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Implications of Diabetes for

Psychosocial Functioning Among


Children and Parents
Vicki S. Helgeson, Ph.D.
Carnegie Mellon University
40th Annual Conference of the International Society of Pediatric and Adolescent Diabetes

Toronto, CA
September 3, 2014

Presentation Goals
1.
2.

Impact of Type 1 Diabetes on


psychosocial functioning
Impact of social relations on outcomes
among youth with type 1 diabetes
Relationships with friends
Relationships with parents

Comparing Children with Diabetes to Peers:


A Meta-Analysis
Identified 44 studies with well-being outcomes
22 met criteria for review

Required comparison group


Conducted since 1990

Examined moderators

Year of publication
Age
Sex
Time since diagnosis
Glycemic control
Comparison group equivalence
Reynolds & Helgeson (2011) Annals of Behavioral Medicine

Table 2 Effect sizes for meta-analysis of psychological well-being


Respondent

Variable

Mean ES
(fixed)

Significance

Homogeneity

Parent

Psychological distress

0.62

0.00

ns

Behavioral problems

0.25

0.00

ns

Internalizing problems

0.25

0.02

ns

Depressive symptoms

0.05

ns

ns

Depressive symptoms

0.26

0.00

Q=62.58, p<0.01

Depression (clinical)

0.40

0.00

Q=13.15, p=0.01

Anxiety

0.18

0.02

Q=15.77, p<0.01

Psychological distress

0.17

0.00

Q=14.09, p<0.05

Self-esteem

-0.09

ns

Q=32.05, p<0.01

Peer difficulties

-0.09

ns

Q=6.18, p<0.05

Psychopathology

0.04

ns

Q=8.77, p<0.05

Child

Moderator Variable: Year of Publication


ES variable

Beta

Significance

Depressive symptoms

-0.03

-0.33

p<0.01

Depression (clinical)

-0.04

-0.65

p<0.05

Anxiety

-0.02

-0.44

ns

Psychological distress

-0.02

-0.47

ns

Self-esteem

0.03

0.54

p<0.01

Peer difficulties

-0.19

-0.89

p<0.05

Moderator Variable: Quality of Comparison Group


ES variable

Beta

Significance

Depressive symptoms

-0.11

-0.37

p<0.01

Depression (clinical)

-0.06

-0.26

ns

Anxiety

-0.13

-0.84

p<0.01

Psychological distress

0.06

0.36

ns

Self-esteem

0.00

0.01

ns

Peer difficulties

0.58

0.89

p<0.05

Conclusions
Children with type 1 diabetes experience more
of a variety of psychosocial difficulties than
comparison groups
Effects are small to medium in size
Effects are smaller in more recent studies
Effects are smaller when there are better
comparison groups

132 diabetes recruited from


clinic
131 healthy controls recruited
from physician offices/mall
health fairs
Ages 11-13; 5th, 6th, 7th grade
Began 2002
Annual assessments for 5 years

Demographics
Diabetes (n= 132)

Controls (n= 131)

47%

49%

53

51

Race: White

93

91

Black

Asian

American Indian

More than one race

95

95

Hispanic

Unknown

Live with biological mother and


father

74

73

Age (years)

12.10 0.77

12.07 0.69

Social status*

41.97 11.05

46.40 13.31

Sex: Male
Female

Ethnicity: Non-Hispanic

Results (T1, T2, T3)

Depressive symptoms

Anxiety

No group differences
Same for girls over time; decreased for boys

Anger

No group differences
Girls increase over time; boys same

No group differences
Increased over time

Self-Worth

No group differences
Declined over time, especially for girls
Helgeson, Snyder, et al. (2007) Journal of Pediatric Psychology

10

Social Acceptance (Group X Time*)

11

Drive for thinness (Group X Time*)

12

Implications of Diabetes for Parents


Goal 1: predictors of parent
mental health

Parental general stress


Parent diabetes-specific
stress
Benefit-finding

Goal 2: parent predictors of child


mental health and diabetes
outcomes

Depressive symptoms
Monitoring frequency
Child self-care
Glycemic control

Helgeson, Becker, Escobar, & Siminerio


(2012), Journal of Pediatric Psychology

13

Parent Mental Health (HLM; 5 years)


Depression

Life Satisfaction

General Stress

.31***

-.70***

Diabetes-Specific Stress

.13***

-.32***

n.s.

.16*

Benefit Finding

14

Child Outcomes (HLM; 5 years)


Depressive
Symptoms
Coeff

Monitoring
Frequency

Child
Self-Care
Coeff

Coeff

Glycemic
Control
Coeff

Intercept

1.14*** (.45)

4.20*** (1.08)

4.28*** (.36)

9.10*** (1.08)

Social Status

-.00

(.00)

.02

(.01)

.00

(.00)

-.03**

(.01)

Parent Age

.00

(.00)

-.01

(.02)

-.01

(.01)+

.01

(.02)

Household Structure

.00

(.04)

-.62*

(.27)

-.14

(.09)

.44

(.27)

General Stress

.03*

(.02)

-.24+

(.11)

-.08*

(.04)

.26

(.10)

Diabetes-Specific Stress

.01

(.02)

.23*

(.11)

.11**

(.04)

.12

(.09)

Benefit Finding

-.01

(.01)

.06

(.09)

.01

(.03)

-.23**

(.07)

15

Conclusions

General parent stress is associated with poor parent


mental health, poor child mental health, and poor
child self-care
Parent diabetes-specific stress mixed effects:

16

Better child self-care


Increased parent stress

Transition Times Study

Follow youth as they


transition out of high school
3 annual assessments
Compare youth with and
without type 1 diabetes on
Lifestyle choices
Risk behavior
Psychological well-being
Recruited from earlier study
(Teen Health Study)
Palladino, Helgeson et al. (2013) Journal of
Pediatric Psychology

17

Table I Participant Demographics at baseline (T1)


Diabetes (n= 117)

Controls (n= 122)

18.15 (.41)

18.02 (.49)

BMI*

25.68 (4.03)

24.12 (4.72)

Social status
(Hollingshead)*

42.61 (11.08)

46.58 (13.70)

47% (58)

46.3 (56)

Lives with mother and father

66.7% (78)

68.9% (84)

Race White

92.3% (108)

93.4% (1114)

Age

Male

57.50%

Pump
Time since diagnosis (years)

HbA1c (%)

11.12 (3.10, 5.75-17.74)

8.90 (1.75, 6.2-13.7)


Palladino et al (2013) Journal of Pediatric Psychology

18

Comparison of Diabetes and Controls Over Time


(group X time ancovas; covariates BMI and social status)
Time 1

Time 2

Time 3

time

time x group

group

DM

DM

DM

Depr Symptoms

1.70

1.63

1.73

1.66

1.76

1.67

n.s.

n.s.

n.s.

Life satisfaction

5.20

5.50

4.86

5.53

5.21

5.49

n.s.

**

Bulimic symptom

1.56

1.43

1.54

1.41

1.61

1.47

n.s.

n.s.

Drive thinness

1.98

1.84

1.84

1.82

1.82

1.80

n.s.

n.s.

n.s.

Loneliness

1.72

1.60

1.74

1.64

1.79

1.64

n.s.

n.s.

Purpose in life

4.60

4.71

4.55

4.86

4.67

4.86

n.s.

**

Perceived stress

2.51

2.38

2.57

2.40

2.56

2.37

n.s.

n.s.

19

Life Satisfaction
6
5,8
5,6
5,4
5,2
Healthy

Diabetes

4,8
4,6
4,4
4,2
4
T1
20

T2

T3

Purpose in Life
6
5,8
5,6
5,4
5,2
Healthy

Diabetes

4,8
4,6
4,4
4,2
4
T1
21

T2

T3

Conclusions
No group differences on depression
Diabetes greater perceived stress than
controls trends for loneliness and bulimic
symptoms
Some group differences emerged with time:
life sat, purpose

22

Implications of Friendship for Diabetes Outcomes


Palladino & Helgeson (2012) review (Journal of Pediatric Psychology)

Qualitative studies:

Teens believe peers have impact on diabetes behaviors

Quantitative studies less clear:

23

Majority studies show no relation of peer support to selfcare


2 studies showed link between peer support and WORSE
glycemic control (Helgeson, Siminerio, et al., 2009; Hains et al., 2007)
More recently 1 study showed link between peer support
and WORSE self-care (Helgeson, Mascatelli, in press)

Instead, more evidence that peer conflict is


harmful
Stronger findings for diabetes-specific than
general support/conflict
Individual difference variables important
moderators of vulnerability

24

Why might peer conflict be associated with


poor diabetes outcomes?
Peer Conflict

Interpersonal stress
Social competence

Failure to disclose DM
Avoid bullying
25

Self-Care

HbA1c

Limitations of Literature Review

Few studies distinguish between kinds of


support: emotional/instrumental
Few studies measure peer conflict
Few studies examine diabetes-specific
support and conflict

26

Teen Health Study: Predicting Glycemic Control


Risk and Resistance Framework

4 years of follow-up
Risk factors:

Disturbed eating behavior


Depressive symptoms
Unmitigated communion
Friend conflict

Resistance factors:

Parent relationships
Friend support
Helgeson et al. (2009) Journal of
Pediatric Psychology

27

Table III Final Cross-sectional Multilevel Model


B

Standard error

Age

.03

0.26

.92

Pubertal status

.15

0.08

.05

Method of delivery

-.69

0.14

0.00

Baseline BMI

.01

0.03

.88

Baseline social status

-.02

0.01

.06

Sex

-1.23

0.56

.03

Baseline BMI x age

.02

0.01

.08

Self-care behavior

-.14

0.23

.55

Self-care behavior X age

-.13

0.07

.04

Drive for thinness

-.06

0.08

.43

Drive for thinness X sex

.32

0.14

.02

Parent relationship

-.04

0.15

.77

Parent relationship X sex

.52

0.21

.01

Friend support

.26

0.10

.01

28

Table IV Final Longitudinal (Lagged) Multilevel Model


B

Standard error

Previous HbA1c

.70

0.04

0.00

Lag

.30

0.12

.02

Baseline BMI

.04

0.02

.01

Depressive symptoms

.78

0.43

.07

Depressive symptoms x lag

-.57

0.31

.07

Bulimic symptoms

.27

0.11

.02

Friend conflict

.35

0.14

.01

Friend conflict x lag

-.37

0.12

.002

29

Transition Times Study: Impact of Friends and


Parents

Friend support

Friend conflict

Parent support

Parent control

Examined buffering effects


Helgeson, Palladino et al. (in press) Health Psychology

30

Table 3 Multiple Regression Models: Social Environment Variables Predicting Health Behaviors
(Standardized Betas)

Depressive
Symptoms

Perceived
Stress

Bulimic
Drive for
Symptoms Thinness

HbA1C

.57**

.41***

.66***

.72***

.72***

Time since Diagnosis

.11

Delivery method

.03

Parent support

-.15**

-.20***

-.08

.01

.10

Parent control

.13**

.07

.05

-.02

-.12

Friend support

-.03

-.10+

-.00

-.01

.07

Friend conflict

.14**

.11*

.17***

.14***

.03

Time 1 DV

+p

< .10; *p < .05; **p < .01; ***p < .001; DV= dependent variable
31

Bulimic: Parent Support x Friend Conflict

32

Table 3 Logistic Regression Models: Social Environment Variables Predicting Health Behaviors

Smoking

Alcohol Use

Binge Alcohol

SE

OR

SE

OR

SE

OR

Time 1 DV

3.38**
*

.42

.29

1.72***

.34

5.59

1.68***

.39

5.38

Parent support

-.45*

.23

.64

-.03

.19

.97

-.21

.19

.81

Parent control

.48*

.22

1.61

.12

.18

1.13

-.03

.18

.97

Friend support

.18

.23

1.19

.32

.20

1.38

.24

.20

1.28

Friend conflict

.05

.33

1.05

1.27***

.32

3.55

.59*

.27

1.81

+p

< .10; *p < .05; **p < .01; ***p < .001; DV= dependent variable
33

Alcohol: Friend Support x Parent Control

34

Conclusions

Friend conflict more potent predictor than friend


support of changes in health behavior, well-being, and
glycemic control
Parent support associated with positive changes in
psych well-being, decrease in smoking, and better
glycemic control in girls
Parent controlling behavior related to increase in
smoking and depressive symptoms
Some evidence of cross-domain buffering

35

supportive relationships in one domain buffered adverse


effects of problematic relationships in the other domain on
health outcomes

Overall Conclusions

Psychosocial diffs between diabetes and controls

Parents clearly affected by diabetes

Smaller in more recent studies


Evident on more subtle indicators of well-being
Concern with effects on life satisfaction and purpose
How to minimize parent distress and maintain benefit of
parent involvement on child self-care behavior

Peers important factor in diabetes

36

Mixed effects of support


Mechanisms linking peer conflict to poor outcomes

Thank you for your attention.

Acknowledgements

Co-Investigators/Collaborators

Dorothy Becker, M.B.B.Ch.


Oscar Escobar, M.D.
Kerry Reynolds, Ph.D.
Linda Siminerio, Ph.D.

Collaborators

37

Katilyn Mascatelli, B.A.


Dianne Palladino, M.A.
Pamela Snyder, M.A.

38

Transition Times Study

Support and conflict


from friends and
romantic partners
predictors
Compared diabetes and
controls
Limited to those in a
romantic relationship at
each wave (roughly half
of the sample)
Helgeson, Mascatelli, Reynolds, Becker,
Escobar, & Siminerio (in press) Journal of
Pediatric Psychology

39

40

Table 4 Multiple Regression: Predicting Diabetes Outcomes (Standardized Betas, Change in R2 at Each Step, and Total R2)
Self-Care

HbA1c

T2

T3

T2

T3

n = 46

n = 50

n = 33

n = 37

R2

R2

R2

R2

Social Status

-.22

.04

-.23

.01

BMI

-.10

-.36**

.00

-.10

Sex

.01

.14

.01

.22

.04

.09

.02

.04

Friend Support

.07

-.29*

.04

-.06

Friend Conflict

.13

-.22

-.01

-.06

Romantic Support

.18

-.28+

.11

.17

Romantic Conflict

-.15

-.54**

.32

.36

Total R2

41

.06

.30

.11

.10

.10

.39

.13

.14

Diabetes and Friendship

Effects of diabetes on
friendship
Effects of friendship on
health
Data from time 1 and
time 2 (2 years)

42

Helgeson, Reynolds, Escobar, Siminerio, Becker


(2007) Journal of Adolescent Health

Friend Support: (Group X Sex X Time)


4.5

Support

Male DM
Male H
Female DM
Female H
3.5

3
T ime 1

43

T ime 2

Table 2 : Final Equation from Hierarchical Regression s Predicting Psychological Health


Time 1 Psychological Health

beta

SE

Step 1: social status

.00

.00

Tanner stage

-.05

.05

body mass index

-.02+

.01

-.20*

.10

group

-.09

.08

support

.12+

.07

negative relations

-.36***

Step 1: Time 1 Psychological Health


Step 2: social status

Change in R 2 Cumulative R

.04

.04

.07

.11

.15

.53 ***

.05

.36

.36

-.00

.00

Tanner stage

-.01

.04

body mass index

-.01

.01

.02

.38

-.18*

.08

group

-.03

.07

support

-.08

.06

negative relations

-.16**

.06

.03

.41

Step 2: sex

Time 2 Psychological H ealth

Step 3: sex

Note: SE = standard error of beta; + p < .10; * p < .05; ** p < .01; *** p < .001

44

Table 3: Final Equation from Hierarchical Regressions Predicting Metabolic Control


Time 1 Metabolic Control

beta

SE

Step 1: social status

-.02+

.01

Tanner stage

.20

.14

body mass index

.03

.03

-.38

.28

support

.32+

.19

negative relations

.35*

Step 1: Time 1 Metabolic Control

Change in R2 Cumulative R2

.09

.09

.18

.05

.14

.67***

.08

.44

.44

Step 2: social status

-.02*

.01

Tanner stage

.22+

.12

body mass index

.03

.02

.04

.48

.57*

.25

support

.19

.17

negative relations

.59***

.15

.07

.55

Step 2: sex

Time 2 Metabolic Control

Step 3: sex

Note: SE = standard error of beta;+ p < .10; *p < .05; **p < .01; ***p < .001

45