HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bryden, K. S. Articles by Dunger, D. B. Search for Related Content PubMed PubMed Citation Articles by Bryden, K. S. Articles by Dunger, D. B. Social Bookmarking                What's this?

Clinical and Psychological Course of Diabetes From Adolescence to Young Adulthood

A longitudinal cohort study

¹ University Department of Paediatrics, John Radcliffe Hospital, Oxford
² Mental Health Group, Southampton
³ Leopold Muller Centre for Child and Family Mental Health, Royal Free and University College Medical School, UCL and Tavistock Clinic, London
⁴ Division of Public Health and Primary Health Care, University of Oxford, Oxford
⁵ University Department of Psychiatry, Warneford Hospital, Oxford, U.K.

	ABSTRACT

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
OBJECTIVE—To determine the clinical and psychological course of diabetes through adolescence and the relationship with glycemic control in young adulthood.

RESEARCH DESIGN AND METHODS—A longitudinal cohort study of adolescents recruited from the register of the outpatient pediatric diabetes clinic. A total of 76 individuals (43 male patients, 33 female patients) aged 11–18 years completed baseline assessments, and 65 individuals (86%) were reinterviewed as young adults (20–28 years of age). Longitudinal assessments were made of glycemic control (HbA_1c), weight gain (BMI), and development of complications. Adolescents completed self-report questionnaires to assess emotional and behavioral problems as well as self-esteem. As young adults, psychological state was assessed by the Revised Clinical Interview Schedule and the self-report Brief Symptom Inventory.

RESULTS—Mean HbA_1c levels peaked in late adolescence and were worse in female participants (average 11.1% at 18–19 years of age). The proportion of individuals who were overweight (BMI >25.0 kg/m²) increased during the 8-year period from 21 to 54% in female patients and from 2 to 28% in male patients. Serious diabetes-related events included death in one patient and cognitive impairment in two patients. Individuals in whom diabetic complications developed (25% of male patients and 38% of female patients) had significantly higher mean HbA_1c levels than those without complications (difference 1.9%, 95% CI 1.1–2.7, P < 0.0001). Behavioral problems at baseline were related to higher mean HbA_1c during the subsequent 8 years (ß = 0.15, SEM (ß) 0.04, P < 0.001, 95% CI 0.07–0.24).

CONCLUSIONS—The outcome for this cohort was generally poor. Behavioral problems in adolescence seem to be important in influencing later glycemic control.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
Adolescence is a difficult time for people with type 1 diabetes because glycemic control often deteriorates (1) and the risk of developing long-term complications seems to accelerate (2). The role of hyperglycemia in the development of microvascular complications has been demonstrated conclusively by the results of the Diabetes Control and Complications Trial (3). It has been argued that poor control in adolescence relates to the physiological changes of puberty (4); however, problems of adherence to treatment regimens (5) and attendance at outpatient visits (6) suggest that psychological factors are also important.

Psychiatric disorders have been shown to be more common in both adolescents and young adults with type 1 diabetes than in nondiabetic populations (7,8). However, the influence of psychological state in adolescence on later diabetic outcomes has not been established; the three previous longitudinal cohort studies in adolescents were based on younger children and comprised small numbers of participants or selective samples (9,10,11).

We used a prospective longitudinal design in a representative population of teenagers to determine the clinical and psychological course of diabetes from adolescence to young adulthood and the relationship between psychological state in adolescence and later diabetes outcomes.

	RESEARCH DESIGN AND METHODS

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
Subjects
The index group of adolescents were identified through the case register of the pediatric outpatient clinic at the John Radcliffe Hospital, Oxford, U.K. The clinic provides specialist treatment by a multidisciplinary team of doctors, nurses, dieticians, and a child psychologist. It is the only clinic serving children and adolescents with type 1 diabetes within the catchment area of John Radcliffe Hospital, and almost all children with type 1 diabetes in this area are known to the clinic, whether or not they attend regularly. If patients were experiencing problems, they were encouraged to attend the clinic more frequently. In 1989, 86 patients aged 11–18 years who had been diagnosed with diabetes more than 1 year prior were identified. Of these, 76 patients (88%) agreed to participate in a study of psychological well-being and eating habits (12). In 1997, these patients were approached again and reinterviewed to determine their progress. Most patients were still attending clinics in Oxford; others were traced through general practitioners or the computerized records of the district health authority health service. Clinical notes were audited in 69 patients (91%), and 65 patients (85%) agreed to a second interview and assessment.

Of the patients who were not reinterviewed at follow-up, two had died; one died from diabetic ketoacidosis and the other died from a cause unrelated to diabetes. One patient developed cognitive impairment from hypoglycemia, and another patient was excluded from the follow-up assessment because of a concurrent illness that would have confounded his responses to the interview. Three patients refused to participate, three patients could not be traced, and one physician declined to give permission to contact a patient with a known psychiatric disorder.

Measures
Baseline assessment (1989–1990).
Adolescent psychological state was assessed using Achenbach and Edelbrock’s Youth Self Report and Profile, a well-validated scale that yields two summary scales: an "internalizing scale" relating to emotional problems, including symptoms of anxiety and depression, and an "externalizing scale" relating to behavioral problems of aggressive antisocial conduct (13). Self-esteem was assessed using the Coopersmith Inventory (14). In addition, parents completed the Child Behavior Checklist, which is the parents’ corresponding version of the Youth Self Report (15). Height, weight, and HbA_1c were measured. Eating habits and attitudes were also assessed, and these results have been reported previously (12,16).

Follow-up assessment (1997–1998).
Most patients were attending the specialist diabetes young-adult clinic. Informed consent was obtained, and patients were invited for a second interview with the research nurse. Assessments of psychological symptoms were made using the self-report Brief Symptom Inventory (17,18), which measures severity of mood and other symptoms (the Global Severity Index gives a continuous score of increasing symptoms), and the Revised Clinical Interview Schedule (19), a research diagnostic interview that yields categorical diagnoses. Height, weight, and blood pressure were measured, and details of social characteristics, smoking, alcohol consumption, and diabetes management were recorded. A capillary blood sample was obtained for measurement of HbA_1c, and three consecutive early morning or overnight urine specimens were collected for measurement of urinary creatinine:albumin ratio. The Central Oxford Research Ethics Committee approved the study.

Case note review.
Medical notes were reviewed after completion of the follow-up assessment to ensure blinding of the research nurse. Details recorded included clinic attendance, serial measurements of HbA_1c (minimum 4 years for each patient, average 20–25 results per patient), and documented laser-treated proliferative retinopathy and/or incipient nephropathy. Prescription of antihypertensive medication was noted, and referrals for psychiatric assessment during the follow-up period were recorded.

Assay
From 1987 to 1991, HbA₁ was measured by a Glytrac electroendosmosis method (Ciba Corning Diagnostics, Halstead, U.K.). From 1991 and thereafter, HbA_1c was measured by high-performance liquid chromatography (normal range 4.3–6.1%) using a Biorad Diamat automated glycosylated hemoglobin analyzer (Biorad Laboratories, Hemel Hempstead, Hertfordshire, U.K.) (20). The changeover between the two methods was carefully documented, and appropriate regression equations were available for conversion of the earlier data to the current method, which is documented in detail elsewhere (2).

Albumin was measured by double-antibody enzyme-linked immunosorbent assay (2). Creatinine was measured using the modified Jaffe method (Unimate 7) on a Cobas Mira automated spectrophotometer (Roche Diagnostic Systems, Basel, Switzerland). Details of interassay and intra-assay variability of the glycated hemoglobin assays and of the albumin and creatinine assays are documented elsewhere, along with the definitions of incipient nephropathy (microalbuminuria) (2).

Statistical methods
Parametric data were analyzed using Student’s t test, nonparametric data were analyzed using Mann-Whitney U test, and categorical data were analyzed with Fisher’s exact test. BMI was calculated (kg/m²), and the standard deviation score was derived from published standards (21,22).

Multiple and logistic regression analyses were performed to examine the potential role of psychological factors and self-esteem on the following outcomes: mean HbA_1c during the 8-year follow-up period, psychological state at follow-up, and admission for diabetic ketoacidosis. The following variables were entered as independent variables: gender, behavioral (externalizing) subscale, emotional (internalizing) subscale, self-esteem (all from baseline), and baseline HbA_1c (as an index of diabetes control).

	RESULTS

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 
Characteristics of the patients participating in each assessment are shown in Table 1. There was no difference between the mean age or duration of diabetes in patients who participated in the initial study at baseline and patients who were not interviewed or between patients who completed both interviews and patients who were interviewed only at baseline.

Social characteristics.
At follow-up, five male patients (13%) and 14 female patients (54%) were married. None of the patients were unemployed; by comparison, the rates of unemployment for age-/sex-matched strata in the general U.K. population ranged from 4–13% (23). A total of 47 patients (72%) had undertaken further education after 16 years of age, including 17 patients (26%) taking degree courses. This proportion was similar to data for the general U.K. population (23).

Smoking and alcohol consumption.
At follow-up, 14 male patients (36%) and one female patient (4%) were regular smokers (10 cigarettes or more per day), and 11 male patients (28%) and 1 female patient (4%) routinely consumed more than 21 and 14 units of alcohol per week, respectively.

Diabetes management.
The number of patients on multiple-injection regimens increased from 36 patients (47%) at baseline to 52 patients (80%) at follow-up. There was no significant difference in HbA_1c at either assessment between patients on multiple-injection regimens and those who received injections twice daily. Median home blood glucose testing at both assessments was 28 times per month (baseline interquartile range 12–56 tests per month, follow-up interquartile range 5–76 tests per month).

Glycemic control.
There was no difference in the mean HbA_1c between baseline and follow-up (Table 1), although longitudinal data showed that mean HbA_1c was highest during late adolescence (Figs. 1A and B). Individual HbA_1c data demonstrated that glycemic control had improved in 31 patients (46%) between assessments and deteriorated in 37 patients (54%). The patients in whom HbA_1c improved between assessments were significantly older than those in whom HbA_1c deteriorated (24.4 [1.8] vs. 23.2 years [2.0], difference 1.2, 95% CI 0.3–2.2, P < 0.01). In the patients >22 years of age at follow-up, mean HbA_1c decreased from 18 to 22 years of age by 1.4% for the male patients and 2.8% for the female patients (the mean HbA_1c at 18 years of age was comparable to the mean HbA_1c from the whole cohort).

View larger version (17K): [in this window] [in a new window]   Figure 1— Mean HbA1c (and SEM [bars]) for male patients (A) and female patients (B) by age.

Serious events.
During the 8-year follow-up (622 person-years exposure), serious events occurred in three patients (4%) as a result of diabetes. One male patient died at 19 years of age during his 11th episode of diabetic ketoacidosis in a 3-year period. Another male patient had undergone long-term rehabilitation after an episode of cerebral edema that developed during diabetic ketoacidosis at 14 years of age. In total, two male patients (5%) and eight female patients (26%) were admitted with recurrent diabetic ketoacidosis (defined as two or more admissions during the study period). One female patient was cognitively impaired after an episode of severe hypoglycemia due to an insulin overdose. Other serious events, unrelated to diabetes, were the death of one female patient and development of schizophrenia in another female patient shortly after the initial interview.

Complications.
At baseline, none of the patients had diabetic complications. By follow-up, 10 male patients (25%) and 11 female patients (38%) had serious microvascular complications or required treatment for hypertension (Table 1). Mean HbA_1c level during the 8-year study period was significantly higher in patients with complications (11.3 [1.4] vs. 9.4% [1.7], difference 1.9%, 95% CI 1.1–2.7, P < 0.0001); the occurrence of frequent admissions for diabetic ketoacidosis was also higher in patients with complications (24 vs. 4%, difference 20%, 95% CI 0.6–39, P < 0.02). Duration of diabetes was not related to the presence of complications.

Psychological outcomes
At baseline, female patients had more emotional symptoms than male patients (difference 8.0, 95% CI 3.0–13.0, P < 0.001) and lower self-esteem (difference -8.41, 95% CI -16.0 to -0.61, P < 0.03). There was an association between the total scores of the children’s self-report and the parents’ report (Spearman’s r_s = 0.40, P < 0.001).

At follow-up, seven female patients (27%) and three male patients (8%) scored as suffering from a psychiatric disorder on the Clinical Interview Schedule. During the study period, psychiatric referrals had been sought for four male patients (10%) and seven female patients (23%); reasons were varied and included assessment for repeated time out of school, treatment for an eating disorder, and depression. In three female patients in whom follow-up interviews were not possible, extensive psychiatric care was required. Reasons included recurrent insulin or tablet overdoses, self-harm, and mismanagement of diabetes; inpatient treatment for schizophrenia was required in one patient.

Psychological predictors
In multivariate analysis, adolescent behavioral problems were significantly related to higher mean HbA_1c during the subsequent 8 years (Table 2). A trend also showed an association between adolescent emotional problems and lower mean HbA_1c level. Although self-esteem was associated with concurrent psychological adjustment (Spearman’s r_s = 0.59, P < 0.0001), when entered into the model, it was not a significant predictor of mean HbA_1c, indicating that self-esteem did not act as a mediating factor. Recurrent hospital admission for diabetic ketoacidosis was the only significant predictor of psychological state at follow-up, as measured by the Global Severity Index (t = 4.4, P < 0.001, 95% CI 0.4–1.1). None of the baseline variables were related to recurrent hospital admissions for diabetic ketoacidosis.

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

General outcomes
As a direct consequence of diabetes, one patient died and two patients became cognitively impaired. In addition, one other patient died, one female patient developed schizophrenia after a history of drug abuse and poor diabetes control, and one female patient with multiple diabetic complications was too psychologically disturbed to be reinterviewed. The number of these serious events is of great concern and is consistent with a recent study that demonstrated this as a high-risk age group (24). Although there are few comparable available data, one other adolescent longitudinal cohort study of a similar size also reported two deaths (25).

Despite the overall failure to achieve good glycemic control, especially in female patients, longitudinal HbA_1c data did improve with age. Although the mean HbA_1c level was still relatively poor at follow-up, this was probably due to the proportion of patients in late adolescence, when HbA_1c levels were highest. This peak at 18–19 years of age is later than might have been expected. Since the baseline study, multiple-injection regimens have become normal practice and appropriate adjustments are now made for insulin requirements during puberty (4). However, the effect this changing pattern of care has had on glycemic control is unclear. Although HbA_1c levels in the Oxford clinics have decreased over the years, in the ongoing Oxford Regional Prospective Study of Childhood Diabetes, which provides comparable longitudinal HbA_1c data over a wider geographical area, the recently reported mean HbA_1c level from 468 children was similar to this earlier cohort at 9.9% (1.7) (2).

Psychological outcomes
Adolescent behavioral problems of aggression and antisocial conduct were adversely associated with poorer glycemic control (HbA_1c) during adolescence and young adulthood. Interestingly, there was a trend for emotional problems, such as anxiety and depression, to be associated with lower glycemic control. This association was found in a previous study, which suggested that anxious children may be more diligent in monitoring and may take more effective action in response to signs of poor blood glucose control (26). Low self-esteem was also associated with poor glycemic control, but this did not seem to mediate the relation between psychological problems and poor outcome. The high prevalence of psychiatric morbidity at follow-up in our young adults is comparable to our previous study of young adults, which reported higher psychiatric morbidity in patients with diabetes compared with the general population (8). Referral for psychiatric assessment was common and was most often observed in those patients who also had recurrent hospital admissions for diabetic ketoacidosis. The only predictor of the Global Severity Index of mental state at follow-up was recurrent hospital admissions for diabetic ketoacidosis, suggesting that when diabetes is significantly out of control, it raises the risk of psychological morbidity.

Implications of the study
This longitudinal cohort study demonstrated a poor outcome in a significant proportion of young adults with diabetes, despite intensive individualized care and support by the diabetes team and, when required, psychiatric and psychological referrals. Identification of psychological and behavioral problems at a young age will require targeting more effective intervention for at-risk patients, if the significant morbidity associated with diabetes during the transition from childhood to young adulthood is to be reduced.

	ACKNOWLEDGMENTS

 
The baseline study was funded by Oxford Regional Health Authority and Oxford District Health Authority, and the follow-up study was funded by the British Diabetic Association.

We thank the staff and patients of the pediatric diabetes clinic at John Radcliffe Hospital and the young-adult diabetes clinic at Radcliffe Infirmary. We also thank Irene Boller for collecting the baseline data, Teresa Bahu for her statistical contribution, Sally Strang for assisting in the initiation of the study, and Dot Harris, Angie Watts, and Zahra Madgewick for their assistance in the pediatric laboratory.

	FOOTNOTES

 
Address correspondence and reprint requests to Professor D.B. Dunger, Department of Paediatrics, Box 116, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, U.K. E-mail: dbd25{at}cam.ac.uk.

Received for publication 5 December 2000 and accepted in revised form 10 April 2000.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

	References

TOP ABSTRACT INTRODUCTION RESEARCH DESIGN AND METHODS RESULTS CONCLUSIONS References

 

1. Mann NP, Johnston DI: Total glycosylated haemoglobin levels (HbA1) in diabetic children. Arch Dis Child 57:434–437, 1982[Abstract]
   
2. Schultz CJ, Konopelska-Bahu T, Dalton RN, Carroll TA, Stratton I, Gale EAM, Neil A, Dunger DB: Microalbuminuria prevalence varies with age, sex, and puberty in children with type I diabetes followed from diagnosis in a longitudinal study. Diabetes Care 22:495–502, 1999[Abstract]
   
3. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993[Abstract/Free Full Text]
   
4. Dunger DB: Diabetes in puberty. Arch Dis Child 67:569–570, 1992[Medline]
   
5. Morris AD, Boyle DI, McMahon AD, Greene SA, MacDonald TM, Newton RW: Adherence to insulin treatment, glycaemic control and ketoacidosis in insulin-dependent diabetes mellitus. Lancet 350:1505–1510, 1997[Medline]
   
6. Griffin SJ: Lost to follow-up: the problem of defaulters from diabetes clinics. Diabet Med 15:S14–S24, 1998
   
7. Blanz BJ, Rensch-Riemann BS, Fritz-Sigmund DI, Schmidt MH: IDDM is a risk factor for adolescent psychiatric disorders. Diabetes Care 16:1579–1587, 1993[Abstract]
   
8. Mayou R, Peveler R, Davies B, Mann J, Fairburn C: Psychiatric morbidity in young adults with insulin dependent diabetes mellitus. Psychol Med 21:639–645, 1991[Medline]
   
9. Kovacs M, Goldston D, Obrosky DS, Iyengar S: Prevalence and predictors of pervasive non-compliance with medical treatment among youths with insulin-dependent diabetes mellitus. J Am Acad Child Adolesc Psychiatry 31:112–119, 1992[Medline]
   
10. Dumont RH, Jacobson AM, Cole C, Hauser ST, Wolfsdorf JI, Willett JB, Milley JE, Wertlieb D: Psychosocial predictors of acute complications of diabetes in youth. Diabet Med 12:612–618, 1995[Medline]
    
11. Rydall AC, Rodin GM, Olkmsted MP, Devenyi RG, Daneman D: Disordered eating behavior and microvascular complications in young women with insulin dependent diabetes mellitus. N Engl J Med 336:1849–1854, 1997[Abstract/Free Full Text]
    
12. Peveler R, Fairburn C, Boller I, Dunger D: Eating disorders in adolescents with IDDM. Diabetes Care 15:1356–1360, 1992[Abstract]
    
13. Achenbach T, Edelbrock C: Manual for the Youth Self-Report and Profile. Burlington, University of Vermont, 1987
    
14. Coopersmith S: The Antecedents of Self-Esteem. San Francisco, Freeman, 1967
    
15. Achenbach T, Edelbrock C: Manual for the Child Behaviour Checklist and Revised Child Behaviour Profile. Queen City, TX, Queen City Printers, 1983
    
16. Bryden KS, Neil A, Mayou RA, Peveler RC, Fairburn CG, Dunger DB: Eating habits, body weight, and insulin misuse. Diabetes Care 22:1956–1960, 1999[Abstract/Free Full Text]
    
17. Peveler RC, Fairburn CG: Measurement of neurotic symptoms by self report questionnaire: validity of the SCL-90R. Psychol Med 20:873–879, 1990[Medline]
    
18. Derogatis LR, Lipman RS, Covi L: SCL 90: an outpatient psychiatric rating scale—preliminary report. Psychopharmacol Bull 9:13–28, 1973[Medline]
    
19. Lewis G, Pelosi AJ: Manual of the Revised Clinical Interview Schedule (CIS-R). London, Institute of Psychiatry, 1990
    
20. Davis JE, McDonald JM, Jarett L: A high performance liquid chromatography method for hemoglobin A_1c. Diabetes 27:102–107, 1978[Abstract]
    
21. Freeman JV, Cole TJ, Chinn S, Jones PRM, White EM, Preece MA: Cross-sectional stature and weight reference curves for the UK, 1990. Arch Dis Child73:17–24, 1995
    
22. Cole TJ, Freeman JV, Preece MA: Body mass index reference curves for the UK, 1990. Arch Dis Child73:25–29, 1995
    
23. Office for National Statistics: Living in Britain–The Results From the 1996 General Household Survey. London, The Stationery Office, 1998
    
24. Edge JA, Ford-Adams ME, Dunger DB: Causes of death in children with insulin dependent diabetes 1990–1996. Arch Dis Child81:318–323, 1999
    
25. Jacobson AM, Hauser ST, Willett JB, Wolfdorf JI, Dvorak R, Herman L, Groot M: Psychological adjustment to IDDM: 10-year follow-up of an onset cohort of child and adolescent patients. Diabetes Care 20:811–818, 1997[Abstract]
    
26. Fonagy P, Moran GS, Lindsay MKM, Kurtz AB, Brown R: Psychological adjustment and diabetic control. Arch Dis Child 62:1009–1013, 1987[Abstract]
    

CiteULike

Del.icio.us

Digg

Reddit

Technorati

This article has been cited by other articles:

				S. Schneider, R. J. Iannotti, T. R. Nansel, D. L. Haynie, D. O. Sobel, and B. Simons-Morton Assessment of an Illness-specific Dimension of Self-esteem in Youths with Type 1 Diabetes J. Pediatr. Psychol., July 29, 2008; (2008) jsn078v1. [Abstract] [Full Text] [PDF]

				M. J. Naughton, A. M. Ruggiero, J. M. Lawrence, G. Imperatore, G. J. Klingensmith, B. Waitzfelder, R. E. McKeown, D. A. Standiford, A. D. Liese, B. Loots, et al. Health-Related Quality of Life of Children and Adolescents With Type 1 or Type 2 Diabetes Mellitus: SEARCH for Diabetes in Youth Study Arch Pediatr Adolesc Med, July 1, 2008; 162(7): 649 - 657. [Abstract] [Full Text] [PDF]

				T. R. Nansel, A. J. Rovner, D. Haynie, R. J. Iannotti, B. Simons-Morton, T. Wysocki, B. Anderson, J. Weissberg-Benchell, and L. Laffel Development and Validation of the Collaborative Parent Involvement Scale for Youths with Type 1 Diabetes J. Pediatr. Psychol., June 21, 2008; (2008) jsn058v1. [Abstract] [Full Text] [PDF]

				R. L. Rothman, S. Mulvaney, T. A. Elasy, A. VanderWoude, T. Gebretsadik, A. Shintani, A. Potter, W. E. Russell, and D. Schlundt Self-Management Behaviors, Racial Disparities, and Glycemic Control Among Adolescents With Type 2 Diabetes Pediatrics, April 1, 2008; 121(4): e912 - e919. [Abstract] [Full Text] [PDF]

				R. Amin, B. Widmer, A T. Prevost, P. Schwarze, J. Cooper, J. Edge, L. Marcovecchio, A. Neil, R N. Dalton, and D. B Dunger Risk of microalbuminuria and progression to macroalbuminuria in a cohort with childhood onset type 1 diabetes: prospective observational study BMJ, March 29, 2008; 336(7646): 697 - 701. [Abstract] [Full Text] [PDF]

				F. J. Cameron, E. A. Northam, G. R. Ambler, and D. Daneman Routine Psychological Screening in Youth With Type 1 Diabetes and Their Parents: A notion whose time has come? Diabetes Care, October 1, 2007; 30(10): 2716 - 2724. [Full Text] [PDF]

				J. Weissberg-Benchell, H. Wolpert, and B. J. Anderson Transitioning From Pediatric to Adult Care: A new approach to the post-adolescent young person with type 1 diabetes Diabetes Care, October 1, 2007; 30(10): 2441 - 2446. [Full Text] [PDF]

				C. M. McDonnell, E. A. Northam, S. M. Donath, G. A. Werther, and F. J. Cameron Hyperglycemia and Externalizing Behavior in Children With Type 1 Diabetes Diabetes Care, September 1, 2007; 30(9): 2211 - 2215. [Abstract] [Full Text] [PDF]

				J. A. Altschuler, S. J. Casella, T. A. MacKenzie, and K. M. Curtis The Effect of Cinnamon on A1C Among Adolescents With Type 1 Diabetes Diabetes Care, April 1, 2007; 30(4): 813 - 816. [Abstract] [Full Text] [PDF]

				T. Wysocki, M. A. Harris, L. M. Buckloh, D. Mertlich, A. S. Lochrie, A. Taylor, M. Sadler, N. Mauras, and N. H. White Effects of Behavioral Family Systems Therapy for Diabetes on Adolescents' Family Relationships, Treatment Adherence, and Metabolic Control J. Pediatr. Psychol., October 1, 2006; 31(9): 928 - 938. [Abstract] [Full Text] [PDF]

				T. Wysocki and L. Gavin Paternal Involvement in the Management of Pediatric Chronic Diseases: Associations with Adherence, Quality of Life, and Health Status J. Pediatr. Psychol., June 1, 2006; 31(5): 501 - 511. [Abstract] [Full Text] [PDF]

				A. J. Farmer, O. J. Gibson, C. Dudley, K. Bryden, P. M. Hayton, L. Tarassenko, and A. Neil A Randomized Controlled Trial of the Effect of Real-Time Telemedicine Support on Glycemic Control in Young Adults With Type 1 Diabetes (ISRCTN 46889446) Diabetes Care, November 1, 2005; 28(11): 2697 - 2702. [Abstract] [Full Text] [PDF]

				S. B. Leichter Making Outpatient Care of Diabetes More Efficient: Analyzing Noncompliance Clin. Diabetes, October 1, 2005; 23(4): 187 - 190. [Full Text] [PDF]

				S. P. Laing, M. E. Jones, A. J. Swerdlow, A. C. Burden, and W. Gatling Psychosocial and Socioeconomic Risk Factors for Premature Death in Young People With Type 1 Diabetes Diabetes Care, July 1, 2005; 28(7): 1618 - 1623. [Abstract] [Full Text] [PDF]

				D. J. Wiebe, C. A. Berg, C. Korbel, D. L. Palmer, R. M. Beveridge, R. Upchurch, R. Lindsay, M. T. Swinyard, and D. L. Donaldson Children's Appraisals of Maternal Involvement in Coping With Diabetes: Enhancing Our Understanding of Adherence, Metabolic Control, and Quality of Life Across Adolescence J. Pediatr. Psychol., March 1, 2005; 30(2): 167 - 178. [Abstract] [Full Text] [PDF]

				S. Maharaj, D. Daneman, M. Olmsted, and G. Rodin Metabolic Control in Adolescent Girls: Links to relationality and the female sense of self Diabetes Care, March 1, 2004; 27(3): 709 - 715. [Abstract] [Full Text] [PDF]

				K. D. Hesketh, M. A. Wake, and F. J. Cameron Health-Related Quality of Life and Metabolic Control in Children With Type 1 Diabetes: A prospective cohort study Diabetes Care, February 1, 2004; 27(2): 415 - 420. [Abstract] [Full Text] [PDF]

				C. L Acerini and A. Deeb Review: New approaches to insulin therapy in children and adolescents with type 1 diabetes The British Journal of Diabetes & Vascular Disease, January 1, 2004; 4(1): 16 - 20. [Abstract] [PDF]

				M. A. Fox, R. S. Chen, and C. S. Holmes Gender Differences in Memory and Learning in Children with Insulin-Dependent Diabetes Mellitus (IDDM) over a 4-year Follow-up Interval J. Pediatr. Psychol., December 1, 2003; 28(8): 569 - 578. [Abstract] [Full Text] [PDF]

				C J Wills, A Scott, P G F Swift, M J Davies, A D R Mackie, and P Mansell Retrospective review of care and outcomes in young adults with type 1 diabetes BMJ, July 31, 2003; 327(7409): 260 - 261. [Full Text] [PDF]

				R. Amin, C. Schultz, K. Ong, J. Frystyk, R. N. Dalton, L. Perry, H. Orskov, and D. B. Dunger Low IGF-I and Elevated Testosterone During Puberty in Subjects With Type 1 Diabetes Developing Microalbuminuria in Comparison to Normoalbuminuric Control Subjects: The Oxford Regional Prospective Study Diabetes Care, May 1, 2003; 26(5): 1456 - 1461. [Abstract] [Full Text] [PDF]

				K. S. Bryden, D. B. Dunger, R. A. Mayou, R. C. Peveler, and H. A. W. Neil Poor Prognosis of Young Adults With Type 1 Diabetes: A longitudinal study Diabetes Care, April 1, 2003; 26(4): 1052 - 1057. [Abstract] [Full Text] [PDF]

				P R Betts and P G F Swift Doctor, who will be looking after my child's diabetes? Arch. Dis. Child., January 1, 2003; 88(1): 6 - 7. [Full Text] [PDF]

				H. A. Wolpert and B. J. Anderson Young Adults With Diabetes: Need for a new treatment paradigm Diabetes Care, September 1, 2001; 24(9): 1513 - 1514. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bryden, K. S. Articles by Dunger, D. B. Search for Related Content PubMed PubMed Citation Articles by Bryden, K. S.