Mental Health Screenings in Adolescents With Type I Diabetes

Background: More than 200,000 youth in the United States are affected by T1DM, a chronic
illness that results from an absolute insulin secretion deficiency. Like other chronic
illnesses, T1DM is a known risk factor for additional health related comorbidities.
Furthermore, parenting this particular group of adolescents can present its own unique
challenges and earlier research has established that parenting styles undoubtedly influence a
child's ability to manage their own care and metabolic control. Although mental health
disorders are common among adolescents, diabetic youth are reported to be at even higher risk
for mental health symptoms and adjustment issues. Often, after a diagnosis of T1DM adolescent
youth may develop anxiety, sadness, and experience social withdrawal. In fact, ∼30% of
children develop a clinical adjustment disorder within the first 3 months post diagnosis.
However, these early struggles often resolve within the first year; nevertheless, poor
adaptation during the initial maladjustment phase has shown to be indicative of later mental
health symptoms. The risk of suicide or suicide ideation in patients with T1DM is prevalent.
Previous studies have found that girls with type 1 diabetes appear to be more affected with
depression, and anxiety than are boys with type 1 diabetes. Additionally, adolescent females
are at a higher risk of presenting with recurrent diabetic ketoacidosis (DKA) than adolescent
males. It has also been established that maladaptive child responses to an acute or chronic
medical condition can result in stress symptoms. Despite T1DM's classification as a treatable
or manageable illness, failing to adhere to the prescribed treatment regimen can have
catastrophic results. Severe outcomes can include blindness, DKA, coma, and even death. The
mere daily threat of experiencing one of these conditions can be enough to evoke a traumatic
response. Although there is a plethora of studies reporting clinically significant rates of
post traumatic stress disorder (PTSD) in children who have experienced traumatic injuries,
transplants, and even cancer, fewer studies have aimed at assessing post-traumatic stress
responses to T1DM. Self-Efficacy is defined as the belief that one can be successful in
completing a specific task in a given situation. Adolescent ability to self-manage a chronic
illness can be negatively impacted by mental health comorbidities. More specifically, these
mental health comorbidities correlate to poor glycemic control. Previous studies
investigating Self-Efficacy in adolescents solidified the connection of Self-Efficacy to
diabetes mellitus and glycemic control. Positive and adequate parental involvement for
diabetes care is consistently associated with improved metabolic control and adherence.
Adolescence is marked as a time for increased autonomy, privacy and responsibility, so
constructing a dynamic balance that includes parental involvement and support to ensure
proper daily T1DM care seems an ever present challenge. Parenting style may be a more
specific predictor for diabetes outcomes than other contextual aspects related to the family
since youth with type 1 diabetes typically depend on their parents' help when managing the
condition. Three categories of parenting styles have been described, Authoritarian,
Permissive and Authoritative. Authoritarian parents have high level of assertiveness and
control in their implementation of structure and clear definitions of rules but express very
low levels of responsiveness. Alternatively, permissive parents are typically associated with
addressing childrens' emotional needs yet provide little structure or guidance through
boundaries. Authoritative parents fall between authoritarian and permissive by maintaining a
strong but appropriate structure and nurturing amounts of responsiveness and warmth. Research
has shown parental style to directly affect a child's health outcome, specifically,
authoritative parenting behaviors are associated with positive health outcomes including
better glycemic index control, improved adolescent self-care practices, and well-being with
regards to internalizing and externalizing behaviors. Previous literature has identified
connections between gender, parenting style, and mental illness. For example, females have
shown to be more responsive to parenting style as exemplified through increased occurrences
of depression and poorer adherence when the adolescents view the mother as controlling. The
relational component exhibited through this trend could indicate a vulnerability, more
present in girls than boys, considering the interpersonal dynamic between parent and child
associated with parenting style.

This study will examine whether or not adolescent girls from New Mexico and West Texas
diagnosed with T1DM longer than one year are more likely to be affected with mental health
issues than their male counterparts and to ascertain the impact of these issues on glycemic
control. Participants will be screened for mental health symptoms using three brief
instruments currently used in general practice. Additionally, youth reported self-efficacy
and parenting styles will be assessed. The identified instruments are widely used in
pediatric clinical and research settings and are appropriate for this age group. Upon
completion of each screening the appropriate follow up care or referral for services will be
completed in the interest of patient care. A chart review will be conducted at enrollment to
obtain demographic information and a history of diabetes management and care, then again at
12 months after the enrollment.

Significance: This will be the first study to screen for depression, anxiety, and trauma
mental health symptoms in youth with T1DM within the west Texas - eastern New Mexico
geographic region served by Texas Tech University Health Sciences Center (TTUHSC).
Additionally, self-reported parenting behaviors and parenting styles will be identified.
Gender and racial differences among the participants will be analyzed with respect to parent
reported parenting style. The robust Latino population, combined with the rural community
setting provides a unique perspective regarding measured outcomes. Furthermore, amidst the
wave of implementation of trauma-informed care services across the United States, the field
calls for a closer look at the traumatic experiences resulting from type I diabetes
complications, many of which can be life threatening, and have been found to lead to
traumatic stress symptomatology. The data collected in this study may serve to inform future
directions regarding screening protocols and interventions created to address these issues
and subsequently impact diabetes control and complications among this population.

Aim: This study aims to assess mental health symptoms and self-efficacy in youth with T1DM
receiving care in the TTUHSC pediatric endocrine clinic. Furthermore the study seeks to
analyze the relationships among mental health, parent-reported parenting styles and
youth-reported self-efficacy regarding self-care and diabetes management. Gender and racial
differences will be discussed.

Hypotheses: Adolescent females are more likely to be affected with mental health symptoms
than their male counterparts. Positive mental health screens will be associated with lower
self-efficacy regardless of parenting style. Authoritative style parenting will be associated
with higher self-efficacy, fewer positive mental health screenings, and encounters of
diabetes complications. Authoritative style parenting will be positively associated with
diabetes control. Authoritarian style parenting will be associated with lower self-efficacy,
positive mental health screenings. Authoritarian and permissive style parenting will be
associated with poor diabetes control, and encounters of diabetes complications. Lastly,
those who seek mental health services will see improvement with diabetes control (defined by
hemoglobin A1C levels equal or less than 8.5%) and will be less likely to present to the
emergency room, require hospital admission due to DKA or other complications of T1DM.

Study Design and Methods: On May 17th, 2016 the study received IRB approval. Once the trial
gets registered on ClinicalTrials.Gov, participants will be recruited for enrollment into the
study.

Procedures: 1) Study Coordinator will be notified of potential study participants presenting
to the pediatric endocrine clinic. 2) If the patient meets inclusion criteria for the study,
the coordinator will ask for consent/assent to participate. 3) Demographic Information will
be obtained: age at diabetes diagnosis, number of year since diagnosis, gender, zip code,
race/ethnicity, maternal education, insurance type, length of residence at current home,
anticipated housing relocation, length of employment at current job, anticipated parental job
changes, previous mental health screenings and interventions, number of previous DKA episodes
per year, diabetes control over time by looking at HbA1C measurements during admissions to
the hospital or during office follow up. 4) Mental Health Screen/Assessment - Study
participants will be screened for mental health symptoms using the following screening
instruments: Patient Health Questionnaire for Depression (PHQ - 9), Screen for Child Anxiety
Related Emotional Disorders (SCARED), University of California Los Angeles (UCLA PTSD)
Reaction Index - abbreviated version, Youth participants will also complete the Self-Efficacy
for Diabetes Self-Management scale (SEDM), a parent will complete the self-reported Parenting
Styles and Dimensions Questionnaire (PSDQ). 5) Follow Up to Assessment: If patient indicates
thoughts of self-harm or suicide ideation on question 9 of the PHQ-9, then the C-SSRS
Screener version with triage points risk assessment will be conducted to determine if
Emergency room follow up is necessary. Actively suicidal patients will be referred to the
emergency room (ER) for immediate evaluation as per standard of care. Those non suicidal
patients but with a positive mental health screening(s) will be provided with referral and
resource information including a list of mental health providers if desired. 6) Initial data
will be entered and de-identified in the data base, hard copies will be kept in order to
properly match the participants after the chart review. 7) Twelve months after the initial
mental health screening a chart review will be conducted to collect the following
information: Hemoglobin A1C levels in the preceding 12 months ii, number of follow up visits
with pediatric endocrinology, number of ER visits, number of hospital admissions, number of
DKA episodes, suicidal Ideation or suicidal Attempts (SA), Non-Suicidal self-injury (NSSI),
number of visits to mental health providers (If unable to obtain this information through
their medical chart, then individual mental health providers-from the list provided on
initial screening - will be contacted to obtain the number of visits during the preceding 12
months). Data will be entered and de-identified for analysis. At this time any hard copies of
the assessments will be destroyed.

Statistical Analysis: All demographic data will be expressed as mean + SD and frequencies
(%). The differences between males and females will be analyzed using the Student's t-test
for continuous data and with Chi Square for categorical data during the initial analysis. A
two-tailed p value of <0.05 will be considered statistically significant. Additional analyses
will include ANOVA or MANOVA or a regression model during the full analysis. The latest SPSS
software version will used for statistical analysis

Inclusion Criteria:

- Adolescent patients' from west Texas or eastern New Mexico ages 12-17 years old, who
have been diagnosed with Type I diabetes for at least one year from the time of
enrollment, who present to the pediatric endocrine clinic for care.

Exclusion Criteria:

- Patients who are younger than 12 years old or older than 17 years old. Patients who
were diagnosed less than one-year ago from time of recruitment will also be excluded.
Or, those who decline to participate.