Adolescents with type 1 diabetes

relationship between
problem behavior and glycemic control?
What is the

Minke Eilander, MSc

VU University Medical Center
Amsterdam, The Netherlands

Diabetes type 1

Child / parent responsibility

85% suboptimal glycemic control

Bryden, K.S., Diabetes Care, 2003. 26(4): p. 1052-7;

Luyckx, K., Diabetes Care, 2009. 32(5): p. 797-801

DINO:

Diabetes IN develOpment

Biological development

Psychosocial development

Longitudinal multi center cohort study

Problem
behavior

Glycemic
control

Low self efficacy

Unresponsive to punishment

Low self esteem

Unable to control impulses

Dysfunctional coping mechanisms

Concentration problems

Risk taking behaviour

Duke DC, Geffken GR, Lewin AB, Williams LB, Storch EA and Silverstein JH. Glycemic control in youth with type 1 diabetes: family predictors and
mediators. J.Pediatr.Psychol. 2008; 33: 719-727.
Cohen DM, Lumley MA, Naar-King S, Partridge T and Cakan N. Child behavior problems and family functioning as predictors of adherence and glycemic
control in economically disadvantaged children with type 1 diabetes: a prospective study. Journal of Pediatric Psychology 2004; 29: 171-184.
Carr A. The Handbook of Child and Adolescent Clinical Psychology. A Contextual Approach. Londen: Routledge; 2006.

Problem
behavior

Glycemic
control

Confidence in
diabetes
self-care
Mismanagement

Online survey completed by 11-15 year olds

Glycemic
control

Problem
behavior

Confidence in
diabetes
self-care
Mismanagement

Strengths and Difficulties questionnaire (SDQ)

Total problem behavior:

External + Internal

van Widenfelt, B.M., et al., Dutch version of the Strengths and Difficulties Questionnaire (SDQ). Eur Child
Adolesc Psychiatry, 2003. 12(6): p. 281-9

Problem
behavior

Glycemic
control

Confidence in
diabetes
self-care
Mismanagement

Confidence in diabetes self care youth (CIDS youth)

Van Der Ven N, Weinger K, Yi J, Pouwer F, Ader H, Van Der Ploeg HM, Snoek FJ: The confidence in diabetes self-care scale:
psychometric properties of a new measure of diabetes-specific self-efficacy in Dutch and US patients with type 1
diabetes. Diabetes Care 26:713-718, 2003.

Problem
behavior

Glycemic
control

Confidence in
diabetes
self-care
Mismanagement

Renewed version of Mismanagement scale

Weissberg-Benchell, J., Glasgow, A. M., Tynan, W. D., Wirtz, P., Turek, J., & Ward, J. (1995). Adolescent diabetes management
and mismanagement.Diabetes Care, 18(1), 77-82.

Problem
behavior

Glycemic
control

Confidence in
diabetes
self-care
Mismanagement

HbA1c: Derived from hospital charts

Problem
behavior

Glycemic
control

Confidence in
diabetes
self-care
Mismanagement

Multiple mediation analyses

Corrected for age and gender
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect
effects in multiple mediator models. Behavior Research Methods, 40, 879-891

Results
M

SD

Boys / Girls (N / %)

45 / 43

51.1 / 48.9

Age

13

1.2

Diabetes duration (yrs)

5.8

3.8

Glycemic control (HbA1c)

64.3 mmol/mol (8.0%)

11.5

Age onset

7.1

3.9

Total

problem behavior
Problem
behavior

Direct effect
=0.625
P=0.029*

Glycemic
control

Total

problem behavior
Problem
behavior

Direct effect
=0.120
P=0.685

Confidence in
diabetes
self-care
Mismanagement

Total indirect effect

BCa 95% 0.25 to 0.85*

Point estimate = 0.50

Glycemic
control

External problem behavior

Problem
behavior

Direct effect
=1.00
P=0.02*

Glycemic
control

External problem behavior

Problem
behavior

Direct effect
=0.27
P=0.56

Confidence in
diabetes
self-care
Mismanagement

Total indirect effect

BCa 95% 0.36 to 1.25*
Point estimate = 0.73

Glycemic
control

Internal problem behavior

Problem
behavior

Direct effect
=0.494
P=0.270

Glycemic
control

Internal problem behavior

Problem
behavior

Direct effect
= -0.01
P=0.981

Confidence in
diabetes
self-care
Mismanagement

Total indirect effect

BCa 95% 0.14 to 0.96*
Point estimate = 0.50

Glycemic
control

Conclusion
Problem behavior is associated with increased HbA1c,
mediated by less confidence in diabetes self-care
and more diabetes mismanagement.
Assumed causality

In clinical practice
Solving problem behaviours and building confidence in

diabetes self-care at an early stage might optimize glycemic control.

More attention for external problem behavior

Maartje de Wit, PhD

Vumc, Amsterdam

Roos Nuboer, MD
Meander MC, Amersfoort

Willie Bakker-van Waarde, MD-PhD

UMCG, Groningen

Prof. Frank Snoek, PhD

Vumc, Amsterdam

Henk-Jan Aanstoot, MD-PhD

Diabeter, Rotterdam

Per Winterdijk, MD
Diabeter, Deventer

Joost Rotteveel, MD-PhD

Vumc, Amsterdam

Mieke Houdijk, MD-PhD

HAGA Hospital, The Hague

One minute puberty

https://www.youtube.com/watch?v=zCxxLY73nBE

Alexander Gellner
www.alexandergellner.de

Results
M

SD

Boys/Girls (N / %)

45 / 43

51.1 / 48.9

Age

13

3.8

HbA1c

64.3 mmol/mol (8.0%)

11.5

Age onset

7.1

3.8

Diabetes duration (yrs)

5.8

3.8

Total problem behavior (SDQ)

13 normal

8.6

(N>13: 13)

4.3

External problem behavior (SDQ)

8 normal

4.9

(N>8: 11)

2.8

Internal problem behavior (SDQ)

6 normal

3.7

(N>6: 14)

2.8

Mismanage (4-16)

6.4

2.0

CIDS-youth (12-60)

51.2

5.3

Total effect (c path)

=0.625; P=0.029

Total problem behavior

HbA1c

Total

Direct effect (c' path)

= 0.120; P=0.685

Direct effect (a path)

= -0.362; p<0.01

Direct effect (a path)

=0.183; P<0.01

Direct effect (b path)

=-0.794; P<0.01

Confidence in diabetes self

care
Specific indirect effect (ab path)
Point estimate=0.29;
BCa 95% CI 0.10 to 0.53

Mismanagement
Specific indirect effect
(abpath)
Point estimate=0.22;
BCa 95% CI 0.02 to 0.51

CIDS and Mismanage scores not related:

pearson rho: -0.114, p=0.291
Total indirect effect
(ab+ab path)
Point estimate = 0.50
BCa 95% 0.25 to 0.85

Direct effect (b path)

=1.189; P=0.057

Total effect (c path)

=1.00; P=0.02

External problem
behavior

HbA1c

External

Direct effect (c' path)

=0.27; P=0.56

Direct effect (a path)

= -0.49; p=0.02

Direct effect (a path)

=0.32; P<0.01

Direct effect (b path)

=-0.77; P<0.01

Confidence in diabetes self

care
Specific indirect effect (ab
path)
Point estimate=0.38;
BCa 95% CI 0.11 to 0.71

Mismanagement
Specific indirect effect
(abpath)
Point estimate=0.35;
BCa 95% CI 0.02 to 0.81

Total indirect effect

(ab+ab path)
Point estimate = 0.73
BCa 95% 0.36 to 1.25

Direct effect (b path)

=1.12; P=0.08

Total effect (c path)

=0.494; P=0.270

Internal problem behavior

Internal

HbA1c

Direct effect (c' path)

= -0.01; P=0.981

Direct effect (a path)

= -0.418; p=0.042

Direct effect (a path)

=0.126; P=0.104

Direct effect (b path)

=-0.820; P<0.01

Confidence in diabetes self

care
Specific indirect effect (ab path)
Point estimate=0.34;
BCa 95% CI 0.04 to 0.73

Mismanagement
Specific indirect effect
(abpath)
Point estimate=0.16;
BCa 95% CI -0.004 to 0.49

Total indirect effect

(ab+ab path)
Point estimate = 0.50
BCa 95% 0.14 to 0.96

Direct effect (b path)

=1.286; P=0.027

Strenghts and Difficulties Questionnaire

CIDS - youth

Renewed Mismanagement scale