Abstract
Objectives: Severe hypoglycemia is more common among young children with type 1 diabetes mellitus (T1DM) than older youth, and parents report significant hypoglycemia fear (HF). Parents experiencing HF describe constant and extreme worry about the occurrence of hypoglycemia and may engage in potentially risky behaviors to avoid hypoglycemia. Our team developed and tested a behavioral intervention, Reducing Emotional Distress for Childhood Hypoglycemia in Parents (REDCHiP), to decrease HF in parents of young children with T1DM. Here, we qualitatively analyzed parent feedback to refine and optimize future intervention iterations. Methods: The randomized pilot study included parents (n = 73) of young children with T1DM who participated in the 10-session video-based intervention. We qualitatively analyzed 21 recordings of the final intervention session, where parents provided feedback about intervention content. Trained coders independently reviewed each session. The frequency of parent quotes regarding active REDCHiP treatment components were calculated. Results: The coded themes reflected active treatment components [viz., Use of Cognitive Behavioral Therapy (CBT) Skills, Coping, Behavioral Parenting Strategies]. Also, two secondary process codes were identified: Appreciate REDCHiP Content and Challenges in Applying REDCHiP Strategies. Parents provided examples of skills or concepts they applied from REDCHiP, the challenges they encountered, and if they planned to apply these skills in the future. Conclusions: A qualitative analysis provided insight into parent perceptions of the active treatment components within the REDCHiP intervention, their acceptability, and parents’ intention to apply REDCHiP skills/concepts within daily T1DM cares. Future iterations of the intervention that trial alternative formats (i.e., individual vs. group and asynchronous vs. telehealth) may increase accessibility and scalability.
1. Introduction
The prevalence of type 1 diabetes mellitus (T1DM) in youth aged 19 years or younger is approximately 2.15 per 1000, based on a report of youth in the United States (US) from 2001 to 2017 [1]. T1DM requires intensive, daily management tasks to keep blood glucose levels in the desired target range throughout the day and night to avoid hyperglycemia (severe high blood glucose values) and hypoglycemia (severe low blood glucose values) [2]. Daily tasks include carefully monitoring carbohydrate intake, administering accurate insulin doses, managing physical activity safely, and monitoring blood glucose values constantly. In very young children (<7 years old) living with T1DM, the frequency of severe hypoglycemia is two times higher than the rate for older children and adolescents [3]. One reason for this may be very young children’s heightened sensitivity to insulin [4]. However, very young children are also unpredictable in their eating and exercise patterns, and they are often less able to recognize and report symptoms of mild hypoglycemia, making it harder to treat falling glucose levels early to prevent severe events (e.g., seizure and loss of consciousness) [5]. Because management of T1DM is complex, parents must assume responsibility for their very young child’s T1DM care, leaving many parents vulnerable to higher stress and anxiety [6,7]. In particular, parents of very young children with T1DM report moderate to severe levels of hypoglycemia fear (HF) [8].
HF is characterized by constant and extreme worry about the occurrence of hypoglycemia coupled with engagement in potentially maladaptive behaviors to avoid hypoglycemia (potentially resulting in hyperglycemia, e.g., purposefully underdosing or skipping insulin when eating or at certain times of day and/or treating normal glucose levels) [9,10,11]. Data suggest about 60% of parents of young children with T1DM report at least moderate levels of HF, and we see a positive association between parents’ fear and children’s glucose levels [8,12,13,14], suggesting parental HF could be a barrier to achieving within-target glycemic levels. Long-term risks (retinopathy, nephropathy, and neuropathy) may be increased due to the impact of out-of-range glycemic levels on metabolic memory, highlighting the importance of targeting parental HF for child health [15,16].
Our team, comprised of psychologists and physicians who provide care to children with T1DM, has been interested in the impact of parent HF on families’ quality of life and children’s health outcomes. We have engaged in a systematic process to develop and test a behavioral intervention to help parents manage their HF. Specifically, employing the Obesity-Related Behavioral Intervention Trials (ORBIT) model for developing behavioral interventions [17], we completed formative studies to identify potential evidence-based treatment components to reduce HF (Phase 1a), and we conducted a Phase 2b randomized pilot trial of our intervention to test its treatment effect compared to an active attention control [18].
In our pilot trial, we recruited parents of very young children with T1DM (2–6.99 years old) to participate in the intervention, Reducing Emotional Distress for Childhood Hypoglycemia in Parents (REDCHiP), and we collected qualitative data from parents in a summative group session (session 10) designed to solicit feedback about REDCHiP [18]. We asked parents to reflect on what they learned during treatment, to review the benefits and challenges of applying treatment components, and to set goals for the treatment strategies that they want to keep using. Here, we report on our qualitative analysis of parents’ comments and discuss how they may help us to refine and optimize our intervention to reduce HF in parents of very young children with T1DM.
2. Materials and Methods
2.1. Participants
Our REDCHiP pilot trial recruited parents of young children with T1DM from a national registry and from three pediatric diabetes centers located in the midwestern, mountain, and southeastern regions of the United States. REDCHiP operated under a single Institutional Review Board (IRB) agreement (IRB#STUDY00000545, 17 June 2019), with Children’s Mercy Kansas City identified as the IRB of record. Families who enrolled in the pilot participated for up to seven months. There were n = 197 families who enrolled, with n = 93 families randomized to the intervention arm, and n = 80 families who completed the treatment arm. Prior to randomization and other trial activities, all parents provided informed consent and permission to participate in REDCHiP. Parents received compensation for completing the three study assessment visits, but they were not compensated for attending telehealth treatment visits. Due to the COVID-19 pandemic, a slight format change was required after the third cohort was run, increasing the number of individual sessions to seven and decreasing the number of group sessions to three. Parents (n = 73) who participated in cohorts 4–28 were included in the following analyses. See Table 1 for participant demographics.
Table 1.
Demographics.
2.2. Reducing Emotional Distress for Childhood Hypoglycemia in Parents (REDCHiP)
Our REDCHiP intervention merges principles of cognitive behavioral therapy with behavioral parenting strategies and diabetes education. It involves 10 video-based telehealth sessions completed over a 12-week period. The telehealth sessions include seven individual sessions, wherein parents work one-on-one with a trained REDCHiP leader (either a licensed psychologist, a supervised psychology trainee, or a supervised certified diabetes educator) and three group sessions led by 1–2 trained REDCHiP leaders and including up to five other parents of very young children with T1DM. In individual sessions, parents learned to identify unhelpful thoughts and behaviors related to their HF, built a personalized fear hierarchy of situations that evoke HF, developed alternative coping strategies to manage their fear and worry, and practiced using the new coping strategies to manage fear related to in vivo and/or imagined exposures to feared situations. In group sessions, parents learned evidence-based behavioral parenting strategies, such as contingency management, they reviewed T1DM management information and skills to promote their confidence in managing their young child’s T1DM (such as pattern analysis), and they gave and received support from other parents. With parental permission, we recorded the video-based telehealth sessions to facilitate evaluating treatment fidelity after the sessions. As noted previously, the present analyses focused only on data collected during REDCHiP session 10 (final group session, composed of 2 or more parent participants and 1–2 group leaders). Attendance at session 10 was calculated at 94.5% (missing attendance data on two participants imputed to 0, equivalent to did not attend). We conducted qualitative analyses of 21 recordings of session 10.
2.3. Data Analysis
A priori, we determined a list of codes (primary codes) based on active treatment components and content from the first 9 REDCHiP sessions. Then, a posteriori, we used an iterative approach to define additional codes (process codes). To promote the scientific rigor of our main qualitative coding analysis, we used a team of three independent reviewers and calculated inter-rater reliability. We devised a plan so each session 10 was watched and independently reviewed by two team members. In cases where the two reviewers disagreed on which codes to apply, a third reviewer stepped in to resolve the discrepancy. Each team member watched up seven recordings of session 10 to identify salient parent quotes reflecting the codes and developed a list of potential themes, which we translated and refined into 40 themes through group consensus. We then calculated a kappa coefficient to evaluate our inter-coder reliability. Overall, we achieved a k = 0.94, indicating excellent agreement. Finally, we calculated the frequency of parent quotes about our primary themes (active components of REDCHiP).
3. Results
The primary codes developed a priori based on the content of the REDCHiP intervention included Use of Cognitive Behavioral Therapy (CBT) Skills, Coping, Behavioral Parenting Strategies, Communication/Modeling, and Increasing Child Independence in T1DM (Table 2). To better understand parent feedback and to aid in future intervention refinement, we also identified two process-based codes a posteriori: Appreciate REDCHiP Content and Challenges in applying REDCHiP Strategies (Table 3).
Table 2.
Frequency of parent comments related to REDCHiP session topics.
Table 3.
Frequency of process codes and themes.
3.1. Use of CBT Skills
Within Use of CBT Skills, themes included identifying cognitive distortions, the use of talk-backs (statements to make in response to cognitive distortions), exposure/fear hierarchies, and mindfulness. Parents most often described using fear hierarchies and exposure-based skills. Parents described planned, in vivo exposures, such as allowing their child to practice self-management in safe settings. For example, one parent noted, “A lot of my fears have to do with control, so we’ve been trying to do in vivo exposures in a safe setting where, so the one that we’ve been doing is she goes to dance class for two hours…so we’ve been practicing her managing her own diabetes, cause she’s in the care of people that literally don’t have training at all, and so I’ll go to a coffee shop nearby, and just tell her, you know, walk her through the steps like, okay, what is a low number, what is a high number, what do you do when you’re low, what do you do when you’re high…and I think those little in vivo exposures are building up my trust that if I’m not there, then I can trust her”. Parents also described spontaneous exposures to feared scenarios, such as a child experiencing a low glucose event at school. Parents demonstrated a strong understanding of the value of exposure exercises and described the positive impact on their daily life, with one parent noting, “It [exposures] helped me be better at not sitting and staring at his Dexcom all day”. The next most frequently cited themes included the use of talk-backs and identifying cognitive distortions. Parents described the benefit of decreasing personalization when identifying thinking traps, noting that even simply noticing that they were experiencing a cognitive distortion allowed them to step back and think more logically about the situation. Additional quotes are presented in Table 4.
Table 4.
Representative quotes from parent participants during REDCHiP visit 10.
3.2. Coping
Within Coping, we identified themes including self-care, relaxation, mindfulness, celebrating little wins, planning/simplifying, and acceptance. Relaxation was the most frequently described coping skill used. Parents reported using relaxation strategies (e.g., deep breathing) independently and with their children. Parents also reported using planning/simplifying strategies to make unexpected challenges feel more manageable. Additionally, one parent described that practicing acceptance allowed them to stop trying to figure out the exact cause of morning high glucose levels and instead to notice the pattern and decide how to manage the high glucose levels when they happen. Parents also noted that practicing acceptance was helpful when managing worries about the future (Table 4). For instance, one parent reported that “hearing [other families’] struggles at 13, their struggles at 11, their struggles at 18, at going off to college in their 20s, it was just like oh my God it’s never going to end… but just accepting like, that’s in the future and we will cross that bridge when we come to it” was a helpful way to reduce worry about the future.
3.3. Behavioral Parenting Strategies
Parents shared that Behavioral Parenting Strategies were both helpful and challenging to implement. Parents identified active ignoring as a particularly useful strategy and described instances when this was used with T1DM-specific tasks (e.g., whining during site changes) as well as non-T1DM tasks (e.g., disruptive mealtime behaviors). However, many parents identified that, while effective, consistently implementing ignoring was challenging. One parent specifically noted, “I’ve tried it…I want to so bad…but I cannot ignore the whining!”. In addition, parents identified that use of praise and rewards have helped in many ways, including providing praise for selecting site locations and using contingency-based rewards for compliance (Table 4). For example, one parent stated, “Yeah, cause when we started with praise, site changes were like…almost like an hour long and they’re, um, about as fast as I can get the stuff together [now]”.
3.4. Communication/Modeling
When discussing REDCHiP content focused on communication about T1DM and modeling behavior, parents primarily commented on modeling coping skills for their children and noticing an increase in use of these skills after seeing parents implement them. For example, one parent described “she likes to imitate what I do…I’ve been trying to get her to do the relaxation techniques because I think it’s really beneficial”. Occasionally, parents referenced increased communication with other adults, such as spouses or extended family members, to solicit support or to set expectations about T1DM management and family availability.
3.5. Increasing Child Independence
Several parents described an increase in their child’s independence, for example their ability to connect physical sensations with high and low blood glucose and to verbalize and communicate about symptoms. One parent noted, “she’s starting to be able to tell her symptoms a lot more, if she’s high or low… she will say she ’feels weird’… she’s more able to tell how she’s feeling”. Parents reflected on this necessary step in their child’s ability to self-manage T1DM in the future.
3.6. Appreciate REDCHiP Content
Parents often reported a general appreciation for REDCHiP content, noting that participating in the program “completely changed our way of thinking” and helped them better understand their own thinking patterns around T1DM. When themes relating to the process code, Appreciating REDCHiP Content, were identified, parents reported that normalization by other parents was helpful, noting that the sense of solidarity around the stressful experience of parenting a child with T1DM and recognizing that other parents experienced the same thoughts and fears was a validating experience (Table 3).
3.7. Challenges in Applying REDCHiP Strategies
A second process code was identified when parents reported Challenges in Applying REDCHiP Strategies. When parents described difficulties with a particular skill (e.g., acceptance or setting and maintaining limits), or applying a skill consistently, they frequently noted that they were not giving up on the skill, but rather needed additional practice. One parent referred to the experience of skill acquisition as “a marathon, not a sprint”. Common skills that were challenging to implement included the use of active ignoring to manage behavioral problems and utilizing CBT strategies such as in vivo exposures. Some parents noted that they continued to experience fear and worries related to their child’s future, despite the use of REDCHiP strategies. Rarely did parents note that a particular skill did not work for them or indicate having no plans to continue trying in the future (Table 4).
4. Discussion
The current study sought to capture and analyze the voices of participants of a 10-session intervention which targeted HF in parents of young children with T1DM. Through an iterative coding process, we examined quotes from parent participants captured during the final group session (session 10). Analyzing these sessions allowed us to reflect on parent perceptions about active treatment components within the REDCHiP intervention. Themes included specific strategies that parents found to be helpful, whether these were manageable versus challenging to implement, and/or if they would like to try to use or continue to use these strategies in the future.
Our expectations when launching this qualitative review of the final intervention session were that we might identify topics consistently noted to be of less utility or lower preference by participants, allowing us to design a more streamlined intervention in the future; however, this was not the case. While social desirability may have impacted limited negative feedback, overwhelmingly, parents’ reflections on the REDCHiP intervention were positive. Even when the feedback analyzed indicated a lower utility of, or challenge applying, certain strategies, the overall perspective was one of wanting to continue trying to use these strategies, or to implement them in the future. Although universally critical comments surrounding sessions or topics were not identified, it is our hope that the positive feedback provided can be of benefit to not only our team, but also to other clinicians and researchers who target HF. The challenges in implementing new and difficult skills, and caregiver persistence to continue to “do hard things”, can be recognized by facilitators in similar interventions to reinforce engagement and skill acquisition. Recognizing that skills learnt may be more applicable/approachable in the future may be beneficial to reduce perfectionism, discouragement, or other negative emotional experiences for families who have challenges integrating strategies more immediately.
As parent feedback based on our qualitative analysis was overwhelmingly positive, team members who served as REDCHiP facilitators were also consulted and have made informal suggestions for refining the treatment protocol. For example, though each session included a homework assignment, improved integration of goal setting (first introduced as part of session 10) throughout future similar interventions may be warranted. Similarly, the concept of acceptance was not included until session 10, which was perceived positively by both parents (coded with the second highest frequency, see Table 2). This, combined with facilitator feedback, has led our group to consider earlier and more cohesive inclusion of components from acceptance and commitment therapy (ACT) in future iterations of a treatment targeting HF. Finally, as parents identified challenges in implementing behavioral parenting techniques, our group is considering allotting two individual sessions to this topic to allow for more personalized coaching and encouragement to apply these strategies.
Family comments during the final session primarily reflected on their Use of CBT Skills throughout the intervention, and the benefit of these strategies. Parents most often identified learning about and/or using strategies specific to building fear hierarchies and engaging in either planned or spontaneous exposures to be of particular importance. This feedback has led our team to consider the potential need to increase opportunities, or support, for engaging in more exposures during the treatment period to increase competence and efficacy. While these techniques are often incorporated into individual cognitive behavioral therapy for anxiety [19,20,21], many families may not have the ability to engage in individual therapy with providers who are also knowledgeable about T1DM and able to effectively or safely incorporate T1DM-specific exposures into treatment. The perceived benefit of exposure-based content in this intervention can guide future interventions specific to HF. Other areas that appear to be important to include in future treatment of HF include reviewing coping skills and strategies, teaching behavioral parenting techniques, discussing modeling/communication of learnt skills to others, and supporting families in increasing child independence in T1DM skills. Anecdotally, several families asked for recommendations on how to find individual therapy providers for themselves during/after participating in the REDCHiP intervention, further highlighting the perceived benefit of, and interest in, continuing to work on integrating treatment components.
Some topics from the intervention were less commonly reflected on by participants. Specifically, Communication and Modeling and Increasing Child Independence were infrequently discussed and may have been less salient topics from the REDCHiP intervention. Given the age of the children included in this study (2–7 years old), it is possible that strategies discussed throughout the intervention from these two domains may have been more related to precursor behaviors and scaffolded skills, rather than skills being modeled to/independently performed by the young children with T1DM. Additionally, with regards to communication, while some families had multiple caregivers participating together, the majority of participants (mothers) attended individually. It is possible that these participants were the primary caregivers and/or mostly responsible for child T1DM management, and thus, communication with others was not perceived to be as relevant when compared to other session topics. Future interventions may benefit from working with parent stakeholders of very young children to better understand the importance of these topics, and how to integrate them.
Of note, some constructive feedback during session 10 indicated an interest in the intervention being offered to families closer to diagnosis, which is consistent with prior work [22]. However, other parents noted the potential challenge with offering the intervention earlier given the steep learning curve and distress often felt in the time immediately following T1DM diagnosis, which might make participating in a similar intervention challenging. Participants also reflected on the benefit of group meetings, the opportunity for shared experiences, tips and tricks, and being with others who “truly get it”. Despite this perceived benefit, challenges with group attendance were consistent, even when taking participant availability into account when designing the groups and offering flexible group times, including in evenings. It is challenging to identify the ideal/preferred structure for interventions that balance individual therapeutic support, psychoeducation, and the benefits of group participation. Future interventions might benefit from exploring ways to increase scalability, for example with hybrid live/recorded content and asynchronous communications via a social media tool, which may allow for group sessions to still be prioritized, while also allowing individuals to access other materials and treatment content on their own time.
We acknowledge a few limitations in this work. First, as noted previously, we acknowledge the possibility of social desirability bias which may have reduced parents’ willingness to openly share negative feedback about REDCHiP in a group setting. Second, because group leaders gave prompts throughout session 10 that included “pop quiz” style questions about what participants remembered, direct questions about what participants did or did not appreciate, and asked for suggestions for future interventions, we acknowledge that this may have led to less spontaneous opportunities for feedback. Third, we acknowledge that our qualitative data were collected from families who persisted in the REDCHiP treatment through session 10, and therefore we are missing additional constructive feedback from parents who left the treatment early.
In conclusion, reviewing session 10 of our intervention allowed us to examine participant understanding of concepts, use of strategies, and recommendations for future treatments. Key takeaways include the following: (1) There were salient aspects of CBT that resonated with parents of young children with T1DM, including both general information about the cognitive triangle, cognitive distortions, using a fear hierarchy, relaxation, and coping, as well as when moving beyond general and into the specific application of CBT to disease-specific needs such as HF. (2) When moving into the refining phase of the ORBIT model, current analyses indicate that, for this particular intervention, cutting content may not be easy, as parents seemed to appreciate most of it; however, trialing ways to implement this content in other formats to increase accessibility and dissemination appear warranted. It is our hope that examining parents’ reflections about active treatment components and our thematic coding can inform future behavioral and psychological interventions for HF, including revisions to REDCHiP and exploring ways increase access to REDCHiP content and uptake of the intervention in clinic settings.
Author Contributions
Conceptualization, N.A.K., S.R.P. and M.S.C.; methodology, N.A.K., S.R.P. and M.S.C.; formal analysis, N.A.K., S.R.P. and M.S.C.; data curation, N.A.K., S.R.P. and M.S.C.; writing—original draft preparation, N.A.K., S.R.P. and M.S.C.; writing—review and editing, M.A.C., K.A.D., A.I.M. and H.K.O.; project administration, A.I.M. and S.R.P.; funding acquisition, S.R.P. All authors have read and agreed to the published version of the manuscript.
Funding
This research was funded by the National Institute of Diabetes and Digestive and Kidney Diseases grant 1R01DK118514 (principal investigator S.R.P.) Clinical trial reg. No NCT3914547, clinicaltrials.gov.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Children’s Mercy Hospital and Clinics (STUDY00000545, 17 June 2019).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
Upon request, the authors will make raw data supporting the conclusions of this article available. The authors will consider requests to access the datasets on a case-by-case basis and subject to review and approval by the appropriate ethics board.
Acknowledgments
We thank the families who participated in this study. We thank Paige Trojanowski, Ashlee Ernst, Alicia Pardon, Cheyenne Renolds, and Sara Wetter for their assistance in leading REDCHiP treatment sessions.
Conflicts of Interest
M.A.C. receives consulting fees from Glooko and has research support from Dexcom and Abbott Diabetes Care that is unrelated to this project. The remaining authors report no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
Abbreviations
The following abbreviations are used in this manuscript:
| T1DM | Type 1 Diabetes Mellitus |
| HF | Hypoglycemia fear |
| REDCHiP | Reducing Emotional Distress for Childhood Hypoglycemia in Parents |
| ORBIT | Obesity-Related Behavioral Intervention Trials |
| CBT | Cognitive Behavioral Therapy |
| US | United States |
| ACT | Acceptance and Commitment Therapy |
References
- Lawrence, J.M.; Divers, J.; Isom, S.; Saydah, S.; Imperatore, G.; Pihoker, C.; Marcovina, S.M.; Mayer-Davis, E.J.; Hamman, R.F.; Dolan, L.; et al. Trends in Prevalence of Type 1 and Type 2 Diabetes in Children and Adolescents in the US, 2001–2017. JAMA 2021, 326, 717–727. [Google Scholar] [CrossRef]
- American Diabetes Association Professional Practice Committee 14. Children and Adolescents: Standards of Care in Diabetes—2025. Diabetes Care 2024, 48, S283–S305. [Google Scholar] [CrossRef]
- Shalitin, S.; Phillip, M. Hypoglycemia in Type 1 Diabetes. Diabetes Care 2008, 31, S121–S124. [Google Scholar] [CrossRef] [PubMed]
- Streisand, R.; Monaghan, M. Young Children with Type 1 Diabetes: Challenges, Research, and Future Directions. Curr. Diabetes Rep. 2014, 14, 520. [Google Scholar] [CrossRef]
- McCrimmon, R.J.; Sherwin, R.S. Hypoglycemia in Type 1 Diabetes. Diabetes 2010, 59, 2333–2339. [Google Scholar] [CrossRef]
- Kimbell, B.; Lawton, J.; Boughton, C.; Hovorka, R.; Rankin, D. Parents’ Experiences of Caring for a Young Child with Type 1 Diabetes: A Systematic Review and Synthesis of Qualitative Evidence. BMC Pediatr. 2021, 21, 160. [Google Scholar] [CrossRef]
- Streisand, R.; Swift, E.; Wickmark, T.; Chen, R.; Holmes, C.S. Pediatric Parenting Stress Among Parents of Children with Type 1 Diabetes: The Role of Self-Efficacy, Responsibility, and Fear. J. Pediatr. Psychol. 2005, 30, 513–521. [Google Scholar] [CrossRef]
- Patton, S.R.; Dolan, L.M.; Henry, R.; Powers, S.W. Fear of Hypoglycemia in Parents of Young Children with Type 1 Diabetes Mellitus. J. Clin. Psychol. Med. Settings 2008, 15, 252–259. [Google Scholar] [CrossRef]
- Driscoll, K.A.; Raymond, J.; Naranjo, D.; Patton, S.R. Fear of Hypoglycemia in Children and Adolescents and Their Parents with Type 1 Diabetes. Curr. Diabetes Rep. 2016, 16, 77. [Google Scholar] [CrossRef]
- Shepard, J.A.; Vajda, K.; Nyer, M.; Clarke, W.; Gonder-Frederick, L. Understanding the Construct of Fear of Hypoglycemia in Pediatric Type 1 Diabetes. J. Pediatr. Psychol. 2014, 39, 1115–1125. [Google Scholar] [CrossRef]
- Verbeeten, K.C.; Perez Trejo, M.E.; Tang, K.; Chan, J.; Courtney, J.M.; Bradley, B.J.; McAssey, K.; Clarson, C.; Kirsch, S.; Curtis, J.R.; et al. Fear of Hypoglycemia in Children with Type 1 Diabetes and Their Parents: Effect of Pump Therapy and Continuous Glucose Monitoring with Option of Low Glucose Suspend in the CGM TIME Trial. Pediatr. Diabetes 2021, 22, 288–293. [Google Scholar] [CrossRef]
- Van Name, M.A.; Hilliard, M.E.; Boyle, C.T.; Miller, K.M.; DeSalvo, D.J.; Anderson, B.J.; Laffel, L.M.; Woerner, S.E.; DiMeglio, L.A.; Tamborlane, W.V. Nighttime Is the Worst Time: Parental Fear of Hypoglycemia in Young Children with Type 1 Diabetes. Pediatr. Diabetes 2018, 19, 114–120. [Google Scholar] [CrossRef] [PubMed]
- Haugstvedt, A.; Wentzel-Larsen, T.; Graue, M.; Søvik, O.; Rokne, B. Fear of Hypoglycaemia in Mothers and Fathers of Children with Type 1 Diabetes Is Associated with Poor Glycaemic Control and Parental Emotional Distress: A Population-Based Study. Diabet. Med. 2010, 27, 72–78. [Google Scholar] [CrossRef]
- Patton, S.R.; Dolan, L.M.; Henry, R.; Powers, S.W. Parental Fear of Hypoglycemia: Young Children Treated with Continuous Subcutaneous Insulin Infusion. Pediatr. Diabetes 2007, 8, 362–368. [Google Scholar] [CrossRef] [PubMed]
- Lind, M.; Odén, A.; Fahlén, M.; Eliasson, B. The Shape of the Metabolic Memory of HbA1c: Re-Analysing the DCCT with Respect to Time-Dependent Effects. Diabetologia 2010, 53, 1093–1098. [Google Scholar] [CrossRef]
- Lachin, J.M.; Nathan, D.M.; DCCT/EDIC Research Group. Understanding Metabolic Memory: The Prolonged Influence of Glycemia During the Diabetes Control and Complications Trial (DCCT) on Future Risks of Complications During the Study of the Epidemiology of Diabetes Interventions and Complications (EDIC). Diabetes Care 2021, 44, 2216–2224. [Google Scholar] [CrossRef] [PubMed]
- Czajkowski, S.M.; Powell, L.H.; Adler, N.; Naar-King, S.; Reynolds, K.D.; Hunter, C.M.; Laraia, B.; Olster, D.H.; Perna, F.M.; Peterson, J.C.; et al. From Ideas to Efficacy: The ORBIT Model for Developing Behavioral Treatments for Chronic Diseases. Health Psychol. 2015, 34, 971–982. [Google Scholar] [CrossRef]
- Patton, S.R.; McConville, A.; Marker, A.M.; Monzon, A.D.; Driscoll, K.A.; Clements, M.A. Reducing Emotional Distress for Childhood Hypoglycemia in Parents (REDCHiP): Protocol for a Randomized Clinical Trial to Test a Video-Based Telehealth Intervention. JMIR Res. Protoc. 2020, 9, e17877. [Google Scholar] [CrossRef]
- Martyn-Nemeth, P.; Duffecy, J.; Quinn, L.; Park, C.; Mihailescu, D.; Penckofer, S. A Cognitive Behavioral Therapy Intervention to Reduce Fear of Hypoglycemia in Young Adults with Type 1 Diabetes (FREE): Study Protocol for a Randomized Controlled Trial. Trials 2019, 20, 796. [Google Scholar] [CrossRef]
- Cox, D.J.; Gonder-Frederick, L.; Polonsky, W.; Schlundt, D.; Kovatchev, B.; Clarke, W. Blood Glucose Awareness Training (BGAT-2): Long-Term Benefits. Diabetes Care 2001, 24, 637–642. [Google Scholar] [CrossRef]
- O’Donnell, H.K.; Berget, C.; Wooldridge, J.S.; Driscoll, K.A. Graduated Exposure to Treat Fear of Hypoglycemia in a Young Adult with Type 1 Diabetes: A Case Study. Pediatr. Diabetes 2019, 20, 113–118. [Google Scholar] [CrossRef] [PubMed]
- Marker, A.M.; Monzon, A.D.; Goggin, K.; Clements, M.A.; Patton, S.R. Parent Perspectives on Educational and Psychosocial Intervention for Recent-Onset Type 1 Diabetes in Their School-Age Child: A Qualitative Study. Diabetes Spectr. 2021, 34, 166–174. [Google Scholar] [CrossRef] [PubMed]
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).