**4. New technology influencing adherence and glycemic control**

Many aspects of medical care are undergoing a technological revolution; diabetes management is no exception. The advent of portable insulin pumps has had positive implications for youth with T1D mellitus in that this new technology simplifies diabetes management and allow for a more flexible lifestyle. Insulin pumps allow users to follow a less strict diet than non-pump users. Moreover, insulin pumps administer insulin more accurately than by hand thereby rendering individual insulin injections unnecessary and decreasing the incidence of severe hypoglycemia[71][72]

Compared to those administering multiple daily injections (MDI), youth using a continuous subcutaneous insulin infusion (CSII), more simply known as an insulin pump, have significantly lower A1C levels[73][73] and reduced daily insulin requirements.[74] Compared to MDI regimens, children using CSII experienced a significant reduction in their glycosylated hemoglobin level.[74] In addition to the positive effects of using a CSII, pumps are safe and well tolerated even among young children.[75][76]

The sensor-augmented insulin pump (SAP), a sophisticated tool, is an advancement in CSII technology that facilities the administration of insulin and monitors blood glucose. These insulin pumps represent a new era of diabetes management that simplifies the daily treatment regimens youth and their parents must follow. For instance, among youth using either a conventional insulin pump or SAP for a duration of six months to 3 years, SAP users' glycosylated hemoglobin level improved significantly more than that of conventional insulin pump users'.[77] In a study by Hirsch and colleagues,[78] SAP users had significantly decreased hypoglycemia and improved A1C levels as compared with conventional insulin pump users. As diabetes management becomes easier due to technological developments in insulin pump design, children and adolescents will become more likely to adhere to their diabetes regimens.

Technological devices in diabetes management are not the only promising tools for youth with Type 1 Diabetes. Carbohydrate counting is a simple and effective strategy that helps youth and their parents decide how much insulin to administer and can lead to an improvement in glycemic control. In a study by Mehta, Quinn, Volening, and Laffel[79] with children aged 4 through 12 found a relationship between parents who precisely counted the amount of carbohydrates consumed each day and lower A1C levels. Furthermore researchers found that it is feasible for children and their caregivers to accurately estimate the amount carbohydrates in food. In a study with 2530 children and children with diabetes, 73 percent were within 10-15 grams of the actual carbohydrate amount.[80] However, a study by Bishop and colleagues[81] found that in their sample of 48 adolescents aged 12 to 18, most youth could not accurately count carbohydrates. However they found that children who did successfully count carbohydrates had significantly lower A1C levels. As evidenced by the aforementioned studies, knowing how to accurately count carbohydrates is strongly associated with adherence to diabetes treatment.

Assessment of diabetes related knowledge is a means of understanding a patient's level of illness-specific knowledge as a necessary prerequisite of a youth's adherence to their diabetes regimen. The Diabetes Awareness and Reasoning Test (DART) is composed of 122

Contributing Factors to Poor Adherence and Glycemic

satisfaction with the level of health care provided.[91]

was the significant variability in the strategies used.[92]

ideas, e) implement the plan, and f) revise the goal.[95][96]

adherence and metabolic control.

rehearsal.[95][96]

Control in Pediatric Type 1 Diabetes: Facilitating a Move Toward Telehealth 149

telehealth services in increasing the likelihood of therapy attendance with no loss in treatment benefits. Preliminary data suggests that this approach may be effective in increasing adherence to medical regimens, and can be used as a tool to support ongoing therapy. Piette and colleagues[91] designed an intervention where adult patients with diabetes received biweekly telephone calls from diabetes educators to discuss diabetes care. The educators were allowed to individualize the information provided to the specific needs of each patient. They found that their intervention improved glycemic control, and reduced diabetes-related symptoms.[90] Additionally, they found that this intervention reduced patient-reported depressive symptoms, improved self-efficacy with regard to diabetes care, and reduced the number of days spent in bed. These patients also reported greater

Polisena and colleagues[92] metaanalysis on telehealth for diabetes found that telehealth had a positive impact on both the utilization of health services as well as glycemic control. In the 26 studies they examined, they consistently found significant benefits of home telemonitoring on glycemic control, reduced hospital visits, and shorter hospital stays. The results on telephone support in the metaanalysis by Polisena and colleagues[92] were less clear although some studies found increased patient satisfaction and reported improved quality of life. A possible reason for the inconsistent findings within the telephone support

A possible strategy to address this problem in youth with T1D would be implementing Behavioral Family Systems Therapy (BFST) through telehealth. BSFT has shown to improve family relationships and communication in families with children who have diabetes.[92][93] In addition, Wysocki and colleagues[95] found that BSFT led to improved treatment

BSFT includes numerous strategies to improve adherence.[95][96] More specifically, BSFT has 4 treatment strategies including problem solving, communication skills training, structural family therapy for role clarification, and cognitive restructuring. The first strategy is a structured approach to problem solving. As adolescence can be a period of increased conflict between parents and teens, the use conflict resolution skills to reduce family tension can be very therapeutic. The steps in the problem solving technique are: a) define the problem, b) set a goal, c) brainstorm ways to accomplish the chosen goal, d) evaluate the

The second strategy in BFST is communication skills training that focuses on improving communication between parents and adolescents around diabetes related tasks and adherence. Often parents and adolescents engage in negative communication patterns, particularly during times of conflict or when negotiating adherence strategies. The communication skills training component is designed to remediate negative communication patterns within the family. This can be an idiosyncratic component, which allows the therapist to tailor interventions to the specific needs of the families. The steps in communication skills are: a) feedback, b) instruction, c) modeling, and d) behavioral

The third strategy in BSFT that is useful in improving adherence and glycemic control in families with youth with T1D is the use of structural family therapy to focus on defining roles within the family. Individuals may have ideas about the roles of each family member that have not been shared with other family members. Role confusion within the family can contribute to increased communication problems and conflict. Role clarification and explicit role negotiation within the family, as explicated in structural family therapy, can be used to reduce problems in the family that adversely impact adherence and glycemic control.[95][96]

questions that effectively measures general diabetes knowledge, nutrition, diabetes care at school, hyperglycemia/hypoglycemia, insulin pump, problem solving, blood glucose testing, and sick days diabetes care. The DART was given to both children and their caregivers and A1C levels of each child were provided. It was shown that the children's insulin pump sub-score and children's parents total DART score significantly predicted A1C levels in that higher test scores predicted lower A1C levels.[82] The PedCarbQuiz is another questionnaire that was completed by adolescents or their caregivers and measures carbohydrate and insulin-dosing knowledge. Similar to the results of the study by Heidgerken and colleagues,[82] higher scores achieved by adolescent and their caregivers on the PedCarbQuiz[83] significantly correlated with lower A1C levels. The relationship between diabetes knowledge and A1C levels underlines the importance of diabetes management education in treatment adherence. New interventions are being developed to help enhance adherence and glycemic control.
