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OBJECTIVE: To test models of unidirectional and bidirectional change between treatment adherence and glycemic control in youth with type 1 diabetes. RESEARCH DESIGN AND METHODS: We conducted a 2-year longitudinal, multisite study of 225 youth with type 1 diabetes recruited at the cusp of adolescence (aged 9–11 years) to describe the mutual influences of glycemic control as measured by HbA1c and treatment adherence as measured by blood glucose monitoring frequency (BGMF) during the transition to adolescence. RESULTS: HbA1c increased from 8.2 to 8.6% (P < 0.001) and BGMF decreased from 4.9 to 4.5 checks per day (P < 0.02) during the 2-year period. Changes in the BGMF slope predicted changes in HbA1c. A change (increase) in HbA1c was associated with a change (decrease) in BGMF of 1.26 (P < 0.001) after controlling for covariates. CONCLUSIONS: The magnitude of the effect of declining treatment adherence (BGMF) on glycemic control in young adolescents may be even greater than declines observed among older adolescents. BGMF offers a powerful tool for targeted management of glycemic control for type 1 diabetes during the critical transition to adolescence.

To examine the effectiveness of an interdisciplinary intervention for pediatric asthma. Randomized, controlled study. Urban tertiary-referral pediatric hospital. One hundred seventy-five patients with asthma lacking written treatment plans and presenting with asthma-related emergency department visits (two or more) and/or hospitalizations (one or more) in the past year were randomized to a comparison group receiving medical care alone (n = 86) or to an interdisciplinary intervention group receiving medical care, asthma education, and problem-solving therapy (n = 89) All participants received written asthma management plans, peak flow meters, and spacer devices. The intervention group also received asthma education, an asthma risk profile assessment, brief problem-solving therapy, and access to a 24-h nurse advice line. The primary outcome measure was change in asthma symptoms, and secondary outcomes included health-care utilization and asthma-related quality of life. Both groups demonstrated significant reductions in asthma symptoms and improvements in quality of life without any between-group differences identified over the course of follow-up. In contrast, the intervention group demonstrated less frequent health-care utilization than the comparison group, with 28% of the intervention group requiring emergency department or inpatient services for asthma compared to 41% of the comparison group (adjusted odds ratio, 1.92; 95% confidence interval, 1.00 to 3.69) over the 12-month follow-up period. This study examined the effectiveness of an interdisciplinary intervention for undertreated asthma. The intervention did not result in improvements in asthma symptoms, but accomplished modest reductions in the utilization of acute medical care.

The purpose of this study was to examine the prevalence and characteristics of pain in children with Duchenne (DMD) or Becker (BMD) muscular dystrophy, including the nature of disagreements concerning pain symptoms among children, parents, and physicians, and limitations in daily activities. Male children (age 8–18y, n=53) and parents (n=53) completed questionnaires assessing pain intensity (visual analogue scale), pain frequency (Likert scale [LS]), pain duration (LS), emotional distress due to pain (LS), and pain location (body outline markings). The Child Activity Limitations Interview was also completed by both raters to assess daily activities that are limited by recurrent pain. Physicians completed a form indicating medical history and pain symptoms. The majority of children with DMD (mean age 13y 11mo [SD 3.38]; range 8–18y) or BMD (mean 14y 10mo [SD 1.48]; range 12–17y) were non‐ambulatory (79 and 50% respectively) and experienced pain according to self (54–80%) and parent reports (70–90%). Pain typically occurred at least once per week and was of mild to moderate intensity. Most children experienced pain for less than a few hours and little to moderate levels of emotional distress due to pain. Pain occurred in the lower back, spine, and legs, and was described as ‘aching’. Children and parents indicated significantly more intense pain than the physician. Actual agreement between parent and child report on pain symptoms was poor to fair. Pain is a common occurrence in children with DMD or BMD, yet may be under‐recognized. Pain assessment needs to be a standard part of care and may identify difficulties faced by these children to be targeted by interventions.

OBJECTIVE: The primary aim of the study was to investigate the relationship among executive functioning, diabetes treatment adherence, and glycemic control. RESEARCH DESIGN AND METHODS: Two hundred and thirty-five children with type 1 diabetes and their primary caregivers were administered the Diabetes Self-Management Profile to assess treatment adherence. Executive functioning was measured using the Behavior Rating Inventory of Executive Functioning and glycemic control was based on A1C. RESULTS: Structural equation modeling indicated that a model in which treatment adherence mediated the relationship between executive functioning and glycemic control best fit the data. All paths were significant at P < 0.01. CONCLUSIONS: These results indicate that executive functioning skills (e.g., planning, problem-solving, organization, and working memory) were related to adherence, which was related to diabetes control. Executive functioning may be helpful to assess in ongoing clinical management of type 1 diabetes.

Collaborative or shared decision-making between health care providers and families can facilitate treatment adherence, health outcomes, and satisfaction with care in the management of pediatric chronic illness, but raises special challenges. Barriers such as authoritarian models of medical care as well as absence of time and opportunity for dialogue limit collaborative decision making and can disrupt treatment adherence. However, models of provider-family communication that emphasize communication and shared goal-setting inform an anticipatory guidance model of collaborative decision-making that can enhance treatment adherence. Salient challenges and strategies involved in implementing collaborative decision-making in pediatric chronic illness care are described. Research is needed to: 1) describe the communication and decision-making process in the management of pediatric chronic illness; and 2) evaluate the impact of interventions that enhance collaborative decision-making on provider-family communication, illness management, and treatment adherence.

Depressive Symptoms and Glycemic Control in Adolescents With Type 1 Diabetes Mediational role of blood glucose monitoring Meghan E. McGrady , 1 , 2 , Lori Laffel , MD, MPH 3 , Dennis Drotar , PHD 1 , 4 , David Repaske , MD, PHD 4 , 5 and Korey K. Hood , PHD 1 , 4 1 Center for Treatment Adherence, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; 2 Department of Psychology, University of Cincinnati, Cincinnati, Ohio; 3 Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts; 4 Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; 5 Diabetes Center, Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Corresponding author: Korey K. Hood, korey.hood{at}cchmc.org Abstract OBJECTIVE To determine whether the association between depressive symptoms and glycemic control is mediated by blood glucose monitoring (BGM). RESEARCH DESIGN AND METHODS A total of 276 adolescents with type 1 diabetes (mean age ± SD, 15.6 ± 1.4 years) completed a measure of depressive symptoms. Sociodemographic and family characteristics were obtained from caregivers. BGM frequency and glycemic control were obtained at a clinic visit. RESULTS Separate regression analyses revealed that depressive symptoms were associated with lower BGM frequency (B = −0.03; P = 0.04) and higher A1C (B = 0.03; P = 0.05) and that lower BGM frequency was associated with higher A1C (B = −0.39; P < 0.001). With depressive symptoms and BGM frequency included together, only BGM frequency was associated with A1C and depressive symptoms became nonsignificant (B = 0.02; P = 0.19). The Sobel test was significant ( Z = 1.96; P < 0.05) and showed that 38% of the depression-A1C link can be explained by BGM. CONCLUSIONS BGM is a mediator between depressive symptoms and glycemic control in adolescents with type 1 diabetes. Footnotes The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Received November 25, 2008. Accepted February 6, 2009. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details. © 2009 by the American Diabetes Association.

OBJECTIVE: To review interventions with adherence-promoting components and document their impact on glycemic control via meta-analysis. RESEARCH DESIGN AND METHODS: Data from 15 studies that met the following criteria were subjected to meta-analysis: 1) randomized, controlled trial, 2) study sample included youth aged <19 years, 3) youth had type 1 diabetes, 4) study reported results on glycemic control; and 5) study reported use of adherence- or self-management-promoting components. RESULTS: The 15 studies included 997 youth with type 1 diabetes. The mean effect size for pre- to posttreatment change for the intervention versus control group comparison was 0.11 (95% CI -0.01 to 0.23). This is a small effect, demonstrating very modest improvements in glycemic control. However, analysis for the pre- to posttreatment effects for the intervention group alone did show significant variability [Q(14) = 33.11; P < 0.05]. Multicomponent interventions, those that targeted emotional, social, or family processes that facilitate diabetes management, were more potent than interventions just targeting a direct, behavioral process (e.g., increase in blood glucose monitoring frequency). CONCLUSIONS: Interventions that focus on direct, behavioral processes and neglect emotional, social, and family processes are unlikely to have an impact on glycemic control; multicomponent interventions showed more robust effects on A1C. Future clinical research should focus on refining interventions and gathering more efficacy and effectiveness data on health outcomes of the pediatric patients treated with these interventions.

OBJECTIVE: To determine whether the association between depressive symptoms and glycemic control is mediated by blood glucose monitoring (BGM). RESEARCH DESIGN AND METHODS: A total of 276 adolescents with type 1 diabetes (mean age ± SD, 15.6 ± 1.4 years) completed a measure of depressive symptoms. Sociodemographic and family characteristics were obtained from caregivers. BGM frequency and glycemic control were obtained at a clinic visit. RESULTS: Separate regression analyses revealed that depressive symptoms were associated with lower BGM frequency (B = -0.03; P = 0.04) and higher A1C (B = 0.03; P = 0.05) and that lower BGM frequency was associated with higher A1C (B = -0.39; P < 0.001). With depressive symptoms and BGM frequency included together, only BGM frequency was associated with A1C and depressive symptoms became nonsignificant (B = 0.02; P = 0.19). The Sobel test was significant (Z = 1.96; P < 0.05) and showed that 38% of the depression-A1C link can be explained by BGM. CONCLUSIONS: BGM is a mediator between depressive symptoms and glycemic control in adolescents with type 1 diabetes.

The relationship between adherence to antiretroviral therapy (ART) and virologic outcomes in HIV+ children, adolescents, and young adults has been notably understudied, with much of the extant research focused on specific sub-literatures, such as resource-limited regions, specific clinical outcomes and time frames. The authors sought to better characterize the relationship between adherence to ART and virologic functioning along various sample and methodological factors. The authors conducted a meta-analysis of thirty-seven studies and utilized a random effects model to generate weighted mean effect sizes. In addition, the authors conducted meta-ANOVAs to examine potential factors influencing the relationship between adherence and three categories of clinical outcomes, specifically Viral Load (VL) <100, VL < 400, and continuously measured VL. The analyses included 5,344 HIV+ children, adolescents, and young adults. The relationship between adherence behaviors and virologic outcomes varied across different methods of measurement and analysis. The relationship between adherence and continuously measured VL was significantly larger than for dichotomously-coded VL < 400 at Qb (20.69(1), p  < .0005). Caregiver self-report indices elicited very small to small magnitude effects across both VL < 100 and VL < 400 outcomes and combined informant reporting (youth/adolescent and parent) produced significantly larger effects than caregiver report alone with adherence and VL < 400 outcomes at Qb (9.28(1), p  < .005). More recently published trials reported smaller relationships between adherence and categorical clinical outcomes, such that year of publication significantly negatively correlated with VL < 100 ( r  = −.71(14), p  < .005) and VL < 400 ( r  = −.43(26), p  < .02). The data suggest that the magnitude of the relationship between ART adherence and virologic outcomes among heterogeneous samples of HIV+ children, adolescents and young adults varies across virologic outcomes and may be affected by moderating sample and methodological factors. Methodological and research recommendations for the interpretation of the current findings as well as for future HIV adherence related research are presented.

Developed the Cleveland Adolescent Sleepiness Questionnaire (CASQ), a brief, self-completed instrument to measure excessive daytime sleepiness in adolescents. Cross-sectional analysis. A subsample of 411 adolescents 11-17 years of age recruited from area schools, churches, and \"control\" participants in a sleep disordered breathing cohort study; a second subsample of 62 adolescents with diagnosed sleep disordered breathing also participating in the sleep disordered breathing study. Participants completed the CASQ along with two other available measures of daytime sleepiness and other sleep parameters (sleep duration on school nights, sleep duration on non-school nights, and sleep debt, defined as non-school night sleep duration minus school-night sleep duration). Demographic information was obtained from a caregiver-completed questionnaire. The CASQ was developed using exploratory factor analysis, followed by confirmatory factor analysis using structural equation modeling techniques. Goodness-of-fit measures for the final 16-item scale structure ranged from good to excellent. The CASQ's internal consistency was good (alpha = 0.89). Correlations between the CASQ, two other measures of daytime sleepiness, and sleep parameters gave preliminary evidence of the CASQ's construct validity. The CASQ shows promise as a valid measure of daytime sleepiness in adolescents.