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Only 17% of adolescents with type 1 diabetes achieve glycemic control targets (1), and many are at risk for psychological concerns (e.g., depression, anxiety, and diabetes distress) (2,3), diminished quality of life (4), and the development of diabetes complications (5,6). Psychological functioning and the quality of parent-child interactions can heavily influence self-management in adolescents with type 1 diabetes and are therefore among the greatest concerns of adolescents with type 1 diabetes, their parents, and their health care providers (HCPs) (7). However, conventional models of care are ill equipped to address these issues effectively. Approximately 30% of diabetes teams do not have access to mental health providers (8), and teams with access to such professionals struggle to efficiently incorporate them into routine care (9). The increasing incidence of youths diagnosed with type 1 diabetes each year (10,11), coupled with the limited supply of pediatric endocrinologists (12) to treat these patients, exacerbates these challenges. Thus, there is a need for novel and alternative models of health care delivery for adolescents with type 1 diabetes that address behavioral and psychological barriers to diabetes management and dietary management and are more time-efficient for diabetes clinicians. Multiple models for integrated pediatric care of type 1 diabetes exist and aim to meet American Diabetes Association (ADA) guidelines for care (13). The ADA recommends a collaborative care approach among HCPs and families, including the incorporation of shared decision-making, medical nutrition therapy, and psychosocial support during routine ambulatory care visits (13). These treatment teams may include endocrinologists, advanced practice nurses, physician assistants, dietitians, certified diabetes care and education specialists (CDCESs), social workers, and psychologists. Multidisciplinary care, typifying much of type 1 diabetes care in the United States, engages several disciplines, but each discipline stays within its boundaries, and knowledge of other disciplines …

Background: The sustainability of health benefits in response to lifestyle-based interventions remains unclear in children with overweight and obesity, and cardiometabolic disease (CMD). We determi...

This study describes the development and psychometric evaluation of the Pediatric Diabetes Routines Questionnaire for Parents of Young Children (PDRQ-PYC) with type 1 diabetes, a measure adapted from the school-age and adolescent versions of the PDRQ, to measure diabetes-specific routines in families with children under age 6 years with type 1 diabetes. Participants included 173 parents of young children with type 1 diabetes (YC-T1D) who completed measures of diabetes-specific routines, diabetes adjustment, self-efficacy, benefit finding, depression, child behavior problems, spousal support, and T1D treatment engagement. Exploratory factor analysis supported a one-factor model consisting of a unidimensional PDRQ-PYC total score. The PDRQ-PYC total score demonstrated good internal consistency, convergent validity, and criterion validity. The present study demonstrates that PDRQ-PYC is a valuable and feasible tool for measuring the consistency and regularity with which families of YC-T1D perform T1D management tasks. Along with the school-age and adolescent versions of the PDRQ, the PDRQ-PYC now provides the ability to assess diabetes-specific routines from early childhood through adolescence and findings support the notion that routines are associated with engagement in diabetes tasks.ClinicalTrials.gov Identifier NCT03222180 (first posted July 19, 2017).

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.

Rationale Obesity in children increases the risk for new asthma. How age, sex, race/ethnicity, and allergy status affect the relationship between obesity and asthma is unclear. This study describes the relationship between high body mass index (BMI) and incident asthma. Methods We conducted a retrospective cohort study to compare asthma incidence among normal weight, overweight, and obese 2 to 6, 7 to 11, and 12 to 17 year olds to define the effects of sex, race/ethnicity, and allergy status. Weight status was determined at baseline and asthma incidence was defined as ≥2 asthma encounters and ≥1 asthma prescriptions. We used multivariable Poisson regression to estimate adjusted incident asthma rates and risk ratios. Results Data from 192 843 2 to 6 year olds, 157 284 7 to 11 year olds, and 157 369 12 to 17 year olds were included. The relative risks (95% confidence interval [CI]) of new asthma among obese children in 2 to 6 year olds, 7 to 11 year olds, and 12 to 17 year olds were 1.25 (1.15, 1.37), 1.49 (1.32, 1.69) and 1.40 (1.21, 1.63), respectively. Among children with underlying allergic rhinitis, obesity did not increase the risk of new asthma. In children without allergic rhinitis, the risk for obesity-related asthma was highest in 7 to 11 year olds (risk ratio = 1.50 95% CI, 1.33, 1.60). Before age 12, females had a higher risk for obesity-related asthma; but after age 12, obese males had a higher asthma risk (interaction P-value Conclusion Obesity is a major preventable risk factor for pediatric asthma that appears to vary along the pediatric age continuum and depends on sex, race/ethnicity and atopy status.

BACKGROUND: The American Diabetes Association recommends a family-centered approach that addresses each family’s specific type 1 diabetes self-management barriers. OBJECTIVE: To assess an intervention that tailored delivery of self-management resources to families’ specific self-management barriers. SUBJECTS: At two sites, 214 children 8–16 years old with type 1 diabetes and their parent(s) were randomized to receive tailored self-management resources (intervention, n=106) or usual care (n=108). METHODS: Our intervention 1) identified families’ self-management barriers with a validated survey, 2) tailored self-management resources to identified barriers, and 3) delivered the resources as four group sessions coordinated with diabetes visits. Mixed effects models with repeated measures were fit to A1c as well as parent and child QOL during the intervention and one year thereafter. RESULTS: Participants were 44% youth (8–12 years) and 56% teens (13–16 years). No intervention effect on A1c or QOL was shown, combining data from sites and age groups. Analyzing results by site and age group, post-intervention A1c for teens at one site declined by 0.06 more per month for intervention teens compared to usual care (p8.5 (−0.08, p10 (−0.19, p

Background: Diabetes-specific risk taking (DSRT) refers to unhealthy, risky behaviors that put someone with diabetes at increased risk for suboptimal health outcomes (e.g., drinking alcohol with others who are unaware you have T1D). DSRT is associated with less engagement in T1D management and higher HbA1c. This study set out to determine if lower levels of parental involvement in T1D care and higher levels of diabetes distress, also associated with less optimal T1D outcomes, were associated with DSRT among adolescents with T1D. Methods: Participants were 104 adolescents with T1D (Mage = 13.50 years, SDage = 1.69 years, 53.8% female, MHbA1c = 8.74%, SDHbA1c = 1.24%) who enrolled with their caregivers in a randomized controlled trial integrating psychologists and dietitians into T1D care visits (35% enrollment). Adolescents completed baseline measures of parental involvement, diabetes distress, and DSRT; caregivers reported demographics; and HbA1c was collected from the electronic medical record. Hierarchical linear regression was used to examine whether parental involvement and diabetes distress predicted DSRT after controlling for participants’ sex, race, ethnicity and HbA1c. Results: The full model was statistically significant and accounted for 29.7% of the variance in diabetes-specific risk taking (F(2, 91)= 19.1, p < .001). Neither HbA1c, sex, race nor ethnicity were statistically significant predictors of DSRT. Higher levels of diabetes distress (β = .23, p = .01) and lower parental involvement (β = -.44, p < .001) predicted more frequent DSRT. Conclusions: Adolescents with more diabetes distress and less collaborative parental involvement in T1D management reported more diabetes-specific risk taking. While causality cannot be asserted, these results can inform targeted behavioral interventions to help youth who are more likely to take risks in their T1D care. Future research should consider other factors contributing to diabetes-specific risk taking. Disclosure C. Thomas: None. T. Wysocki: None. M. A. Alderfer: None. P. Enlow: None. R. M. Wasserman: None. A. Milkes: None. J. Pierce: None. S. Gurnurkar: None. M. Carakushansky: None. D. A. Doyle: None. J. S. Pendley: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (DP3DK113235)

Editor's Note: This article is adapted from the address Dr. Wysocki delivered as the recipient of the American Diabetes Association’s Richard R. Rubin Award for 2018. This award recognizes a behavioral researcher who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes in diverse populations. Dr. Wysocki delivered the address in June 2018 at the association’s 78th Scientific Sessions in Orlando, Fla.

Objective To describe a novel, five-phase approach to collecting qualitative data from hard-to-reach populations using crowdsourcing methods. Methods Drawing from experiences across recent studies with type 1 diabetes and congenital heart disease stakeholders, we describe five phases of crowdsourcing methodology, an innovative approach to conducting qualitative research within an online environment, and discuss relevant practical and ethical issues. Results Phases of crowdsourcing methodology are: (I) Preparing; (II) Forming Crowds; (III) Collecting Crowdsourced Data; (IV) Coding and Analyzing Crowdsourced Data; and (V) Generating and Disseminating Findings. Iterative feedback from stakeholders is obtained in all five phases. Practical and ethical issues include accessing diverse stakeholders, emotional engagement of crowd participants, responsiveness and transparency of crowdsourcing methodology, and limited personal contact with crowd participants. Conclusions Crowdsourcing is an innovative, efficient, feasible, and timely approach to engaging hard-to-reach populations in qualitative research.

OBJECTIVES: The National Patient-Centered Clinical Research Network (PCORnet) supports observational and clinical research using healthcare data. The PCORnet Antibiotics and Childhood Growth Study is one of PCORnet’s inaugural observational studies. The objectives of this manuscript are to describe (1) the processes used to integrate and analyze data from children across 36 participating institutions and (2) the cohort characteristics and prevalence of antibiotic use. METHODS: We included children in the cohort if they had at least one same-day height and weight measured in each of three age periods: 1) before 12 months, 2) 12 to 30 months, and 3) after 24 months. We distributed statistical queries that each institution ran on its local version of the PCORnet Common Data Model, with aggregate data returned for analysis. We defined overweight or obesity as age-sex-specific body mass index ≥ 85(th), obesity ≥95(th) percentile, and severe obesity ≥120% of the 95(th) percentile. RESULTS: 681,739 children met the cohort inclusion criteria and were racially/ethnically diverse (24.9% black, 17.5% Hispanic). Before 24 months, 55.2% of children received at least one antibiotic prescription; 21.3% received a single antibiotic prescription, 14.3% received four or more, and 33.3% received a broad spectrum antibiotic. Overweight and obesity prevalence was 27.6% at 4 to

OBJECTIVE: Ethnic minority youth with type 1 diabetes (T1D) often have poorer glycemic control and lower rates of adherence compared to White Non-Hispanic (WNH) youth. Variables such as family conflict, autonomy support, and youth regimen responsibility have been shown to change over adolescence and impact diabetes management. However, these factors have been investigated in predominantly White samples. Few studies have examined potential differences in these variables and their trajectories for Hispanic youth over early adolescence. METHODS: Youth with T1D (178 WNH and 33 Hispanic youth participants), as well as their maternal caregivers (174 WNH and 32 Hispanic maternal caregivers), completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency at 4 timepoints over a 3-year period. RESULTS: At baseline, Hispanic youth had significantly poorer glycemic control, more family conflict, and fewer blood glucose checks on average compared to WNH youth. Similar to WNH youth, Hispanic youth have increasing independence for regimen tasks and decreasing parent autonomy support during this developmental period. However, while Hispanic youth had worsening diabetes management during early adolescence (as did WNH youth), Hispanic parents reported a more gradual change in youth’s diabetes management over early adolescence. CONCLUSIONS: This study presents an important contribution to the existing literature on youth with T1D. Findings suggest potential strengths and targets for Hispanic youth navigating diabetes management during the adolescent period. It is important to continue to investigate the trajectories of ethnic minority youth with diabetes.

Little is known about the career satisfaction of pediatric psychologists, who specialize in psychological research, teaching, and clinical service in the context of pediatric healthcare. As part of the larger Society of Pediatric Psychology Workforce Survey and in collaboration with the American Psychological Association Center for Workforce Studies, this study aimed to: (1) describe the career domains which pediatric psychologists perceive to be important and their satisfaction in each domain, and (2) compare satisfaction of pediatric psychologists across work settings, number of positions, appointment duration, professional roles, career stage, academic rank, and gender. Responses from 336 pediatric psychologists demonstrated high career satisfaction. Domains of career satisfaction that received mean scores indicating high importance include balance of work and personal lives, peer/collegial support, and flexibility and choice in the workplace, but on average respondents reported being only somewhat satisfied in these domains. Total satisfaction scores were significantly higher among pediatric psychologists in 9-10 month appointments, primarily research careers, and at higher academic ranks, but scores were similar across employment settings and genders. To enhance career satisfaction and retention, pediatric psychologists may seek additional mentorship or explore new employment roles, and administrators and managers may consider adopting workplace policies or making environmental changes that could address specific areas of need. Public significance statement This study suggests that overall, pediatric psychologists are highly satisfied with their employment. However, there may be some important aspects of their work that could be more satisfying. The findings have implications for identifying professional development strategies that can maintain or enhance satisfaction.

This article describes the methodology, recruitment, participant characteristics, and sustained, intensive stakeholder engagement for Project ACE (Achieving control, Connecting resources, Empowering families). Project ACE is a randomized controlled trial of children and youth ages 8-16 with type 1 diabetes evaluating the impact of tailored self-management resources on hemoglobin A1c (A1c) and quality of life (QOL). Despite strong evidence that controlling A1c reduces long-term complications,25% of US youth with type 1 diabetes meet A1c targets. Many interventions are efficacious in improving A1c and QOL for these youth, whose families often struggle with the substantial demands of the treatment regimen. However, most such interventions are ineffective in the real world due to lack of uptake by families and limited healthcare system resources. Project ACE is a multi-site trial designed to improve diabetes outcomes by tailoring existing, evidence-based interventions to meet families' needs and preferences. We hypothesize that this family-centered approach will result in better A1c and QOL than usual care. Project ACE has recruited and randomized 214 eligible 8-16year old youth and their parents. The 9-month intervention consisted of 4 group sessions tailored to families' self-management barriers as identified by a validated instrument. Outcomes including A1c and QOL for parents and youth will be assessed for 1year after the intervention. Stakeholder engagement was used to enhance this trial's recruitment, retention and integration into routine clinical care. Findings will inform implementation and dissemination of family-centered approaches to address self-management barriers.NCT02024750 Trial Registrar: Clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT02024750.

Objective To summarize compensation results from the 2015 Society of Pediatric Psychology (SPP) Workforce Survey and identify factors related to compensation of pediatric psychologists. Methods All full members of SPP ( n = 1,314) received the online Workforce Survey; 404 (32%) were returned with usable data. The survey assessed salary, benefits, and other income sources. The relationship between demographic and employment-related factors and overall compensation was explored. Results Academic rank, level of administrative responsibility, and cost of living index of employment location were associated with compensation. Compensation did not vary by gender; however, women were disproportionately represented at the assistant and associate professor level. Conclusions Compensation of pediatric psychologists is related to multiple factors. Longitudinal administration of the Workforce Survey is needed to determine changes in compensation and career advancement for this profession over time. Strategies to increase the response rate of future Workforce Surveys are discussed.

Background The literature on the specification and measurement of the outcomes of the healthcare transition from pediatric to adult centered-care is scarce and methodologically weak. To address these gaps, we conducted a series of studies to develop a multidimensional, multi-informant (young adults, parents, and healthcare providers) measure of healthcare transition outcomes for young adults with type 1 diabetes (T1D), the Healthcare Transition Outcomes Inventory (HCTOI). The current study describes the development and refinement of the HCTOI item pool. Methods Following Patient Reported Outcomes Measurement Information System (PROMIS) standards, the research team conducted qualitative interviews to define six content domains of healthcare transition outcomes from the perspectives of multiple stakeholders, developed an initial item pool of the HCTOI based on the six domains, analyzed expert item ratings and feedback for content validation, and conducted cognitive interviews with informants (patients, parents, and healthcare providers) for further item pool refinement. Results Qualitative findings revealed six healthcare transition outcome domains: 1) Biomedical markers of T1D control; 2) Navigation of a new health care system; 3) Possession of T1D self-management skills and knowledge; 4) Integration of T1D care into emerging adult roles; 5) Balance of parental involvement with autonomy; and 6) Attainment of T1D “ownership.” An initial pool of 88 items focused on the extent to which a young adult with T1D is successful on each of the six domains. Experts rated all content domains and all but six items as relevant. In addition to suggesting additional items, experts were concerned about the length of the measure, response burden, and whether every informant type would have sufficient knowledge to rate items in particular content domains. Cognitive interviews resulted in retaining all six content domains, but dropping some items and yielded fewer items for the healthcare provider version (47 items versus 54 items for the young adult- and parent-versions). Conclusions Expert review and cognitive interviews confirmed that all six domains of HCT outcomes were relevant and both procedures resulted in retaining a sufficient number of clear and representative items for each content domain. The HCTOI represents the first multi-informant, rigorously developed item pool that comprehensively measures the multiple components of the transition from pediatric to adult specialty healthcare.

Benefit finding, perceived positive effects of adversity, has been associated with psychological well-being in people with chronic illnesses and with better adherence for adolescents with type 1 diabetes (T1D). Our qualitative research with parents of young children (< 6 years old) with T1D indicated that benefit finding (BF) is a common parental coping mechanism, but no tools exist to measure BF in parents. We determined psychometric properties of the Diabetes Benefit Finding Scale for Parents (DBFS-P), a 16-item questionnaire adapted from the validated adolescent version. Parents of young children with T1D (n = 172) were participants in a randomized trial of an online intervention. We examined the DBFS-P factor structure through principal component analysis (PCA); internal consistency through Cronbach's alpha; convergent validity via bivariate correlations between the DBFS-P and measures of parental depression, anxiety, T1D self-efficacy, and hypoglycemia fear; and discriminant validity via bivariate correlations between the DBFS-P and measures of parental somatization and child behavior problems. PCA revealed one factor (56.47% variance) with Cronbach's α = 0.95. Convergent validity of the DBFS-P was supported by significant correlations with parental depression (r = -0.35, P < 0.001), anxiety (r = -0.20, P = 0.008), T1D self-efficacy (r = 0.36, P < 0.001), and hypoglycemia fear (r = 0.27, P < 0.001). Non-significant correlations with parental somatization (r = -0.06, P = 0.42) and child behavior problems (r = -0.12, P = 0.14) support its discriminant validity. The DBFS-P demonstrated good psychometric properties as a tool for assessing BF among caregivers.

ObjectiveThis article extends work on a social-ecological model of caregiver adjustment and describes the: (a) development and (b) validation of the Parent-Preschoolers Diabetes Adjustment Scale (PP-DAS), a broad measure of caregiver adjustment.MethodsParticipants were caregivers (nstudy1 = 51; nstudy2 = 177) of very young children (ResultsAfter review by parents and researchers, 52 items were removed resulting in the 40-item version used in study 2. The CFA demonstrated poor fit with the five proposed domains of the social-ecological model, so an EFA was conducted and supported a different five-factor solution. Twenty items were removed due to low factor loadings or communalities, resulting in a final 20-item measure. The PP-DAS demonstrated adequate internal consistency (α’s = .73–.84), convergent validity with parent psychological functioning and self-efficacy in T1D management, and criterion validity with hemoglobin A1c and adherence.ConclusionsThe PP-DAS is a valid and reliable measure of adjustment in caregivers of very young children with T1D. The PP-DAS may help identify caregivers who are having adjustment difficulties and would benefit from additional support.

The American Academy of Pediatrics recommends screening young children for behavioral and emotional problems (BEP) during primary care visits. Because of time constraints, few primary care providers (PCPs) use standardized screening tools to detect BEP. The Early Childhood Screening Assessment (ECSA) is a brief screening tool developed specifically to meet the needs of pediatric primary care providers (PCPs). The ECSA has established psychometric properties, but the feasibility and acceptability of the ECSA have not been established. This study examines the degree to which PCPs would incorporate ECSA screening and how PCPs value the ECSA as a tool to detect children with BEP. Twenty-seven pediatric PCPs were trained to implement ECSA screening. Six months after training, 96% of PCPs reported that the ECSA was practical for use at well-visits, 70% were still screening and 89% agreed that it helped detect more cases of BEP than by routine history-taking alone.

Relationships between health care providers and families may be critical to effective weight management for youth with obesity. In this study, 50 youth with obesity (ages 5–16) and their caregivers completed questionnaires at three successive obesity clinic visits. Results suggest that visit satisfaction and treatment alliance contribute positively to parent/youth self-efficacy and self-reported treatment adherence. However, more weight loss was associated with less favorable treatment alliance and visit satisfaction. Findings suggest that an optimal approach to weight management may require a balance between maintaining a positive rapport and challenging families to make and sustain meaningful lifestyle changes.

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.

OBJECTIVES: Adult obesity is linked to asthma cases and is estimated to lead to 250 000 new cases yearly. Similar incidence and attributable risk (AR) estimates have not been developed for children. We sought to describe the relationship between overweight and obesity and incident asthma in childhood and quantify AR statistics in the United States for overweight and obesity on pediatric asthma. METHODS: The PEDSnet clinical data research network was used to conduct a retrospective cohort study (January 2009–December 2015) to compare asthma incidence among overweight and/or obese versus healthy weight 2- to 17-year-old children. Asthma incidence was defined as ≥2 encounters with a diagnosis of asthma and ≥1 asthma controller prescription. Stricter diagnostic criteria involved confirmation by spirometry. We used multivariable Poisson regression analyses to estimate incident asthma rates and risk ratios and accepted formulas for ARs. RESULTS: Data from 507 496 children and 19 581 972 encounters were included. The mean participant observation period was 4 years. The adjusted risk for incident asthma was increased among children who were overweight (relative risk [RR]: 1.17; 95% confidence interval [CI]: 1.10–1.25) and obese (RR: 1.26; 95% CI: 1.18–1.34). The adjusted risk for spirometry-confirmed asthma was increased among children with obesity (RR: 1.29; 95% CI: 1.16–1.42). An estimated 23% to 27% of new asthma cases in children with obesity is directly attributable to obesity. In the absence of overweight and obesity, 10% of all cases of asthma would be avoided. CONCLUSIONS: Obesity is a major preventable risk factor for pediatric asthma.

Screening can detect adolescent idiopathic scoliosis (AIS). The objective was to determine if computer-based simulation (CBS) and computerized clinical decision-support systems (CCDSS) would improve primary care providers' AIS screening exams as noted in their documentation. All participants received AIS screening CBS training. Participants were then randomized to receive either CCDSS when an eligible patient was seen (intervention arm) or no further intervention (comparison arm). Eligible patients' documentation was analyzed looking for a complete AIS screening exam. Over the span of 17 weeks, 1051 eligible patients were seen; 468 by providers in the intervention arm, 583 in the comparison arm. In all, 292/468 (62%) of eligible patients seen in the intervention arm and 0/583 (0%) in the comparison arm had a complete AIS screening exam documented. Compared with single CBS training alone, repeated exposure to CCDSS after CBS training resulted in improved documentation of the screening exam for AIS.

ISPAD Clinical Practice Consensus Guidelines 2018 : Management and support of children and adolescents with type 1 diabetes in school

OBJECTIVE To compare glycemic control, quality of life, and pregnancy outcomes of women using insulin pumps and multiple daily injection therapy (MDI) during the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT). RESEARCH DESIGN AND METHODS This was a prespecified analysis of CONCEPTT involving 248 pregnant women from 31 centers. Randomization was stratified for pump versus MDI and HbA1c. The primary outcome was change in HbA1c from randomization to 34 weeks’ gestation. Key secondary outcomes were continuous glucose monitoring (CGM) measures, maternal-infant health, and patient-reported outcomes. RESULTS At baseline, pump users were more often in stable relationships (P = 0.003), more likely to take preconception vitamins (P = 0.03), and less likely to smoke (P = 0.02). Pump and MDI users had comparable first-trimester glycemia: HbA1c 6.84 ± 0.71 vs. 6.95 ± 0.58% (51 ± 7.8 vs. 52 ± 6.3 mmol/mol) (P = 0.31) and CGM time in target (51 ± 14 vs. 50 ± 13%) (P = 0.40). At 34 weeks, MDI users had a greater decrease in HbA1c (−0.55 ± 0.59 vs. −0.32 ± 0.65%, P = 0.001). At 24 and 34 weeks, MDI users were more likely to achieve target HbA1c (P = 0.009 and P = 0.001, respectively). Pump users had more hypertensive disorders (P = 0.011), mainly driven by increased gestational hypertension (14.4 vs. 5.2%; P = 0.025), and more neonatal hypoglycemia (31.8 vs. 19.1%, P = 0.05) and neonatal intensive care unit (NICU) admissions >24 h (44.5 vs. 29.6%; P = 0.02). Pump users had a larger reduction in hypoglycemia-related anxiety (P = 0.05) but greater decline in health/well-being (P = 0.02). CONCLUSIONS In CONCEPTT, MDI users were more likely to have better glycemic outcomes and less likely to have gestational hypertension, neonatal hypoglycemia, and NICU admissions than pump users. These data suggest that implementation of insulin pump therapy is potentially suboptimal during pregnancy.

Background: Experts recommend family-centered self-management approaches that address specific T1D self-management barriers for each child and family. However, no system-level method currently exists to identify and address these barriers. Objectives: To assess the impact on glycemic control and QoL for the child and parent of a family-centered approach to the delivery of diabetes self-management resources. Methods: Children 8-16 years old with T1D and their parent(s) were randomized to receive either tailored self-management resources (intervention) or usual care. Our intervention 1) identified families’ self-management barriers with a validated survey, 2) tailored self-management resources to identified barriers, and 3) delivered these resources as group sessions coordinated with diabetes visits to optimize convenience, efficiency, and sustainability. Mixed effects models with repeated measures were used to examine the intervention’s impact on A1c and parent and child QoL during the 9-month intervention period and for a year thereafter. Results: Among 363 potentially eligible families, 267 (74%) consented to participate. Randomization allocated 1families to usual care and 1to the intervention. Participants were children (8-12 years, 44%) and teens (13-16 years, 56%). Mean diabetes duration was 5.4 years (sd 3.3) and 14% had an A1c Conclusions: Findings can inform healthcare organizations’ decisions about ways to best deliver diabetes self-management resources. Disclosure R.V. Fiallo-Scharer: None. V.P. Rajamanickam: None. B.A. Chewning: None. M. Palta: None. T.B. Wetterneck: None. T. Wysocki: None. E.D. Cox: None.

Background: Much of the literature on the healthcare transition from pediatric to adult centered-care focuses on how to prepare adolescents and young adults with chronic illness for a successful healthcare transition, with much less emphasis on how to measure whether the healthcare transition was successful. Research on healthcare transition outcomes is fraught with methodological difficulties, making it difficult to generalize and compare findings across studies. To address these gaps, we began an integrative research agenda to develop a multidimensional, multi-informant (i.e., young adult, parent, and healthcare provider versions) measure of healthcare transition outcomes, the Healthcare Transition Outcomes Inventory (HCTOI). Our preliminary qualitative study defined six content domains for the measure. The current study describes the development and refinement of the HCTOI item pool. Results: Using rigorous measurement development methods including mixed qualitative and quantitative methods, the researchers developed a pool of 88 items evaluating the extent to which a young adult with T1D is successful on each of the six domains of healthcare transition outcomes. Ten physician and psychologist experts provided content validity ratings and feedback and the item pool was reduced and refined to 69 items. Cognitive interviews were then conducted on every item with end users (young adults, parents, and healthcare providers) and the item pool was further reduced to 54-item young adult- and parent-versions and a 47-item healthcare provider version. Conclusions: Each stage informed development and refinement of the item pool. The HCTOI represents the first multi-informant, rigorously developed item pool that comprehensively measures the multiple components of the transition from pediatric to adult specialty healthcare. Discussion includes clinical implications and next steps for validation, item reduction and refinement. Disclosure J. Pierce: None. T. Wysocki: None. A. Gannon: None.

Decision aids (DAs) are central to shared decision making (SDM) interventions, yet little is known about patients’ actual DA use. Adequate utilization of DAs could optimize SDM effectiveness. Electronic DAs enable more objective tracking and analysis of actual DA utilization than do paper DAs. This report is part of an ongoing randomized controlled SDM trial enrolling adolescents with type 1 diabetes and their caregivers ( n = 153) who were considering use of an insulin pump or continuous glucose monitor. Extensive stakeholder engagement guided creation of two online DAs. After completing baseline measures, 133 dyads were randomized to SDM (access to the pertinent DA) or Usual Care (clinic routines for preparing candidates for adopting these devices). Utilization data showed that 80% of caregivers and 66% of youths logged into a DA at least once; youths and caregivers, respectively, dedicated a mean of 44.7 and 55.0 minutes to website use and viewed 72.2% and 77.4% of the DA content. Median total duration from enrollment to last DA logout was 48.2 days for adolescents and 45.6 days for caregivers. Bivariate comparisons showed that non-Hispanic, Caucasian females from households with higher socioeconomic status were significantly more likely to login to the assigned DA at least once. Hierarchical multiple regression showed that adolescent males with lower levels of health literacy demonstrated fewer DA logins ( F = 2.59; P < 0.009), but identified no significant predictors of adolescents’ or caregiver’ duration of DA use or proportion of DA content viewed. Future SDM trials should seek to promote DA use, especially by non-White adolescents, perhaps with direct assistance with the initial DA login. Trials employing electronic DAs should routinely report and analyze utilization data.

Objectives Understanding the factors associated with child communication during subspecialty encounters may inform interventions promoting shared decision-making in chronic disease management. Objectives were to (1) describe the quantity and quality of child communication during outpatient subspecialty encounters and (2) determine if and how the quantity and quality of child communication vary by demographic and visit characteristics. Methods We videotaped subspecialty clinic encounters involving 20 health care providers and 155 children with one of the following conditions: acute lymphoblastic leukemia (consolidation/maintenance), persistent asthma, cystic fibrosis, type 1 diabetes, and obesity. The Roter interaction analysis system was used to code child utterances into one of 10 discrete categories. Results Children exhibited a mean of 15% of all utterances made during clinical encounters. Children spoke more during obesity encounters. Conclusions Similar to the findings of studies in primary care settings, children spoke infrequently during the subspecialty visits, and the most common utterances tended to be replies to questions from adults. Practice implications In this study, there was relatively higher engagement of children during obesity clinic encounters in the area of lifestyle choices. Strategies used to engage children in conversation in obesity clinics may be useful for engaging children in other subspecialty clinics.

Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health (a broad term referring to mental health, substance use, and health behavior) care in the United States. Advances in knowledge regarding effective treatment and services coupled with incentives for innovation in health and behavioral health care delivery systems make this a unique time for mobilizing our science to enhance the success of health and behavioral health care redesign. To optimize the potential of our current health care environment, a team was formed composed of leaders from the Societies of Clinical Child & Adolescent Psychology, Pediatric Psychology, and Child and Family Policy and Practice (Divisions 53, 54, and 37 of the American Psychological Association). This team was charged with reviewing the scientific and policy literature with a focus on five major issues: (a) improving access to care and reducing health disparities, (b) integrating behavioral health care within primary care, (c) preventive services, (d) enhancing quality and outcomes of care, and (e) training and workforce development. The products of that work are summarized here, including recommendations for future research, clinical, training, and policy directions. We conclude that the current emphasis on accountable care and evaluation of the outcomes of care offer numerous opportunities for psychologists to integrate science and practice for the benefit of our children, families, and nation. The dramatic changes that are occurring in psychological and behavioral health care services and payment systems also require evolution in our practice and training models.

Introduction Phase III/IV clinical trials are expensive and time consuming and often suffer from poor enrollment and retention rates. Pediatric trials are particularly difficult because scheduling around the parent, participant and potentially other sibling schedules can be burdensome. We are evaluating using the internet and mobile devices to conduct the consent process and study visits in a streamlined pediatric asthma trial. Our hypothesis is that these study processes will be non-inferior and will be less expensive compared to a traditional pediatric asthma trial. Materials/methods Parents and participants, aged 12 through 17 years, complete the informed consent process by viewing a multi-media website containing a consent video and study material in the streamlined trial. Participants are provided an iPad with WiFi and EasyOne spirometer for use during FaceTime visits and online twice daily symptom reporting during an 8-week run-in followed by a 12-week study period. Outcomes are compared with participants completing a similarly designed traditional trial comparing the same treatments within the same pediatric health-system. After 8 weeks of open-label Advair 250/50 twice daily, participants in both trial types are randomized to Advair 250/50, Flovent 250, or Advair 100/50 given 1 inhalation twice daily. Study staff track time spent to determine study costs. Results Participants have been enrolled in the streamlined and traditional trials and recruitment is ongoing. Conclusions This project will provide important information on both clinical and economic outcomes for a novel method of conducting clinical trials. The results will be broadly applicable to trials of other diseases.

BACKGROUND Management of type 1 diabetes (T1D) among children aged OBJECTIVE The objectives of this paper are to (1) describe the application of UCD principles to the development of a Web-based coping intervention designed by and for parents of very young children ( METHODS This paper illustrates the application of UCD principles to create a Web-based coping resource designed by and for parents of YC-T1D. A Web-based Parent Crowd, a Health Care Provider Crowd, and a Focus Group of minority parents provided input throughout the design process. A formal usability testing session and design webinars yielded additional stakeholder input to further refine the end product. RESULTS This paper describes the completed website and the ongoing RCT to evaluate the effects of using this Web-based resource on pertinent parent and child outcomes. CONCLUSIONS UCD principles and the targeted application of crowdsourcing methods provided the foundation for the development, construction, and evaluation of a continuously accessible, archived, user-responsive coping resource designed by and for parents of YC-T1D. The process described here could be a template for the development of similar resources for other special populations that are enduring specific medical or psychosocial distress. The ongoing RCT is the final step in the UCD process and is designed to validate its merits.

Background: Pregnant women with type 1 diabetes are a high-risk population who are recommended to strive for optimal glucose control, but neonatal outcomes attributed to maternal hyperglycaemia remain suboptimal. Our aim was to examine the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control and obstetric and neonatal health outcomes. Methods: In this multicentre, open-label, randomised controlled trial, we recruited women aged 18-40 years with type 1 diabetes for a minimum of 12 months who were receiving intensive insulin therapy. Participants were pregnant (≤13 weeks and 6 days' gestation) or planning pregnancy from 31 hospitals in Canada, England, Scotland, Spain, Italy, Ireland, and the USA. We ran two trials in parallel for pregnant participants and for participants planning pregnancy. In both trials, participants were randomly assigned to either CGM in addition to capillary glucose monitoring or capillary glucose monitoring alone. Randomisation was stratified by insulin delivery (pump or injections) and baseline glycated haemoglobin (HbA1c). The primary outcome was change in HbA1c from randomisation to 34 weeks' gestation in pregnant women and to 24 weeks or conception in women planning pregnancy, and was assessed in all randomised participants with baseline assessments. Secondary outcomes included obstetric and neonatal health outcomes, assessed with all available data without imputation. This trial is registered with ClinicalTrials.gov, number NCT01788527. Findings: Between March 25, 2013, and March 22, 2016, we randomly assigned 325 women (215 pregnant, 110 planning pregnancy) to capillary glucose monitoring with CGM (108 pregnant and 53 planning pregnancy) or without (107 pregnant and 57 planning pregnancy). We found a small difference in HbA1c in pregnant women using CGM (mean difference -0·19%; 95% CI -0·34 to -0·03; p=0·0207). Pregnant CGM users spent more time in target (68% vs 61%; p=0·0034) and less time hyperglycaemic (27% vs 32%; p=0·0279) than did pregnant control participants, with comparable severe hypoglycaemia episodes (18 CGM and 21 control) and time spent hypoglycaemic (3% vs 4%; p=0·10). Neonatal health outcomes were significantly improved, with lower incidence of large for gestational age (odds ratio 0·51, 95% CI 0·28 to 0·90; p=0·0210), fewer neonatal intensive care admissions lasting more than 24 h (0·48; 0·26 to 0·86; p=0·0157), fewer incidences of neonatal hypoglycaemia (0·45; 0·22 to 0·89; p=0·0250), and 1-day shorter length of hospital stay (p=0·0091). We found no apparent benefit of CGM in women planning pregnancy. Adverse events occurred in 51 (48%) of CGM participants and 43 (40%) of control participants in the pregnancy trial, and in 12 (27%) of CGM participants and 21 (37%) of control participants in the planning pregnancy trial. Serious adverse events occurred in 13 (6%) participants in the pregnancy trial (eight [7%] CGM, five [5%] control) and in three (3%) participants in the planning pregnancy trial (two [4%] CGM and one [2%] control). The most common adverse events were skin reactions occurring in 49 (48%) of 103 CGM participants and eight (8%) of 104 control participants during pregnancy and in 23 (44%) of 52 CGM participants and five (9%) of 57 control participants in the planning pregnancy trial. The most common serious adverse events were gastrointestinal (nausea and vomiting in four participants during pregnancy and three participants planning pregnancy). Interpretation: Use of CGM during pregnancy in patients with type 1 diabetes is associated with improved neonatal outcomes, which are likely to be attributed to reduced exposure to maternal hyperglycaemia. CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy. This study is the first to indicate potential for improvements in non-glycaemic health outcomes from CGM use. Funding: Juvenile Diabetes Research Foundation, Canadian Clinical Trials Network, and National Institute for Health Research.

This Internet study surveyed 321 parents of youth with type 1 diabetes about family education regarding long-term complications (LTC). Parents reported their LTC learning experiences and opinions about the amount/timing of LTC education. Parents reported intense worry about LTC, but focused initially on daily management. Most parents want input into their children’s LTC education and endorsed diverse methods to motivate children’s self-care. Parents felt that LTC education of younger children should be deferred for several months after diagnosis but that LTC education of parents and adolescents should begin soon after diagnosis. A flexible approach respecting parental preference is likely optimal.

Objectives Parenting young children with type 1 diabetes (YC-T1D) entails pervasive challenges; parental coping may influence child and parent outcomes. This study used a qualitative descriptive design to describe these challenges comprehensively to inform the user-centered design of an Internet coping resource for parents. Methods A "Parent Crowd" of 153 parents of children with T1D onset at ≤ 5 years old submitted textual responses online to open-ended questions about parenting YC-T1D. Systematic coding organized responses into domains, themes, and examples. A supplemental focus group of racial/ethnic minority parents enhanced the sample's diversity and validated findings from the Parent Crowd. Results Similar domains and themes emerged from responses of crowdsourcing and focus group participants. In each domain, parenting YC-T1D was challenging, but there was also substantial evidence of positive coping strategies and adaptability. Conclusions The study yielded rich data to inform user-centered design of an Internet resource for parents of YC-T1D.

For every original research study that has been published in the Journal of Pediatric Psychology, the researchers began with framing one or more research questions and then determined how best to answer those questions. It is the second part of this process that is the focus of this special issue. Once a research question has been framed and specified adequately, the next critical step in designing and conducting a valuable research study is to decide what to measure and how to measure it. The papers that appear in this special issue have something in common: all of them addressed these questions, at least in part, by selecting, adapting, or developing assessment methods that used some variant of direct behavioral observation to quantify variables that were of primary interest in their studies. As you read on, I think you will be impressed with the breadth, creativity, and elegance of the papers that were selected for this special issue. The papers represent an impressive array of contributions that span many of the medical diagnoses that are commonly studied by pediatric psychologists, including the interface of psychological variables with child and family adaptation to cancer, asthma, diabetes, cystic fibrosis, obesity, and neonatal critical care. Tremendous gratitude is due to the editor, Dr Grayson Holmbeck, for supporting the solicitation of this special issue, to the many authors and their colleagues who submitted such high-quality papers for consideration, and to the many dedicated and conscientious reviewers who helped to make this issue truly special. Why Direct Observation?

Obesity is the most prevalent chronic disease in childhood. There are many comorbidities associated with excess weight that are preventable with improved health. Prevention of medical comorbidities associated with obesity is critical and should begin early, particularly in childhood and preadolescen

Objective Brief, well-validated instruments are needed to facilitate screening for early childhood behavioral and emotional problems (BEPs). The objectives of this study were to empirically reduce the length of the Early Childhood Screening Assessment (ECSA) and to assess the validity and reliability of this shorter tool. Methods Using caregiver ECSA responses for 2467 children aged 36 to 60 months seen in primary care, individual ECSA items were ranked on a scale ranging from "absolutely retain" to "absolutely delete." Items were deleted sequentially beginning with "absolutely delete" and going up the item prioritization list, resulting in 35 shorter versions of the ECSA. A separate primary care sample (n = 69) of mothers of children aged 18 to 60 months was used to determine the sensitivity and specificity of each shorter ECSA version using psychiatric diagnosis on the Diagnostic Infant and Preschool Assessment as the gold standard. The version with the optimal balance of sensitivity, specificity, and length was selected as the Brief ECSA. Associations between Brief ECSA scores and other pertinent measures were evaluated to estimate reliability and validity. Results A 22-item measure reflected the best combination of brevity, sensitivity and specificity. A cutoff score of 9 or higher on the 22-item Brief ECSA demonstrated acceptable sensitivity (89%) and specificity (85%) for predicting a psychiatric diagnosis. Brief ECSA scores correlated significantly and in expected directions with scores on pertinent measures and with demographic variables. Conclusion The results indicate that the Brief ECSA has sound psychometric properties for identifying young children with BEPs in primary care.

Objectives Research on the transition to adult care for young adults with type 1 diabetes (T1D) emphasizes transition readiness, with less emphasis on transition outcomes. The relatively few studies that focus on outcomes use a wide variety of measures with little reliance on stakeholder engagement for measure selection. Methods This study engaged multiple stakeholders (i.e., young adults with T1D, parents, pediatric and adult health care providers, and experts) in qualitative interviews to identify the content domain for developing a multidimensional measure of health care transition (HCT) outcomes. Results The following constructs were identified for a planned measure of HCT outcomes: biomedical markers of T1D control; T1D knowledge/skills; navigation of a new health care system; integration of T1D into emerging adult roles; balance of parental involvement with autonomy; and "ownership" of T1D self-management. Discussion The results can guide creation of an initial item pool for a multidimensional profile of HCT outcomes.

PurposeThis article describes the stakeholder-driven design, development, and testing of web-based, multimedia decision aids for youth with type 1 diabetes who are considering the insulin pump or continuous glucose monitoring and their parents. This is the initial phase of work designed to develop and evaluate the efficacy of these decision aids in promoting improved decision-making engagement with use of a selected device.MethodsQualitative interviews of 36 parents and adolescents who had previously faced these decisions and 12 health care providers defined the content, format and structure of the decision aids. Experts in children’s health media helped the research team to plan, create, and refine multimedia content and its presentation. A web development firm helped organize the content into a user-friendly interface and enabled tracking of decision aid utilization. Throughout, members of the research team, adolescents, parents, and 3 expert consultants offered perspectives about the website content, structure, and function until the design was complete.ResultsWith the decision aid websites completed, the next phase of the project is a randomized controlled trial of usual clinical practice alone or augmented by use of the decision aid websites.ConclusionsStakeholder-driven development of multimedia, web-based decision aids requires meticulous attention to detail but can yield exceptional resources for adolescents and parents contemplating major changes to their diabetes regimens.

We studied health utilities in patients with type 1 diabetes to understand potential differences in health utilities as function of age, type of respondent (self report vs. proxy report), and method of assessment (direct vs. indirect).We elicited self-reported health utilities for adults (n=213) and children (n=238) with type 1 diabetes, and by parent proxy report (n=223) for overall quality of life [Health Utilities Index (HUI) Mark 3 and experienced time-trade-off (TTO) questions] and hypothetical complication states (TTO questions).Mean health utilities for overall quality of life (QOL) ranged from 0.81 to 0.91. Children had significantly higher overall QOL compared with adults (0.89 vs. 0.85, P0.01) by HUI, but had no significant difference in QOL by TTO. There were no significant differences in QOL between child self report and parent proxy report. Utilities were higher for HUI versus TTO for parent proxy report (P0.01) but not for adult or child self report. Utilities for hypothetical complication states were lower than for current QOL. Values were lower for stroke (0.34 to 0.53), end stage renal disease (0.47 to 0.55), and blindness (0.52 to 0.69) than for amputation (0.73 to 0.82) and angina (0.74 to 0.80). Complication utilities for parent proxy report were higher compared with adult self report for most hypothetical complication states.Individuals with type 1 diabetes with few complications report a relatively high QOL; however, future end stage complications are rated as having a significant impact on QOL. Differences in utilities by age, self report versus proxy report, and method raise important questions about whose utilities should be used in economic analyses.