Alison L. Miller, Ph.D. - US grants

[unreadable] DESCRIPTION (provided by applicant): This Mentored Research Scientist Award (K01) will enable the candidate, a developmental psychologist, to become an independent researcher in developmental psychopathology, with a focus on emotion processing in low-income children and families. Career goals are to explain how emotional competence relates to readiness for school and to identify factors that influence the development of emotional competence in this underserved population, with an emphasis on implications for prevention. Research goals are to describe emotional competence in low-income preschool and kindergarten-age children during the transition to school and to examine whether preschool emotional competence predicts kindergarten school readiness, including social competence, mental health functioning (internalizing and externalizing behavior), academic knowledge and school skills. The proposed short-term longitudinal study involves assessing 120 low-income preschool children's emotional competence via teacher reports of emotion regulation, interview assessments of child emotion knowledge and understanding, and live observations of emotional expression, regulation, and social engagement in Head Start classroom settings. School readiness will be assessed in a multi-method, multi-informant follow-up after children transition to kindergarten. The candidate will complete rigorous training with Ronald Seller, Ph.D., an expert in developmental psychopathology research, and co-mentors with expertise in emotional competence (Susanne Denham, Ph.D.), low-income children's school readiness (David Arnold, Ph.D.), and clinical implications of such work (Susan Dickstein, Ph.D.). Training goals are to learn new statistical skills (e.g., Hierarchical Linear Modeling); gain expertise both in designing longitudinal studies with high-risk children and families and in conducting methodologically intensive research in school settings; and acquire technical training in observational research (from Roger Bakeman, Ph.D., Deborah Capaldi, Ph.D., and Carroll Izard, Ph.D.). With such specialized training, the candidate will be prepared in future research to test a comprehensive developmental model of emotional competence, examining family influences and using sophisticated methods (e.g., microanalytic analyses) to investigate the significance of individual differences in emotional competence for low-income children's mental health and school readiness. [unreadable] [unreadable]

DESCRIPTION (provided by applicant): This revised proposal, Developing Locally-Tailored Prevention Programming for Children of Incarcerated Mothers, uses a community-based participatory research (CBPR) approach to tailor and deliver an existing selective prevention program (Kumpfer's Strengthening Families Program) to promote mental health and prevent behavior disorders among 5- to 11-year-old children whose mothers have been incarcerated. Children of incarcerated mothers are at very high risk for mental health problems, academic failure, and future criminal offenses, which are both individual and public health problems given that the number of such children is estimated as over 200,000 and increasing rapidly (Bureau of Justice, 2005). Existing evidence-based interventions do not specifically address the children's unique needs, or the needs of the overburdened and often ill- prepared caregivers responsible for the children whose mothers are incarcerated. Locally tailoring empirically-based interventions based on community and participant input has been suggested as a promising direction for prevention research, and may be the best way to help hard-to-reach families like these because families are more likely to be engaged and participate when the program is culturally accepted and responds to community needs (Kumpfer et al. 2002a). The University of Michigan School of Public Health and the Prevention Research Center of Michigan (PRC/MI) have formed a partnership with Motherly Intercession, a community-based organization in Flint, Michigan that serves children of incarcerated mothers and their caregivers, with the goal of using CPBR methods to adapt this model prevention program to address the needs of this population, and implement and evaluate the program in a community setting. This project is a collaborative effort whereby community and university partners have contributed to and will continue to inform the planning, design, writing, and budget plan of the project. Goals for the R21 period are to locally tailor and implement the Strengthening Families Program (SFP) to meet community needs. We will: 1) use focus groups to solicit caregiver concerns and issues about family and child needs, and tailor SFP to incorporate concerns of families with an incarcerated mother;2) build our community partner's organizational capacity to implement and sustain the adapted intervention and participate in research by forming a community advisory board, training local staff, and building data management systems;and 3) deliver and evaluate effects of the adapted intervention on child and caregiver mental health outcomes in a pilot randomized controlled trial (RCT). We will collect process data to document our adaptation methods and to inform implementation strategies for delivering the locally-adapted program on a larger scale.

DESCRIPTION (provided by applicant): Poor biobehavioral self-regulation likely contributes to a number of unhealthy behaviors as individuals seek and consume substances that improve self-regulation at a neurobiological level. Poor self-regulation begins very early in the lifespan, at a time when food is the only accessible substance with biological properties that aid the individual's ability to self-regulate. Children with poor self-regulation may therefore be more likely to tantrum for food, overeat and become overweight. There have been no studies to date integrating knowledge of biobehavioral self-regulation with eating behavior, dietary intake and weight status in early childhood. The study team was awarded a Challenge Grant in 2009 to examine some of these associations in low-income 3- to 5-year-olds, and the preliminary results of this project already demonstrate robust associations between aberrant diurnal salivary cortisol patterns, food-related tantrums, and overweight, beginning at age 36 months. In this low-income population, 40 percent of the children are already overweight by age 36 months, and a significant increase in overweight prevalence seems to occur around age 24 months. This application, therefore, proposes to collect measures of salivary cortisol and alpha amylase, self-regulation, eating behavior, diet, and anthropometry from 250 low-income children longitudinally at ages 21, 27, and 33 months. The study will provide more in-depth measures of these constructs from a younger cohort than has ever previously been studied, and in the low-income demographic that is at very high risk for both poor biobehavioral self-regulation and obesity. Structural equation modeling will be used to examine these potential associations. The aims are to examine, among low-income toddlers longitudinally: (1) the relative contributions of food-related self-regulation, non-food related self-regulation, and salivary cortisol and alpha amylase to preference for comfort foods, emotional eating behavior, and weight status, and to determine if these relationships differ across ages 21, 27, and 33 months; (2) relationships between biobehavioral markers of self-regulation at 21 months with changes in weight status between 21 and 33 months, mediated by preference for comfort foods and emotional eating; (3) trajectories of the development of behavioral self-regulation, and to determine if these trajectories are associated with differences in preference for comfort foods, emotional eating behavior, and weight status at 33 months, independent of physiological markers of self-regulation at baseline. The results of this study will have implications for understanding biobehavioral mechanisms of excessive weight gain in toddlerhood, and thereby potentially contribute to more effective, novel, targeted prevention approaches. The results will also improve the understanding of contributors to health disparities based on socioeconomic status and may also have broad implications for the prevention of a wide range of unhealthy behaviors associated with difficulties with biobehavioral self-regulation. PUBLIC HEALTH RELEVANCE: Poor biobehavioral self-regulation is believed to contribute to a number of unhealthy behaviors, including overeating and the development of obesity. Improved understanding of the development of associations between biobehavioral self-regulation, eating behavior, and excessive weight gain beginning in the toddler years may hold promise for novel targets for obesity prevention. Given that obesity and struggles with biobehavioral self-regulation are both more common among low-income children, the work may also hold particular promise for addressing socioeconomic disparities in obesity prevalence. In addition, overeating in toddlerhood may provide an important and unprecedented model for the early development of biobehavioral self-regulation contributing to a range of unhealthy behaviors. The results could therefore be broadly applicable to more effective prevention of other unhealthy behaviors such as substance abuse.

DESCRIPTION (provided by applicant): Low-income children are significantly more likely to be obese, experience chronic stress, and have difficulty self-regulating their emotions and behavior in response to stress. Socioeconomic disparities in obesity begin in early childhood and track throughout the lifespan, but the etiology of such differences is unclear. One way that stress is hypothesized to "get under the skin" is via changes in the hypothalamic-pituitary-adrenal (HPA), or "stress" axis and patterns of cortisol secretion. Under conditions of chronic stress, such as poverty, aberrations in both the normal diurnal pattern of cortisol secretion and cortisol reactivity to stress occur. Obese, compared to non-obese, adults often show such aberrations. Young children living in poverty can also often demonstrate aberrant patterns of cortisol secretion in response to stress;yet, no study has examined links between stress, cortisol, self-regulation, and obesity in low-income children. Studying how the cycle of poverty, stress, and obesity begins early in life is vital, because once established, obesity typically persists. We propose to build on our existing Challenge Grant parent study of diurnal cortisol patterns, eating behavior and obesity in Head Start children (NIH 1RC1DK086376-01, Cortisol and Eating Behavior in Low-Income Preschool-Aged Children, Principal Investigator Lumeng) to investigate associations between poor emotional and behavioral self-regulation and increased obesity risk. We will specifically examine aberrant patterns of cortisol reactivity to stress as a mediator of such associations in this unique cohort of young, low-income children. We are an interdisciplinary team that studies biologic, psychological, and behavioral processes in order to examine the complex relationships among stress, cortisol, self-regulation, and obesity. Improved understanding of associations between self-regulation and obesity in low-income preschool-aged children will provide new points for targeted obesity prevention and intervention programs for young children that focus on self-regulatory skills. Structural equation modeling will be used to examine potential associations. Specific aims are, among 250 low-income 3- to 5-year old children: Aim 1: Examine the association between self-regulation and child body mass index (BMI) z-score. Aim 2: Examine the association between patterns of cortisol reactivity to stress and child BMI z-score. Aim 3: Examine cortisol stress reactivity patterns as a mediator of the association between self-regulation and child BMI z-score. Aim 4: Examine change in BMI z-score (over 18 months) in relation to these variables, and to predictors from our Challenge Grant parent study (e.g., diurnal salivary cortisol pattern, comfort food intake, emotional eating). Study results will have implications for understanding mechanisms of self-regulation, stress, cortisol, and obesity in young children in relation to the early emergence of health disparities. PUBLIC HEALTH RELEVANCE: Socioeconomic disparities in obesity begin in early childhood and track throughout the lifespan, but the etiology of such differences is unclear. Aberrations in the hypothalamic-pituitary-adrenal (HPA), or "stress" axis, and cortisol production in response to stress is suggested as one way for stress to "get under the skin" and lead to adverse health outcomes such as obesity in chronically stressed, impoverished populations. Altered cortisol patterns are also seen in children with emotional and behavioral self-regulation difficulties. We will examine associations between poor self-regulation and increased obesity risk, and test whether cortisol reactivity to stress mediates such associations, in a sample of 250 low-income preschool-aged children. Results have implications for understanding mechanisms of self-regulation, stress, and obesity in young children, and how early health disparities may arise.

DESCRIPTION (provided by applicant): Highly stressed and impoverished populations are more likely to be obese, and ultimately more likely to develop obesity-associated comorbidities. Preventing these adverse health outcomes relies on preventing the development of obesity early in the life span, since obesity, once established, tends to persist and prevention is more effective than treatment. Preventing obesity is highly urgent for low-income children, since obesity is common early on in this demographic and may contribute to substantial health disparities later in life. Current prevention programs have limited effectiveness, and novel targets for intervention are needed. The association between stress and eating behavior is one potential novel target. Our research program focuses on links between stress, eating behavior, and obesity in low-income children. Our preliminary findings suggest that, in early childhood, patterns of cortisol secretion reflecting chronic stress may promote eating in the absence of hunger, reduced satiety responsiveness, and tantrums over food; these eating behaviors, in turn, may lead to obesity. This early work has made clear, however, that the pathways linking stress to obesity via eating behavior are complex and multifactorial, and involve biologic and behavioral pathways. To date we have examined only a subset of eating behaviors that could mediate links between stress and obesity. Other mechanisms that may be affected by stress, such as high sensitivity to food as a reward or poor ability to delay gratification for food, have not been examined in this model. How such eating behaviors may cluster and develop over time, how different aspects of stress (i.e., chronic vs. immediate stressors) relate to these behaviors, and how genotypes may moderate such associations remains unknown. We propose to examine how these processes may be driven by stress, and ultimately lead to obesity in children. This application is submitted in response to RFA- HL-12-037: Mechanistic Pathways Linking Psychosocial Stress and Behavior with the goal of providing a deeper understanding of the psychological and bio-behavioral processes that connect psychosocial stress with eating behaviors and ultimately obesity. The aims are: Aim 1: To examine the cross-sectional relationship of psychosocial stress (chronic and immediate stress) with obesity-promoting eating behaviors (including satiety responsiveness, reinforcing value of food, and the ability to delay gratification for food) and body mass index (BMI) z-score at age 7 years among low-income children. Aim 2: To test genetic moderators of stress-eating behavior links in our cohort of low-income children. Aim 3: To examine longitudinal associations of chronic stress and reactivity to stress early in life (age 3 years) with changes in obesity-promoting eating behaviors between ages 3 and 7 years. Improved understanding of the development of associations of psychosocial stress during early life with specific, well-phenotyped eating behaviors and excessive weight gain beginning in childhood may hold promise for novel obesity prevention efforts among low-income children, a demographic group at high risk.

? DESCRIPTION (provided by applicant): Childhood obesity is a significant public health problem with 17% of US children being overweight or obese. Once established, obesity tracks into later childhood and adulthood. Parents are vital in shaping child eating behavior, dietary intake, and ultimately obesity risk. Research implicates family mealtimes as important for child obesity prevention and development of healthy eating habits, but findings are not consistent. One reason for the inconsistent associations may be that a substantial proportion of parent-child interactions around food occur outside the mealtime context and have historically been unmeasured. Eating outside of mealtimes, particularly snacking after school hours has increased in recent years and is proposed as contributing to excessive child weight gain and a potentially important context for child socialization around food and eating. Yet, little is known about: 1) naturalistic parent-child interactions around food (i.e., food parenting) outside of mealtimes; 2) how child factors (e.g., persistence in requesting snacks) may contribute; or 3) how food interactions outside of mealtimes vary across development. Understanding food talk outside of mealtimes holds promise for future intervention development to prevent childhood obesity. The proposed work would also fill a critical methodological gap, as extant studies rely on parents' self-reported feeding, observed structured laboratory interactions, or family mealtimes. No prior study has observed parent-child food talk between meals in relation to child obesity risk. Leveraging an ongoing cross-sectional study, we propose to analyze naturalistic parent-child interactions around food and eating during after school hours in relation to detailed, multi-method assessments of child eating behavior, dietary intake, and parent feeding style, family mealtime interactions, and child adiposity. We will use discourse-analysis and behavioral-coding approaches to assess the process and content of naturally occurring parent and child talk about food and eating based on audio recordings using the Language Environment Analysis (LENA) system. Our team has pioneered use of this system to study parenting and is uniquely expert in assessing food parenting and child eating behavior. Our aims are, in families with children ages 12-24 months (n=40), 3-5 years (n=40), and 10-13 years (n=60): Aim 1. To assess frequency, discourse features, and emotional tone of naturalistic parent-child interactions involving food or eating outside of mealtime (food talk), and whether these differ by age. Aim 2. To assess whether food talk is associated with parent-reported child eating behaviors and child dietary intake. Aim 3. To assess whether food talk is associated with parent-reported feeding styles and observed family mealtime interactions. Aim 4. To assess whether food talk is associated with child adiposity indicators (BMIz, skinfolds, and weight status) and with rate of change in BMIz across a six-month period.

? DESCRIPTION (provided by applicant): Poor self-regulation (i.e., inability to harness cognitive, emotional or motivational resources to achieve goals) contributes to a number of unhealthy behaviors across the life course, including overeating, a lack of physical activity, smoking, alcoholism and substance abuse1-12 that are linked to poor long-term health. The self- regulation processes that generate the desire for such substances or that make it difficult t engage in healthy habits are theorized to begin very early in the lifespan. Targeting early self-regulation profiles that signal risk for engaging in unhealthy behaviors would allow more effective intervention. It is thus vital to identify bio- behavioral self-regulation processes thatare 1) evident early in life; 2) associated with behaviors that lead to poor health outcomes; and 3) modifiable. In response to RFA-RM-14-020, Science of Behavior Change: Assay Development and Validation for Self-Regulation Targets, we propose to assess self-regulation during pre-adolescence, a critical transition when children gain responsibility for managing their health choices and self-regulation becomes increasingly associated with health outcomes. Obesity is a complex health issue with early-emerging biological and behavioral precursors that are related to self-regulation; it is a good model for understanding a broad range of health conditions that require active self-management. Childhood obesity is also an ongoing public health crisis, with almost 25% of children overweight by age 4 years (35% by school- age).13 The goal of this proposal is to measure childhood self-regulation targets known to be associated with obesity risk and poor adherence to medical regimens and to assess whether intervening on these mechanisms can improve self-regulation. We propose to do so in a cohort of children with a high rate of obesity who have been extensively phenotyped for bio-behavioral self-regulation and obesity risk factors from early childhood. For the UH2 phase, the Aims are to, in over 250 low-income school-age children from extant ABC cohorts: Aim 1. Field-test measures to assess executive function (cool EF, hot EF, and food-specific hot EF), emotion regulation, and motivation as self-regulation targets relevant for health behavior. Aim 2. Validate measures of the above self-regulation targets against proximal constructs known to be associated with obesity and poor health outcomes (e.g., obesogenic eating behavior, blunted cortisol pattern). Aim 3. Develop and field-test interventions designed to address self-regulation targets using a Multiphase Optimization Strategy (MOST) design to detect intervention effectiveness and child or family factors (e.g., maternal education, family stress) that may moderate intervention effects. For the UH3 phase, the Aims are to, in 94 children drawn from pediatric subspecialty clinics: Aim 4. Test the hypothesis that the interventions developed in Aim 3 enhance self-regulation targets. Aim 5. Explore whether enhancing self-regulation targets predicts general and disease-specific medical regimen adherence (i.e., following weight management recommendations; taking medications).

? DESCRIPTION (provided by applicant): Preschool-aged children are at high risk for obesity; thus, parents play an important role in obesity prevention. Family-based interventions can be effective in reducing childhood obesity risk, particularly when multiple family members work toward the same goal. Despite this, most interventions to treat childhood obesity only focus on one parent, typically the mother. Family systems theory suggests that when family members are unsupportive or undermine treatment goals (e.g., resist healthier diets) the effectiveness of family-based programs for child weight loss is reduced. Maternal, and to a much lesser degree paternal, feeding practices have been linked to childhood obesity. Yet, little is known about how fathers and mothers navigate their joint parenting (i.e., co-parenting) around child feeding. Positive co-parenting (e.g., supporting a spouse's parenting decisions) is associated with better child psychosocial outcomes and health in other domains, yet no studies have examined feeding-related co-parenting in the context of childhood obesity. Further, most food parenting studies consider feeding behaviors during mealtime, with little attention to parenting behaviors around other feeding tasks such as meal planning, grocery shopping, and meal preparation. Given that children who consume more food away from home have a higher risk of obesity and co-parenting efforts may be required to effectively plan and implement meals, this is a notable oversight. Understanding feeding-related co-parenting behaviors and beliefs would allow us to inform the development of family-based interventions that effectively engage fathers and mother in childhood obesity prevention efforts. Extant co-parenting literature has identified three co-parenting styles (cooperative, disengaged, and conflicted); the goal of the proposed work is to identify feeding-related co-parenting styles in mothers and fathers of preschool-aged children, considering the extent to which both parents are engaged in feeding tasks (dyadic engagement) and how much parents support or disagree with each other regarding child feeding. Prior work suggests that individual parent characteristics (e.g., family of origin experience) are associated with co-parenting and that discrepancies in spouses' characteristics and attitudes are associated with poorer co-parenting. It is unknown how such parent characteristics may relate to feeding-related co-parenting. The proposed study will use qualitative methods to identify feeding-related co-parenting styles and correlates in fathers and mothers of children between 3 and 5 years of age. AIM 1: To identify feeding-related co-parenting themes in fathers and mothers of preschool-age children using focus group methods. AIM 2: To identify feeding-related co-parenting typologies in fathers and mothers of preschool-age children using individual semi-structured interview methods. AIM 3: To examine individual differences (parents' own weight status, child eating behavior, and parent feeding style) in relation to feeding-related co-parenting typologies.

? DESCRIPTION (provided by applicant): The prevalence of childhood obesity remains high, and low-income children are at high risk. Children's abilities to self-regulate their intake of foo based on internal cues of hunger and satiety are a focus of interventions that encourage parents to recognize child satiety cues, with the idea that failure to respond appropriately to such cues may override children's ability to self-regulate intake. Yet, the specific child satiety signaling behaviors that may prompt parents to recognize satiety during naturalistic mealtimes are not well-articulated, as prior research on child satiety has primarily utilized either parents' reportsof children's general satiety responsiveness or experimental techniques to assess satiety in laboratory settings. Tools to help parents detect mealtime satiety signals are needed. Despite significant work on observed behavioral indicators of hunger and satiety during infancy, little is known about satiety signaling in older children. Drawing from diverse literatures, we know that children engage in a range of eating behaviors during meals (e.g., slowness in eating, (lack of) food enjoyment, disgust expressions) that could signal satiety. The proposed work seeks to fill the gap in the literature on child satiety and childhood obesity by identifying behavioral indicators of child satiety signaling in the context of naturalistic mealtimes across early to midde childhood (i.e., toddler-age, preschool- age and school-age). We know that parents play an important role in preventing childhood obesity, yet not all parents recognize child satiety responsiveness. Child risk for obesity may be increased when parents are unable to recognize child satiety signals, and children who do not display clear satiety signaling may be at even greater risk. By identifying behavioral indicators of satiety signaling during mealtimes in association with child adiposity, this work has the potential to inform interventions that seek to enhance parents' abilities to identify and respond appropriately to child's satiety signaling durin mealtimes. Leveraging data from multiple longitudinal studies with videotaped naturalistic mealtimes in low-income families, we propose to code theoretically-driven features of child eating behavior that could signal satiety in toddlers (27 months; n=161), preschoolers (M age 5 years; n=271), and school-age children (M age 8 years; n=273). The aims are: Aim 1. To identify observable behavioral indicators of satiety signaling at mealtimes and differences in these indicators across childhood. Aim 2. To test the hypothesis that less observed behavioral satiety signaling is associated with greater concurrent adiposity and prospective increases in child adiposity across a 2-year period. Aim 3. To test the hypothesis that parent-reported child satiety responsiveness moderates the association of observed behavioral satiety signaling and child adiposity such that children at highest risk for excess adiposity are those with either less clear observable behavioral satiety signaling, or those with clear satiety signaling whose parents do not report recognizing the signals.

? DESCRIPTION (provided by applicant): Poor self-regulation (i.e., inability to harness cognitive, emotional or motivational resources to achieve goals) contributes to a number of unhealthy behaviors across the life course, including overeating, a lack of physical activity, smoking, alcoholism and substance abuse1-12 that are linked to poor long-term health. The self- regulation processes that generate the desire for such substances or that make it difficult t engage in healthy habits are theorized to begin very early in the lifespan. Targeting early self-regulation profiles that signal risk for engaging in unhealthy behaviors would allow more effective intervention. It is thus vital to identify bio- behavioral self-regulation processes thatare 1) evident early in life; 2) associated with behaviors that lead to poor health outcomes; and 3) modifiable. In response to RFA-RM-14-020, Science of Behavior Change: Assay Development and Validation for Self-Regulation Targets, we propose to assess self-regulation during pre-adolescence, a critical transition when children gain responsibility for managing their health choices and self-regulation becomes increasingly associated with health outcomes. Obesity is a complex health issue with early-emerging biological and behavioral precursors that are related to self-regulation; it is a good model for understanding a broad range of health conditions that require active self-management. Childhood obesity is also an ongoing public health crisis, with almost 25% of children overweight by age 4 years (35% by school- age).13 The goal of this proposal is to measure childhood self-regulation targets known to be associated with obesity risk and poor adherence to medical regimens and to assess whether intervening on these mechanisms can improve self-regulation. We propose to do so in a cohort of children with a high rate of obesity who have been extensively phenotyped for bio-behavioral self-regulation and obesity risk factors from early childhood. For the UH2 phase, the Aims are to, in over 250 low-income school-age children from extant ABC cohorts: Aim 1. Field-test measures to assess executive function (cool EF, hot EF, and food-specific hot EF), emotion regulation, and motivation as self-regulation targets relevant for health behavior. Aim 2. Validate measures of the above self-regulation targets against proximal constructs known to be associated with obesity and poor health outcomes (e.g., obesogenic eating behavior, blunted cortisol pattern). Aim 3. Develop and field-test interventions designed to address self-regulation targets using a Multiphase Optimization Strategy (MOST) design to detect intervention effectiveness and child or family factors (e.g., maternal education, family stress) that may moderate intervention effects. For the UH3 phase, the Aims are to, in 94 children drawn from pediatric subspecialty clinics: Aim 4. Test the hypothesis that the interventions developed in Aim 3 enhance self-regulation targets. Aim 5. Explore whether enhancing self-regulation targets predicts general and disease-specific medical regimen adherence (i.e., following weight management recommendations; taking medications).

PROJECT SUMMARY Poor self-regulation interferes with individuals' engagement in health maintenance behaviors, including management of type 1 diabetes. However, it is not well understood if parents' self-regulation interferes with their children's engagement in health maintenance behaviors. This proposed supplement to 4UH3HD087979 seeks to expand the work of PIs Miller and Fredericks by providing an opportunity to examine the role of parents' self-regulation in glycemic control and treatment regimen adherence among pre-adolescents and adolescents with type 1 diabetes. While pre-adolescents and adolescents often desire increasing autonomy in their disease management, it is essential that parents remain closely involved by implementing diabetes- specific tasks and providing a low-conflict home environment that supports engagement in health behaviors such as regular physical activity. Poor self-regulation among parents may limit their capacity to provide such support and resources for their children. With the support of this supplement, the study team will: (1) add measures of parents' self-regulation, parent-reported youth SR, and diabetes-relevant family environment characteristics to the baseline assessment of PIs Miller and Frederick's clinical trial of adolescents who have poor type 1 diabetes regulation (N=94), and (2) recruit a new sample of parents of pre-adolescents and adolescents with type 1 diabetes and measure parents' self-regulation and the diabetes-relevant family environment among this sample (N=106). These data from a total sample of 200 mothers will be linked to measures of youth's current glycemic control and recent type 1 diabetes-related health events through the electronic health record, and with the detailed data on adolescents' treatment regimen adherence and health related quality of life collected via the UH3. Together, this information will be used to address the following specific aims: Aim 1. Examine associations between parents' SR and youth T1D outcomes, and Aim 2. Examine how parents' SR is related to key diabetes-relevant family environment characteristics known to support youth T1D treatment adherence and glycemic control. Through an exploratory aim, we will also examine whether parents' baseline self-regulation modifies the effect of the UH3's bundled intervention to improve adolescents' self-regulation on adolescents' treatment regimen adherence. Findings from this study will provide insight into the potential utility of targeting parents' self-regulation, alone or in concert with youth's self-regulation, as a means to improve the health and quality of life among youth with type 1 diabetes.