The goal of this research was to develop and evaluate measures of adolescent diabetes management self-efficacy and outcome expectations that reflect developmentally relevant, situation-specific challenges to current diabetes regimens. Self-efficacy for diabetes management, expected outcomes of adherence, adherence to the diabetes regimen, and glycemic control were assessed in 168 adolescents (ages 10-16 years) with type 1 diabetes. Factor analyses indicated a single scale for self-efficacy and two distinct factors representing positive and negative outcome expectations. Reliability and predictive validity of the new scales were supported. In regression analyses, self-efficacy and the interaction of self-efficacy with expectations of positive outcomes were significantly associated with diabetes self-management adherence and glycemic control in older adolescents. The effect of self-efficacy was greatest when adolescents had stronger beliefs in the beneficial outcomes of adherence. These brief measures can be used to identify youths at risk of poor diabetes self-management. Interventions targeting self-efficacy may lead to improved diabetes self-management.

OBJECTIVE -To evaluate the safety and effectiveness of insulin pump therapy in children and adolescents with type 1 diabetes.RESEARCH DESIGN AND METHODS -All 95 patients who began insulin pump therapy at Johns Hopkins Hospital between January 1990 and December 2000 were included in the study. The mean age was 12.0 years (range 4 -18), and 29% of the patients were Ͻ10 years old. Data were obtained by chart review beginning 6 -12 months before pump start. The median duration of follow-up was 28 months.RESULTS -There was a small but significant decrease in HbA 1c at 3-6 months after pump start (7.7 vs. 7.5%; P ϭ 0.03). HbA 1c levels then gradually increased and remained elevated after 1 year of follow-up; however, this association was confounded by age and diabetes duration, both of which were associated with higher HbA 1c levels. After adjusting for duration and age, mean HbA 1c after pump start was significantly lower than before pump start (7.7 vs. 8.1%; P Ͻ 0.001). The number of medical complications (diabetic ketoacidosis, emergency department visits) was similar before and after pump start. There were fewer hypoglycemic events after pump start (12 vs. 17, rate ratio 0.46, 95% CI 0.21-1.01).CONCLUSIONS -This study suggests that pump therapy is safe and effective in selected children and adolescents with type 1 diabetes. Diabetes Care 26:1142-1146, 2003C ontinuous subcutaneous insulin infusion, or insulin pump therapy, has been used to treat diabetes since the late 1970s (1-3). Since the completion of the Diabetes Control and Complications Trial in 1993 (4) and the introduction of lispro insulin in 1996 (5), children and adolescents with diabetes, and their parents, have increasingly requested insulin pump therapy as an alternative to insulin injections. The Johns Hopkins Pediatric Diabetes Program has been using insulin pumps with children since the early 1980s (6).The theoretical advantage of insulin pump therapy is its ability to mimic physiological insulin release and meet physiological insulin needs in people with insulin deficiency. The basal and bolus functions of the pump allow separate determination and adjustment of both these insulin requirements and also allow flexibility in timing and amounts of nutritional intake and physical activity, allowing for wide variations in lifestyle. In addition, use of short-acting insulin makes coverage of the early-morning glucose rise ("dawn phenomenon") possible, eases sick-day management, and matches nutrient absorption more physiologically, thereby reducing the risk of hypoglycemia.Prior studies of pump users show a high degree of satisfaction (7)(8)(9)(12)(13)(14), and most show a decreased risk of severe hypoglycemia (7-9,14). However, previous studies are mixed regarding safety and effectiveness. Some show a decrease in HbA 1c (7,8,12), whereas others show no durable improvement (9,10). Some report that HbA 1c improved in the first few months but returned to prepump status after 1 year (9,11). Some show an increased risk of diabetic ketoacidosis (DKA) and BMI ...

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

OBJECTIVE -To assess the social-cognitive, behavioral, and physiological outcomes of a self-management intervention for youth with type 1 diabetes.RESEARCH DESIGN AND METHODS -A total of 81 youth with type 1 diabetes aged 11-16 years were randomized to usual care versus a "diabetes personal trainer" intervention, consisting of six self-monitoring, goal-setting, and problem-solving sessions with trained nonprofessionals. Assessments were completed at baseline and multiple follow-up intervals. A1C data were obtained from medical records. ANCOVA adjusting for age and baseline values were conducted for each outcome.RESULTS -At both short-term and 1-year follow-up, there was a trend for an overall intervention effect on A1C (short-term F ϭ 3.71, P ϭ 0.06; 1-year F ϭ 3.79, P ϭ 0.06) and a significant intervention-by-age interaction, indicating a great effect among older than younger youth (short-term F ϭ 4.78, P ϭ 0.03; 1-year F ϭ 4.53, P ϭ 0.04). Subgroup analyses demonstrated no treatment group difference among younger youth but a significant difference among the older youth. No treatment group differences in parent or youth report of adherence were observed. CONCLUSIONS It is well-established that a deterioration in glycemic control accompanies adolescence (1), in part due to hormonal changes associated with puberty (2) but also resulting from worsening adherence (3,4). Consequences include hospitalizations and even mortality from diabetic ketoacidosis (5) and physical damage leading to later complications (6). Because diabetes management during childhood is associated with adult behavior and health outcomes (7,8), intervention to enhance diabetes self-management skills may be critical in decreasing the rate of physical health problems throughout the lifespan.Optimal diabetes management is a formidable undertaking for youth, who are still maturing cognitively and socially. Typically, self-management skills are not well developed, and evaluation of behavioral options and consequences may be inadequate. Despite concerns regarding readiness for diabetes management responsibility, increased independence from parents often results in youth assuming additional responsibility at the cost of poorer adherence.The development of effective intervention models during this transitional period is critical and may be facilitated by predominant theoretical perspectives. Social cognitive theory (9) emphasizes the reciprocal relationship of beliefs and social/environmental factors. One's outcome expectations (expected positive and negative outcomes of behaviors) and selfefficacy (perceived ability to perform behaviors) develop from experience, are influenced by cognitive and behavioral skills, and affect subsequent behavior (10,11). These beliefs provide the underpinnings for motivation and selfmanagement processes, as emphasized by the self-regulation model (12), which explains health-related behavior as a function of appraisal of the situation, perceived choice of actions, and evaluation of the outcomes of those actions (13,14). ...

OBJECTIVE -The purpose of this study is to evaluate two updated measures of diabetes regimen adherence. The Diabetes Self-Management Profile (DSMP) is a widely used, structured interview. Limitations include a substantial interviewer and respondent time burden and the need for well-trained interviewers to use appropriate prompts and score the open-ended responses. The Diabetes Behavior Rating Scale (DBRS) is a self-administered, fixed-choice survey.RESEARCH DESIGN AND METHODS -Both measures were administered to 146 youth with type 1 diabetes (aged 11-18 years) and their parents. Items were added to the DBRS to allow for both flexible and conventional regimens, and the DSMP was modified to use standardized wording across items, accommodate flexible regimens, and permit administration by nonmedical interviewers.RESULTS -Both measures had good evidence of internal consistency (for the DSMP: parent 0.75 and youth 0.70; for the DBRS: parent 0.84 and youth 0.84). Scores on the DSMP and the DBRS were significantly related (r ϭ 0.72 for parents and 0.74 for youth). There was moderate agreement between parent and youth (DSMP, r ϭ 0.51; DBRS, r ϭ 0.48). The measures were correlated with HbA 1c for both parent (DSMP, r ϭ Ϫ0.35; DBRS, r ϭ Ϫ0.35) and youth (DSMP, r ϭ Ϫ0.36; DBRS, r ϭ Ϫ0.34) reports.CONCLUSIONS -Both measures exhibit good psychometric properties and good criterion validity but varied in terms of respondent and interviewer burden, issues that should be considered in selecting assessment procedures. Diabetes Care 29:2263-2267, 2006L ong-term complications of insulindependent diabetes (type 1 diabetes) include higher morbidity and mortality from retinopathy, nephropathy, neuropathy, and cardiovascular disease (1-4). There may be no minimum glycemic threshold for the reduction of longterm complications; long-term risk continues to decrease with HbA 1c (A1C) Ͻ8% accompanied by a lessgradual increase in the risk of hypoglycemia (5). Successful management of type 1 diabetes has been shown to reduce the frequency and severity of these long-term consequences; however, although intensive therapy may improve glycemic control, few families are able to maintain metabolic control within the recommended guidelines (1-6), and control appears to decrease during the adolescent years (7-12). To reduce potential longterm health effects, Cefalu (13) argues for lowering the pediatric glycemic goal Ͻ8% but recognizes that until we can improve diabetes management during adolescence, such a goal is meaningless.Diabetes self-management includes a variety of skills that must be performed daily: monitoring blood glucose, administering insulin, regulating diet and physical activity, and calculating appropriate care based on the results of these activities (14,15). In addition, the process requires adaptation to changing adolescent physiology and shifting parent and youth responsibilities while recognizing that the goals of diabetes management may be changing at the same time (15). Reliable and valid measures of adherence are essential fo...