Close parental monitoring of care completion can contribute to better adherence in adolescents with diabetes. General warmth and support in the absence of careful parental supervision may be insufficient to help youth achieve adequate levels of adherence.

Classical conditioning paradigms, such as trace conditioning, in which a silent period elapses between the offset of the conditioned stimulus (CS) and the delivery of the unconditioned stimulus (US), and delay conditioning, in which the CS and US coterminate, are widely used to study the neural substrates of associative learning. However, there are significant gaps in our knowledge of the neural systems underlying conditioning in humans. For example, evidence from animal and human patient research suggests that the hippocampus plays a critical role during trace eyeblink conditioning, but there is no evidence to date in humans that the hippocampus is active during trace eyeblink conditioning or is differentially responsive to delay and trace paradigms. The present work provides a direct comparison of the neural correlates of human delay and trace eyeblink conditioning by using functional MRI. Behavioral results showed that humans can learn both delay and trace conditioning in parallel. Comparable delay and trace activation was measured in the cerebellum, whereas greater hippocampal activity was detected during trace compared with delay conditioning. These findings further support the position that the cerebellum is involved in both delay and trace eyeblink conditioning whereas the hippocampus is critical for trace eyeblink conditioning. These results also suggest that the neural circuitry supporting delay and trace eyeblink classical conditioning in humans and laboratory animals may be functionally similar.cerebellum ͉ functional MRI ͉ hippocampus C lassical conditioning has been widely used as a model system to study the neural substrates of associative learning. One form of classical conditioning, eyeblink classical conditioning (EBCC), has received considerable attention by the neuroscience community. In EBCC, repeated pairings of a neutral conditioned stimulus (CS), such as a tone, and an unconditioned stimulus (US), such as an airpuff to the eye, eventually result in the CS alone eliciting conditioned responses (CRs), suggesting that an association between the CS and US has been learned. Delay and trace conditioning are two different procedures that vary in timing. In delay conditioning, the CS and US coterminate whereas in trace conditioning, a silent period (called the trace interval) elapses between offset of the CS and delivery of the US. This minor variation in temporal contiguity has significant consequences on behavioral performance in both healthy individuals and medial temporal lobe amnesiacs. For example, hippocampal patients show normal acquisition of delay conditioning but cannot learn trace conditioning (1-4).Considerable evidence from animal and human research suggests that the hippocampus plays a critical role during trace conditioning whereas the cerebellum is involved in both delay and trace conditioning (5-8). Many experimental techniques, such as electrophysiological recordings, lesion procedures, and genetic manipulations, have been used in laboratory animals to test the idea that the hip...

OBJECTIVE -The aim of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could improve adherence and metabolic control and decrease rates of hospital utilization among adolescents with chronically poorly controlled type 1 diabetes. RESEARCH DESIGN AND METHODS-A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and chronically poor metabolic control (HbA 1c [A1C] Ն8% for the past year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants randomly assigned to MST received treatment for ϳ6 months. Data were collected at baseline and at 7 months posttest (i.e., treatment termination). Changes in A1C adherence, as measured by semistructured interviews and blood glucose meters and hospital admissions and emergency department visits, were assessed.RESULTS -In intent-to-treat analyses, participation in MST was associated with significant improvements in the frequency of blood glucose testing as assessed by blood glucose meter readings (F[1,125] ϭ 16.75, P ϭ 0.001) and 24-h recall interviews (F[1,125] ϭ 6.70, P ϭ 0.011). Participants in MST also had a decreasing number of inpatient admissions, whereas the number of inpatient admissions increased for control subjects (F[1,125] ϭ 6.25, P ϭ 0.014). Per protocol analyses replicated intent-to-treat analyses but also showed a significant improvement in metabolic control for adolescents receiving MST compared with control subjects (F[1,114] ϭ 4.03, P ϭ 0.047).CONCLUSIONS -Intensive, home-based psychotherapy improves the frequency of blood glucose testing and metabolic control and decreases inpatient admissions among adolescents with chronically poorly controlled type 1 diabetes. Diabetes Care 28:1604 -1610, 2005T he deterioration in adherence behavior associated with the transition to adolescence is well documented among children with type 1 diabetes (1-3). However, a subset of high-risk adolescents demonstrate more serious adherence problems, as evidenced by chronically poor metabolic control (CPMC). In addition to the health risks associated with CPMC, such adolescents consume a disproportionate share of health care dollars due to inpatient hospitalizations for diabetic ketoacidosis (DKA) (4,5). The development of effective behavioral interventions for these adolescents is therefore of high priority. Given the known declines in adherence during adolescence, several interventions have been developed to improve adherence and metabolic control among youth with type 1 diabetes (6 -9). However, there have been few clinical trials that focus exclusively on those with CPMC. Existing intervention studies targeting adolescents with CPMC (10 -15) are generally characterized by either small sample size, low recruitment rates, short intervention periods, or limited success in improving behavioral and health outcomes.Furthermore, despite the substantial descriptive literature suggesting that adolescents with CPMC are embedded within multiple syste...

Within the framework of a cumulation/nesting theory for the emergence of adult psychopathology, a typing structure for alcoholism based upon variations in life course continuity of antisocial behavior over childhood and adulthood was examined for its ability to differentiate symptomatic and life history variations among alcoholic and nonalcoholic men accessed by way of a population-based recruitment strategy. Results supported the theory and identified two alcoholic types, one high on lifetime antisociality (antisocial alcoholic = AAL), the other low (nonantisocial alcoholic = NAAL), and a third nonalcoholic type with low lifetime antisociality. Types differed in age of onset, severity, number, and life course of alcohol problems, measures of social adaptation, amount and severity of other psychopathology, and salience of family history load of alcoholism. Antisociality and alcoholism tended to be nested characteristics.

The presence of parental depressive symptoms influences both youth depression and poor metabolic control through problematic parenting practices such as low involvement and monitoring.

ABSTRACT. Objective. The goal of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Stress was also evaluated as a mediator of the effect of MST on adherence and metabolic control.Methods. A randomized, controlled trial was conducted with 127 adolescents with type 1 diabetes mellitus and chronically poor metabolic control (hemoglobin A1c levels of >8% at study enrollment and for the past 1 year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants assigned randomly to MST received treatment for ϳ6 months. Data were collected at baseline and at a 7-month posttest (ie, treatment termination). Changes in diabetes-related stress, as measured with a self-report questionnaire, were assessed. Structural equation models were used to test the degree to which changes in stress levels mediated the ability of the MST intervention to improve adherence and metabolic control.Results. In intent-to-treat analyses, participation in MST was associated with significant reductions in diabetes-related stress. Tests for moderation found no significant effects of age, gender, or ethnicity, which suggests that the intervention was equally effective in reducing diabetes stress for all participants. However, structural equation modeling did not provide support for diabetes stress as the mechanism through which MST improved health outcomes. Rather, the final model suggested that MST improved metabolic control through increased regimen adherence.Conclusions. Intensive, home-based psychotherapy reduces diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Such stress reductions are important for the psychological wellbeing of a subset of youths with diabetes who are at high risk for future health complications. A dolescents with type 1 diabetes mellitus face a number of stressors and challenges as a result of their chronic illness. [1][2][3][4] These include the need to manage a complex medical condition that requires daily completion of multiple selfcare behaviors, the impact of diabetes on social interactions with family members, peers, and teachers, and the interference of symptoms such as hypoglycemia with daily activities.Previous studies investigated the impact of stress on health outcomes among persons with type 1 diabetes. The effects of stress on regimen adherence and metabolic control have been of particular interest. Stress has the potential to affect metabolic control directly through its impact on cortisol and other catabolic hormones that interfere with insulin metabolism. It may also affect metabolic control indirectly, by interfering with completion of self-care tasks. However, prior findings have been mixed, with some studies supporting a direct relationship between stress and metabolic control, some suggesting that adherence mediates the relationship between stress and me...

Objective To develop an adaptive behavioral treatment for African American adolescents with obesity. Method In a sequential multiple assignment randomized trial, 181 youth ages 12 to 16 years with primary obesity and their caregiver were first randomized to 3 months of home-based versus office-based delivery of motivational interviewing plus skills building. After 3 months, non-responders to first phase treatment were re-randomized to continued home-based skills or contingency management. Primary outcome was percent overweight and hypothesized moderators were adolescent executive functioning and depression Results There were no significant differences in primary outcome between home-based or office-based delivery or between continued home-based skills or contingency management for non-responders to first-phase treatment. However, families receiving home-based treatment initially attended significantly more sessions in both phases of the trial, and families receiving contingency management attended more sessions in the second phase. Overall, participants demonstrated decreases in percent overweight over the course of the trial (3%), and adolescent executive functioning moderated this effect such that those with higher functioning lost more weight. Conclusions More potent behavioral treatments to address the obesity epidemic are necessary, targeting new areas such as executive functioning. Delivering treatment in the home with contingency management may increase session attendance for this population.

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