serious medical conditions. From January 5, 2014, to April 4, 2016, 258 adolescents were recruited. The post hoc analysis excluded adolescents missing outcome measures at 18 months (2 participants [0.8%]) or continuous glucose monitoring data at baseline (40 participants [15.5%]). Data were analyzed from April to December 2018., Interventions: The FLEX intervention included a behavioral counseling strategy that integrated motivational interviewing and problem-solving skills training to increase adherence to diabetes self-management. The control condition entailed usual diabetes care., Main Outcomes and Measures: Subgroups of FLEX participants were derived from an ITR estimating which participants would benefit from intervention, which would benefit from control conditions, and which would be indifferent. Multiple imputation by chained equations and reinforcement learning trees were used to estimate the ITR. Subgroups based on ITR pertaining to changes during 18 months in 3 univariate outcomes (ie, HbA1c percentage, QoL, and BMIz) and a composite outcome were compared by baseline demographic, clinical, and psychosocial characteristics., Results: Data from 216 adolescents in the FLEX trial were reanalyzed (166 [76.9%] non-Hispanic white; 108 teenaged girls [50.0%]; mean [SD] age, 14.9 [1.1] years; mean [SD] diabetes duration, 6.3 [3.7] years). For the univariate outcomes, a large proportion of FLEX participants had equivalent predicted outcomes under intervention vs usual care settings, regardless of randomization, and were assigned to the muted group (HbA1c: 105 participants [48.6%]; QoL: 63 participants [29.2%]; BMIz: 136 participants [63.0%]). Regarding the BMIz univariate outcome, mean baseline BMIz of participants assigned to the muted group was lower than that of those assigned to the intervention and control groups (muted vs intervention: mean difference, 0.48; 95% CI, 0.21 to 0.75; P = .002; muted vs control: mean difference, 0.86; 95% CI, 0.61 to 1.11; P < .001); this group also had a higher proportion of individuals with underweight or normal weight using weight status cutoffs (95 [69.9%] in muted group vs 24 [54.6%] in intervention group and 11 [30.6%] in control group; χ24 = 24.67; P < .001). The approach identified subgroups estimated to benefit based on HbA1c percentage (54 participants [25.0%]), QoL (89 participants [41.2%]), and BMIz (44 participants [20.4%]). Regarding the HbA1c percentage outcome, participants expected to benefit from the intervention did not have significantly higher baseline HbA1c percentages than those expected to benefit from usual care (9.4% vs 9.2%; difference, 0.2%; 95% CI, -0.16% to 0.56%; P = .44). However, participants in the muted group had higher mean HbA1c percentages at baseline than those assigned to the intervention or control groups (muted vs intervention: 9.9% vs 9.4%; difference, 0.5%; 95% CI, 0.13% to 0.89%; P = .02; muted vs control; 9.9% vs 9.2%; difference, 0.7%; 95% CI, 0.34% to 1.08%; P = .001). No significant differences were found between subgroups estimated to benefit in terms of the composite outcome from the FLEX intervention (91 participants [42.1%]) vs usual care (125 participants [57.9%])., Conclusions and Relevance: The precision medicine approach represents a conceptually and analytically novel approach to post hoc subgroup identification. More work is needed to understand markers of positive response to the FLEX intervention., Trial Registration: ClinicalTrial.gov identifier: NCT01286350.

Aim: To test the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module originally developed in Type 1 diabetes in youth with Type 2 diabetes., Methods: The PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were administered in a field test study to 100 young people aged 9-25 years with Type 2 diabetes. Factor analysis was conducted to determine the factor structure of the items., Results: The 15-item Diabetes Symptoms Summary Score and 12-item Type 2-specific Diabetes Management Summary Score were empirically derived through factor analysis. The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores showed acceptable to excellent reliability across the age groups tested (α = 0.85-0.94). The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores evidenced construct validity through large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.67 and 0.57, respectively). HbA 1c was correlated with the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores (r = -0.13 and -0.22). Minimal clinically important difference (MCID) scores were 5.91 and 7.39 for the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores., Conclusions: The PedsQL 3.2 Diabetes Module Diabetes Symptoms Summary Score and Type 2-specific Diabetes Management Summary Score exhibited satisfactory measurement properties for use as youth self-reported diabetes symptoms and diabetes management outcomes for clinical research and clinical practice for young people with Type 2 diabetes., (© 2018 Diabetes UK.)

Objective: To examine the prevalence and correlates of non-severe hypoglycemia among adolescents with type 1 diabetes and suboptimal glycemic control, an understudied topic in this group., Methods: Seven days of blinded continuous glucose monitor data were analyzed in 233 adolescents at baseline of the Flexible Lifestyle Empowering Change trial (13-16 years, type 1 diabetes duration >1 year, and hemoglobin A1c [HbA1c] 8-13% [64-119 mmol]). Incidence of clinical hypoglycemia (54-69 mg/dL) and clinically serious hypoglycemia (<54 mg/dL) was defined as number of episodes ≥15 minutes. Logistic regression modeling was used to determine the correlates of long duration of hypoglycemia, categorized by median split among those who experienced hypoglycemia., Results: The sample was 76.1% non-Hispanic white, 49.8% female, age = 14.9 ± 1.1 years, diabetes duration = 6.4 ± 3.7 years, and HbA1c = 9.6 ± 1.2% (81 ± 13 mmol/mol). Over 7 days, 79.4% of youth experienced ≥1 hypoglycemic episodes of <70 mg/dL, and 55.4% of youth experienced ≥1 hypoglycemic episodes of <54 mg/dL. Among all adolescents, the median duration of clinical hypoglycemia and clinically serious hypoglycemia was 21.9 (range 0-250.2) and 4.3 (range 0-209.7) minutes/day, respectively. Long duration of clinical hypoglycemia (range 1.8-17.4% time overall) and clinically serious hypoglycemia (range 1.2-14.6% time overall) was associated with older age and decreasing HbA1c. Long duration of clinically serious hypoglycemia also was associated with insulin pump use., Conclusions: Almost 80% of adolescents with elevated HbA1c had an episode of clinical hypoglycemia, and >50% had clinically serious hypoglycemia in a week. Increased education alongside access to emerging diabetes technologies may help to prevent hypoglycemia while improving glycemic control., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: The primary objective was to investigate the mediating effects of diabetes management in the relationship between diabetes symptoms and generic health-related quality of life (HRQOL) in adolescents and young adults (AYAs) with type 1 diabetes. The secondary objective explored patient health communication and perceived treatment adherence barriers as mediators in a serial multiple mediator model., Methods: The PedsQL 3.2 Diabetes Module 15-item diabetes symptoms summary score, 18-item diabetes management summary score, and PedsQL 4.0 generic core scales were completed in a 10-site national field test study by 418 AYA aged 13 to 25 years with type 1 diabetes. Diabetes symptoms and diabetes management were tested for bivariate and multivariate linear associations with overall generic HRQOL. Mediational analyses were conducted to test the hypothesized mediating effects of diabetes management as an intervening variable between diabetes symptoms and generic HRQOL., Results: The predictive effects of diabetes symptoms on HRQOL were mediated in part by diabetes management. In predictive analytics models utilizing multiple regression analyses, demographic and clinical covariates, diabetes symptoms, and diabetes management significantly accounted for 53% of the variance in generic HRQOL (P < 0.001), demonstrating a large effect size. Patient health communication and perceived treatment adherence barriers were significant mediators in an exploratory serial multiple mediator model., Conclusions: Diabetes management explains in part the effects of diabetes symptoms on HRQOL in AYA with type 1 diabetes. Patient health communication to healthcare providers and perceived treatment adherence barriers further explain the mechanism in the relationship between diabetes symptoms and overall HRQOL., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: The objective of the study was to report on the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for children, adolescents, and young adults with type 1 diabetes., Research Design and Methods: The 33-item PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were completed in a 10-site national field test study by 656 families of patients ages 2-25 years with type 1 diabetes., Results: The 15-item Diabetes Symptoms Summary Score and 18-item Diabetes Management Summary Score were derived from the factor analysis of the items. The Diabetes Symptoms and Diabetes Management Summary Scores evidenced excellent reliability (patient self-report α = 0.88-0.90; parent proxy report α = 0.89-0.90). The Diabetes Symptoms and Diabetes Management Summary Scores demonstrated construct validity through medium to large effect size correlations with the Generic Core Scales Total Scale Score ( r = 0.43-0.67, P < 0.001). HbA 1c was significantly correlated with the Diabetes Symptoms and Diabetes Management Summary Scores ( r = -0.21 to -0.29, P < 0.001). Minimal clinically important difference scores ranged from 5.05 to 5.55., Conclusions: The PedsQL 3.2 Diabetes Module Diabetes Symptoms and Diabetes Management Summary Scores demonstrated excellent measurement properties and may be useful as standardized patient-reported outcomes of diabetes symptoms and diabetes management in clinical research, clinical trials, and practice in children, adolescents, and young adults with type 1 diabetes., (© 2018 by the American Diabetes Association.)

Introduction: The Flexible Lifestyle Empowering Change Study (FLEX) is a multi-site randomized controlled trial to test the efficacy of an adaptive behavioral intervention to promote self-management and improve glycemic control for adolescents with type 1 diabetes mellitus. A two-step recruitment process was used to optimize study retention by facilitating informed decision-making regarding participation., Methods: Those who expressed interest at first contact were given more detailed study information followed by telephone calls to the adolescents and their parents to answer questions and explore potential barriers to participation before making a decision regarding study enrollment., Results: Of 694 eligible adolescents who were invited to participate, 397 (57.2%) expressed interest when initially contacted (Step 1). Upon completion of the follow-up telephone calls (Step 2), 276 (39.8%) still agreed to participate; and 258 (37.2%) enrolled and completed a baseline visit with a parent/guardian. Completion rates for measurement visits remained high throughout the study, with an end-of-study retention rate of 93.4%; and only 12 (4.7%) families withdrew from the study., Conclusion: The two-step recruitment process encourages potential participants to thoughtfully evaluate their willingness to participate, as well as their ability to make a commitment to the full completion of study requirements. When demonstrating the efficacy of a randomized controlled trial, it may be preferable to accept lower recruitment rates in order to optimize retention rates. The additional time and effort required to implement this two-step process is worthwhile. With a high retention rate, we can be more confident that the outcomes of the randomized controlled trial actually reflect the impact of the intervention.

Objectives: The objective was to investigate the patient-reported diabetes symptoms predictors of generic health-related quality of life (HRQOL) in adolescents and young adults (AYA) with type 1 or type 2 diabetes., Methods: The 15-item PedsQL™ 3.2 Diabetes Module Diabetes Symptoms Summary Score and PedsQL™ 4.0 Generic Core Scales were completed in a 10-site national field test study by 513 AYA ages 13-25 years with type 1 (n = 424) or type 2 (n = 89) diabetes. Diabetes symptoms were tested for bivariate and multivariate linear associations with generic HRQOL., Results: Diabetes symptoms were associated with decreased HRQOL in bivariate analyses. In predictive analytics models utilizing hierarchical multiple regression analyses controlling for relevant demographic and clinical covariates, diabetes symptoms accounted for 38 and 39% of the variance in patient-reported generic HRQOL for type 1 and type 2 diabetes, respectively, reflecting large effect sizes. The diabetes symptoms facets hyperglycemia symptoms, hypoglycemia symptoms, and nonspecific diabetes symptoms individually accounted for a significant percentage of the variance in separate exploratory predictive analytics models after controlling for demographic and clinical covariates, with small-to-large effect sizes., Conclusions: Diabetes symptoms are potentially modifiable predictors of generic HRQOL in AYA with diabetes. Identifying specific diabetes symptoms or symptoms facets that are the most important predictors from the patient perspective facilitates a patient-centered approach in clinical research, clinical trials, and practice designed to enhance overall generic HRQOL in AYA with diabetes.

Background: Adolescents with type 1 diabetes commonly have poor glycaemic control. We aimed to test the efficacy of a newly developed adaptive behavioral intervention (Flexible Lifestyles Empowering Change; FLEX) on metabolic and psychosocial outcomes in adolescents with type 1 diabetes., Methods: Young people (13-16 years, type 1 diabetes duration >1 year, HbA 1c of 64-119 mmol/mol [8·0-13·0%], and without other serious medical conditions or pregnancy) from two clinical sites (Colorado and Ohio, USA) were eligible for enrolment. One caregiver was required to participate actively in the study. Adolescent participants were randomly assigned to the FLEX intervention, which used motivational interviewing and problem-solving skills training to enhance patients' self-management, or usual care control. Intervention fidelity was assessed by a behavioral psychologist with specific expertise in motivational interviewing and who was not otherwise involved in the study via audiotaped sessions. The primary outcome was measurement of glycated haemoglobin A 1c (HbA 1c ) at 18 months. Secondary outcomes included motivation and intention, problem solving skills, self-management behaviors, symptoms of depression, health related quality of life, fear of hypoglycemia, diabetes family conflict, risk factors for T1D complications (BMI, blood pressure, and plasma lipids), and hypoglycemia derived from continuous glucose monitoring (percent time below 3·0 and 3·9 mmol/l [54 and 70 mg/dl]). Intention-to-treat analyses used mixed effects models, with fixed effects including site, timepoint, intervention group, intervention by timepoint, and baseline level of primary (HbA 1c ) or secondary outcomes (α=0·05). FLEX is registered on clinicaltrials.gov, number NCT01286350., Findings: Young people recruited from May 1, 2014 to April 4, 2016 were randomly assigned to FLEX (n=130) or usual care control (n=128). Mean diabetes duration was 6·4 (SD 3·8) years, and 71% (181 out of 256) of patients used insulin pump therapy. Retention was 93%, with 241 out of 258 completing the 18-month assessment. The intervention fidelity score was 4·40 of 5·00 for motivational interviewing and 97% for session content. At 18 months, HbA 1c was not significantly different between intervention (83 [13] mmol/mol at baseline; 84 [19] mmol/mol at follow-up); and control (80 [14] mmol/mol at baseline; 82 [17] mmol/mol at follow-up); change in intervention versus control was -0·7 mmol/mol (95% CI -4·7 to 3·4, p=0·75). The intervention was associated with improved scores for motivation (p=0·011), problem solving (p=0·024), diabetes self-management profile (p=0·013), youth report of overall quality of life (p=0·0089), selected domains related to fear of hypoglycaemia (p=0·036 for youth's helplessness or worry; p=0·0051 for parent's efforts to maintain high blood glucose), parent report of diabetes family conflict (p=0·0001), total cholesterol (p=0·038), and diastolic blood pressure (p=0·015). A total of 54 serious adverse events were identified; 34 of these were diabetes-related, including low blood glucose requiring assistance (n=3) and high blood glucose with diabetic ketoacidosis and emergency response (n=25)., Interpretation: The FLEX intervention did not significantly change HbA 1c among these adolescents with elevated HbA 1c , but did positively affect several psychosocial outcomes over 18 months. Further analyses will provide information regarding drivers of positive response to the intervention and will point to future directions for improvement in the approach., Funding: National Institutes of Health and National Institute of Diabetes Digestive Diseases and Kidney and the Helmsley Charitable Trust., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: National health organizations and expert committees have issued recommendations for health behaviors related to obesity risk. Behavioral and family-based weight management interventions for preschoolers often target improving adherence to these recommendations, but it is unknown how the health behaviors of preschoolers with obesity enrolled in weight control treatments (WCTs) compare with these guidelines. In this study, the dietary intake, activity, and sleep behaviors of preschoolers with obesity enrolled in a family-based behavioral WCT are described and compared with national health behavior recommendations., Methods: Health behaviors of 151 preschoolers with obesity (M age = 4.60, SD = 0.93) enrolled in a clinical trial of a weight management program were measured at baseline through caregiver-report questionnaires, three 24-hr dietary recalls, and accelerometers., Results: In total, 70% of the sample exceeded daily caloric recommendations, only 10 and 5% met recommendations for fruit and vegetable intake, respectively, and only 30% met the recommendation of consuming no sugar-sweetened beverages. The majority of the sample met the daily recommendations for 60 min of moderate-to-vigorous activity (80%), < 2 hr of screen time (68%), and sleep duration (70%)., Conclusions: Behavioral weight management interventions for preschoolers with obesity should target the health behaviors where children are not meeting recommendations.

The Flexible Lifestyle Empowering Change (FLEX) Intervention Study is a multi-site randomized controlled trial to test the efficacy of an adaptive behavioral intervention to promote self-management for youth with type 1 diabetes mellitus (T1D). This paper details FLEX design, demographic characteristics of the sample, and outcome variables at baseline. Participants were randomized to either an intervention or control arm after their baseline standardized measurement visit. Baseline data for the primary (glycemic levels) and secondary outcome variables (e.g., motivation and problem-solving, health-related quality of life, risk factors associated with T1D complications) as well as the potential mediator variables (e.g., self-management behavior, family conflict and responsibility) suggest that the study sample was representative of the general population of adolescents with T1D and their parents. The FLEX adaptive intervention is an innovative application of a tailored treatment intervention designed to be readily adopted in real-world practice to meet each adolescent's individualized T1D self-management goals., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To test the hypotheses that an innovative skills-based behavioral family clinic and home-based intervention (LAUNCH) would reduce body mass index z score (BMIz) compared with motivational interviewing and to standard care in preschool-aged children with obesity., Study Design: Randomized controlled trial with children between the ages of 2 and 5 years above the 95 th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012 and June 8, 2015. Children were randomized to LAUNCH (an 18-session clinic and home-based behavioral intervention), motivational interviewing (delivered at the same frequency as LAUNCH), or standard care (no formal intervention). Weight and height were measured by assessors blinded to participant assignment. The primary outcome, BMIz at month 6 after adjusting for baseline BMIz, was tested separately comparing LAUNCH with motivational interviewing and LAUNCH with standard care using regression-based analysis of covariance models., Results: A total of 151 of the 167 children randomized met intent-to-treat criteria and 92% completed the study. Children were 76% White and 57% female, with an average age of 55 months and BMI percentile of 98.57, with no demographic differences between the groups. LAUNCH participants demonstrated a significantly greater decrease in BMIz (mean = -0.32, SD = ±0.33) compared with motivational interviewing (mean = -0.05, SD = ±0.27), P < .001, ω 2  = 0.74 and compared with standard care (mean = -0.13, SD = ±0.31), P < .004, ω 2  = 0.75., Conclusions: In preschool-age children, an intensive 6-month behavioral skills-based intervention is necessary to reduce obesity., Trial Registration: Clinicaltrials.gov NCT01546727., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: This study delineates clinical and psychosocial characteristics of adolescents with type 1 diabetes and suicidal ideation (SI) and reports clinical and psychosocial outcomes after mental health intervention (safety assessment and brief in-clinic intervention)., Methods: Adolescents aged 13-17 years with type 1 diabetes completed the Children's Depression Inventory (CDI) from January 2011 to 2012. Youth with significant depressive symptoms and/or SI endorsement underwent mental health intervention. Two control subjects were matched to each adolescent endorsing SI and compared using t-tests to assess clinical and psychosocial variables. Trajectory of depressive symptoms and outcomes for case subjects were observed through January 2013., Results: Twenty-seven percent (127/473) exhibited moderate to high risk for depression based on CDI scores and 38 (8%) endorsed SI. Adolescents who endorsed SI were more likely to have higher CDI scores and public insurance when compared with youth who denied SI. There was no difference in glycemic control, measured by hemoglobin A1c, between case and control groups. During the year after intervention, 28 participants who initially endorsed SI underwent repeat assessment; mean CDI scores declined by 10.57 (standard deviation: 6.92) points and 78% no longer endorsed SI., Conclusions: Given the potential lethality of insulin when taken in intentional overdose, the need for consistent identification of suicidality is an important feature of depression screening. Study findings indicate statistically significant differences in depressive symptoms and insurance status, when comparing adolescents who endorsed SI to those who denied. Improvement in depressive symptoms and SI endorsement occurred after integrating brief mental health intervention into diabetes visits., (Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of this review is to define psychosocial patient-reported outcomes (PROs) relevant to pediatric and adolescent diabetes populations. Potential domains for PROs include a spectrum of emotional, behavioral, social, physical, overall health, and/or care management areas. A literature review of potential PRO measures, selection criteria, and implementation strategies including a case example will be presented., Recent Findings: Among the pediatric, adolescent, and emerging adult populations, research indicates a relative higher risk for distress, depression, anxiety, and eating disorders as compared to peers without diabetes. Use of PRO measures can expand providers' focus beyond glycemic control, or simply hemoglobin A1c, to better appreciate the impact of diabetes on the whole child/adolescent, and provide services that address patients' individually identified needs, which are most salient to them. Successful selection and implementation of psychosocial PRO measures should be designed to include pathways for real-time provider interaction with the patient and respective PRO data to guide clinical care.

Objective: This study was conducted to identify factors contributing to health satisfaction outcomes among emerging adults (ages 18-25) with diabetes., Method: SEARCH for Diabetes in Youth study participants whose diabetes was prevalent in 2001 and were ≥18 years of age when they completed a 2008-2009 follow-up survey (n = 340) were included. We developed a health resilience model (HRM) to identify potentially modifiable factors (anticipatory guidance, social support, physical activity, quality of life) associated with health outcomes (satisfaction with health care, overall personal health, self-report of hemoglobin A1c [HbA1c]). Proportional odds logistic regression models were used to examine relationships between modifiable factors and health outcomes while adjusting for predetermined characteristics; linear regression models were used for reported HbA1c. Comparison of participants who reported HbA1c versus nonreporters was conducted., Results: A majority (70%) of participants rated satisfaction with health care ≥7 out of 10, and most (71%) rated overall health as good, very good, or excellent. Satisfaction with health care was independent of change in provider between the ages of 17 and 24. After controlling for predetermined characteristics, we found that the odds of increased satisfaction with health care and overall personal health were 1.3 and 1.2 greater, respectively, when participants discussed additional diabetes-related anticipatory guidance topics with a provider and 1.3 and 2.1, respectively, for each 10-unit change in quality of life score. Relationship between HbA1c level and modifiable factors was not significant; however, participants reporting HbA1c had higher ratings of health care and overall health versus nonreporters., Conclusions: HRM describes relationships between modifiable factors and patient-reported outcomes of satisfaction with health care and overall personal health among a cohort of ethnically and racially diverse emerging adults with longstanding diabetes, over half of whom experienced a change in provider. HRM may discern candidate areas for intervention, such as effective anticipatory guidance that can impact satisfaction with health care and overall health, to promote positive health outcomes. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Obesity affects nearly 2 million preschool age children in the United States and is not abating. However, research on interventions for already obese preschoolers is limited. To address this significant gap in the literature, we developed an intervention targeting obesity reduction in 2 to 5year olds, Learning about Activity and Understanding Nutrition for Child Health (LAUNCH). This paper describes the rationale, design, participant enrollment, and implementation of a 3-arm randomized, parallel-group clinical trial comparing LAUNCH to a motivational-interviewing intervention (MI) and standard care (STC), respectively. Whereas LAUNCH was designed as a skills based intervention, MI focused on addressing the guardian's motivation to make changes in diet and activity and providing tools to do so at the guardian's level of readiness to implement changes. Child body mass index z-score was the primary outcome, assessed at pretreatment, posttreatment (Month 6), and 6 and 12month follow-ups (Months 12 and 18). Mechanisms of weight change (e.g., dietary intake, physical activity) and environmental factors associated with weight (e.g., foods available in the home, caregiver diet) were also assessed. This study is unique because it is one of the few randomized controlled trials to examine a developmentally informed, clinic and home skills based behavioral family intervention for preschoolers who are already obese. Being obese during the preschool years increases the likelihood of remaining obese as an adult and is associated with serious health conditions; if this intervention is successful, it has the potential to change the health trajectories for young children with obesity., (Copyright © 2016. Published by Elsevier Inc.)

Objective: Identifying differences in transition readiness according to chronic condition is essential for understanding whether special emphasis within specific populations is warranted. Youth with chronic conditions (type 1 diabetes, Turner syndrome, spina bifida, autism spectrum disorder [ASD]) representing various types of impairments were compared with youth without chronic conditions. It was hypothesized that differences would be observed according to condition type, with youth with cognitive/behavioral conditions showing less readiness than youth with other conditions and youth without chronic conditions showing the highest levels of transition readiness., Methods: Patients (N = 163) ages 12 to 22 were recruited via outpatient clinics at a large freestanding children's hospital. Demographic characteristics (age, sex, race, and maternal education), health literacy, perceptions about health care responsibility, importance and confidence about transfer to adult health care, and the Transition Readiness Assessment Questionnaire (TRAQ) were included., Results: Significant differences in transition readiness were found according to condition type; youth with ASD had the lowest transition readiness scores. Patient and family characteristics and condition were predictors of TRAQ scores and self-perceived readiness to take responsibility for health care and transfer to adult care. Item-level analysis indicated that medication, appointment-keeping, and activities of daily living accounted for differences in TRAQ scores according to condition., Conclusions: Disparities in transition readiness were detected across condition types, with potentially modifiable mechanisms identified to address gaps in readiness for youth transferring to adult health care systems. Developing interventions that assist providers in addressing these modifiable characteristics might improve transition to adult health care for adolescents with various chronic conditions., (Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Many adolescents with Type 1 diabetes (T1D) find adherence difficult in social situations because they fear negative evaluations by others. These negative reaction attributions are associated with anticipated adherence difficulties, stress, and glycemic control. It is unclear whether peer versus friend attributions are distinct constructs, or whether there is a differential impact on glycemic control moderated by youth characteristics., Method: Youth with T1D (n = 142; 58% female; 84% Caucasian, mean = 13.79 years, standard deviation = 2.10) completed the Peer Attribution and Diabetes Stress Questionnaires. HbA1cs were obtained from medical records., Results: Negative peer versus friend attributions appear distinct and were differentially related to anticipated adherence difficulties, stress, and glycemic control, with peer attributions having the strongest effect. Grade, age, and sex were not moderators for these relationships., Conclusion: Peer-related attributions may be a particularly salient target for interventions to improve adherence and distress among youth with T1D., (© The Author 2015. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The current study evaluated the support and education families with a child who has Juvenile Idiopathic Arthritis (JIA) received during a weekend family retreat., Methods: Thirty-one parents completed surveys at the end of the retreat session. Survey questions examined parent's perceptions of the family retreat experience including what they learned and how beneficial it was to their family., Results: Results indicated that the family retreat was beneficial to both the children with JIA and their siblings. Children with JIA had the opportunity to see that other children have this disease as well. At the family retreat, siblings were provided the chance to see that children with JIA are capable of many accomplishments. In addition, the family retreat provided opportunities to learn from other families and offered families reduced isolation., Conclusions: The family retreat was successful in delivering education and support to families, which might not otherwise be obtained via a clinical setting. Parents learned how to support their child with JIA, develop their child's pain management skills, and remain positive as a family. Future research should assess if the education and support family retreats provide have long-term improvement to managing and coping with JIA.

The purpose of this study is to examine prevalence rates of pain reports in youth with type 1 diabetes mellitus (T1DM) and potential predictors of pain. Pain is a common and debilitating symptom of diabetic polyneuropathies. There is currently little research regarding pain in youth with T1DM. It was predicted that self-care and general health factors would predict pain as suggested by the general pain literature. Participants (N = 269) ranged in age from 13 to 17 years; youth had a mean time since diagnosis of 5.8 years. Data collected included diabetes self-management variables, ratings of the patient's current functioning and pain intensity ('current'), and information collected about experiences that occurred in the time preceding each appointment ('interim'). About half of the youth (n = 121, 49.0%) reported any interim pain across both appointments. Female adolescents and those individuals who were physically active and/or utilized health-care system more acutely were more likely to report interim central nervous system pain. Improved diabetes self-management and increased level of physical activity may reduce experiences of pain and increase the quality of life of youth with T1DM. Regular monitoring of both current and interim pain experiences of youth with T1DM is recommended., (© The Author(s) 2013.)

Important stakeholders, including the American Diabetes Association (ADA) and the International Society of Pediatric and Adolescent Diabetes (ISPAD), recognize the need for psychologists to be an integral part of diabetes care. This review paper aims to provide a comprehensive examination of pediatric psychologists' roles in working with children and adolescents with diabetes, including during distinct phases of treatment (e.g., diagnosis, outpatient diabetes clinic visits, inpatient hospitalizations, and outpatient psychology visits) and with different modalities of psychological interventions (e.g., screening, individual, family, and group therapy). In addition, the role of the psychologist in diabetes care within various settings (e.g., private practice, academic medical centers, and community organizations) will be explored. Finally, this paper will outline other roles in which psychologists contribute to diabetes-specific efforts (e.g., translational research, program development in transition to adult care, advocacy for health care reform initiatives, health care billing/reimbursement, and alternative methods to psychosocial care delivery) as well as future directions for working with children and adolescents with diabetes. Pediatric psychologists have multiple professional roles in a wide variety of settings; however, there is more that can be done in the future to fully utilize pediatric psychologists in diabetes care for children and adolescents, such as embedding psychologists into integrated clinic visits where families receive comprehensive medical and psychological services to support overall health and well-being. Therefore, there is a need for increased advocacy to obtain even more pediatric psychology engagement in diabetes care to provide new clinical services and develop more translational research.

Objective: To evaluate the factor structure and measurement invariance of the Diabetes Stress Questionnaire (DSQ), a measure of diabetes-specific stress, across sex, age (<9th grade vs. ≥9th grade), and glycemic control (optimal vs. suboptimal)., Methods: Data from 318 adolescent participants were pooled from four archival data sets and the ongoing Predicting Resiliency in Youth with Type 1 Diabetes study in which the DSQ was completed. Confirmatory factor and measurement invariance analyses were conducted to confirm the proposed factor structure and measurement invariance across sex, age, and glycemic control., Results: The DSQ factor structure was found to have an acceptable fit, which was invariant across sex, age, and glycemic control., Conclusions: When using the DSQ, differences in diabetes-related stress with respect to sex, age, or glycemic control can be considered meaningful. This study supports the DSQ as an evidence-based and well-established assessment of perceived diabetes stress in youth with type 1 diabetes., (© The Author 2014. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective. This study provides information about children's learning and goal attainment related to change in their self-management skills during a diabetes camp. Design and methods. One hundred and thirty-one children completed an evaluation for the first year (year 1), and 68 children completed an evaluation for the second year (year 2). All of the children had type 1 diabetes. During both years, parents provided information about goals for their child before camp started. Children's learning about diabetes self-management, as well as their satisfaction with camp, was assessed at the end of the camp session. In the evaluation for year 2, a goal-setting intervention was also developed, and its effectiveness was assessed through both physicians' and children's reports. Results. Children learned new information during camp about recognizing and managing the signs of hypo- and hyperglycemia and about counting carbohydrates and rotating insulin pump sites. Children were better able to recall their self-management goals in year 2. In terms of benefiting from camp, boys reported learning more than girls about diabetes management, whereas girls were more likely than boys to report that greater opportunities to express feelings were of value. Conclusions. Goal-setting was successful in improving children's recall of their self-management goals. Children benefited from the supportive and educational camp atmosphere. Future research should assess the benefits of camp across multiple camp settings and determine whether educational benefits have long-term effects on children's goal-setting and knowledge and whether these benefits lead to psychosocial improvements.

Peer- and family-based group therapies have been used as separate interventions to improve adjustment and self-management among youth with Type 1 diabetes mellitus. This study replicates a treatment protocol that combined these two types of diabetes management groups, while also using a wait-list control design methodology within an outpatient mental health clinic setting. General psychosocial and diabetes-related variables were assessed at baseline, immediately posttreatment, and 4 months posttreatment. Youths' medical information, including metabolic control values, was extracted from medical charts for the 6 months prior to baseline and 6 months after treatment ended. At 4 months posttreatment, parents and youth reported increased parent responsibility, and parents reported improved youth diabetes-specific quality of life. Although there were no statistically significant changes in hemoglobin A1c values and health care utilization frequency from 6 months prior to and 6 months posttreatment, other psychosocial changes (i.e., increases in parent responsibility and diabetes-specific quality of life) were documented. Therefore, this treatment was found to be a promising intervention for use in an outpatient clinical setting to aid in improving the psychosocial functioning of youth with Type 1 diabetes mellitus., ((PsycINFO Database Record (c) 2013 APA, all rights reserved).)

Purpose: The purpose of the study was to examine how physical and social environments, as measured by household chaos, affect the diabetes control (i.e., A1C) in youth with type 1 diabetes (T1DM)., Methods: One hundred and four patients (53 male, 51 female) with T1DM (aged 1-13 years) and their caregivers were recruited from a diabetes clinic at a Midwestern children's hospital. The caregivers completed a demographic questionnaire as well as a questionnaire pertaining to chaos in the household. A medical record review at baseline and 3- and 6-month follow-up was also conducted., Results: Results found that above and beyond the demographic covariates, there still remained a significant relationship between household chaos and glycemic control. Those who scored more than 1 standard deviation above the mean Confusion, Hubbub, and Order Scale (CHAOS) measure score showed significantly worse glycemic control at 6-month follow-up., Conclusions: This study demonstrated the relationship of family environment and glycemic control for youth with T1DM. The findings highlight the need to individually assess the youth's home environment to promote diabetes management and care during clinic visits.

The resiliency of families, based on family functioning and family hardiness, may influence caregivers' anxiety while their child is in the hospital undergoing treatment for his or her chronic illness. The current study assessed the relationship among these factors for caregivers of children with various chronic illnesses who were residing at a local Ronald McDonald House (RMH). Caregivers completed paper-based questionnaires to assess family hardiness, functioning, and parent state anxiety and interviews to identify positive and negative strategies and behaviors affecting how they were coping with their child's illness. Findings indicated that family functioning mediated the relationship between family hardiness and caregiver anxiety as a resilience factor that further reduced caregiver anxiety. During interviews, caregivers suggested that support from family members strengthened their coping abilities. Negative interactions with their child's medical team and not knowing how or being equipped to help their child live with his or her illness heightened caregiver stress. Future research should focus on developing, implementing, and measuring the effectiveness of interventions to improve caregiver support, such as by holding caregiver support groups at local RMHs, especially during a child's hospitalization., (PsycINFO Database Record (c) 2013 APA, all rights reserved.)

Objective: Research on how adolescents with type 2 diabetes mellitus (T2DM) understand and use social support is limited. Therefore, we explored how adolescents with T2DM experience and perceive social support., Methods: Adolescents with T2DM were interviewed, and data were qualitatively analyzed using Consensual Qualitative Research methodology., Results: Four themes emerged: support for nondiabetes and diabetes-specific behaviors, feelings of belonging, and disclosure. All participants expressed emotional and self-care-specific support. For some, disclosure and a sense of belonging with others who had diabetes often led to support elicitation. Participants also expressed a fear of disclosing their diabetes to others., Discussion: Adolescents with T2DM value tangible and emotional support for behaviors both related and not related to diabetes. Fear of disclosure was a typical experience with disclosure often limited to close friends and family. Recommendations for health professionals to assist adolescents in promoting appropriate disclosure and means of requesting support are discussed.

Purpose: The purpose of this study was to explore the perspectives of adolescents diagnosed with type 2 diabetes mellitus (T2DM) in terms of how youths conceptualized the effect of T2DM on daily life, adjustment to the illness, and motivation related to diabetes self-care management. The aims of the study were to gather essential information in order to develop appropriate intervention techniques and inform future studies intended to understand the psychosocial experiences of youths with T2DM., Methods: Eight adolescents diagnosed with T2DM were recruited from an outpatient pediatric diabetes clinic at a Midwestern children's hospital. A qualitative interview was developed, which was scheduled to last about 30 to 45 minutes. Data were analyzed using the consensual qualitative research methodology, wherein qualitative coders developed core ideas and themes related to the adolescent experience of T2DM., Results: Three main themes were identified, including how the youths conceptualized the impact of T2DM, adjustment to self-care, and motivation to perform self-care behaviors. Knowledge related to the cause of T2DM and adjustment to completing self-care behaviors was varied among youths. Few adolescents spoke about motivation sources, although when mentioned, it typically involved witnessing negative health consequences in family members or friends with T2DM., Conclusions: The data represent essential initial information related to youths with T2DM, which will help guide in developing future studies designed to understand the psychosocial experiences of youths with T2DM and appropriate intervention techniques. Future research that aims to increase internal and external motivation may be able to subsequently impact adherence to self-care behaviors.

Objectives: The present study examined four methods of assessing diabetes adherence (self-report, diary measure, electronic monitoring, and provider rating) within a population of youth with Type I Diabetes Mellitus (T1DM)., Methods: Comparisons were conducted among the four methods of assessing diabetes adherence. Associations among the seven different measures of blood glucose monitoring (BGM) and HbA1c were examined. An exploratory stepwise regression analysis was conducted to determine the best predictors of glycemic control (i.e., Hemoglobin A1c; HbA1c) while controlling for relevant demographic variables., Results: The adherence measures appeared to be interrelated. The relationships between many of the BGM measures and HbA1c demonstrated a medium effect size. The Self Care Inventory (SCI) adjusted global score was the strongest predictor of HbA1c, even after taking the demographic variables into account., Conclusions: The SCI is a robust, easy-to-use, and cost-efficient measure of adherence that has a strong relationship to HbA1c. Demographic variables are important to examine within the context of different methods of assessing adherence. The research methodology utilized to assess both general diabetes adherence and more specific behavioral measurements of BGM should be clearly documented in future studies to ensure accurate interpretation of results.

Objective: This study examined the reliability and validity of items assessing adolescent and parent readiness to change the balance of responsibility for managing type 1 diabetes mellitus (T1DM)., Methods: Sixty-nine adolescents with T1DM and their caregivers completed questionnaires assessing readiness to change the balance of responsibility, division of responsibility for diabetes management tasks, self-efficacy, and parenting stress. Stages of change classifications were determined for individual respondents and families., Results: Participant inclusion in the different readiness to change classifications was associated with the variability in scores for indices of responsibility, self-efficacy, and parenting stress. Adolescent, maternal, and paternal characteristics accounted for differing amounts of variance in predicting readiness to change the balance of responsibility scores., Conclusions: Individual assessment of youth and caregivers' readiness to change the balance of responsibility for diabetes management tasks may be beneficial to providers during the youths' transition from adolescence to young adulthood., (© 2011 John Wiley & Sons A/S.)