Sarah S. Jaser, Ph.D. - US grants

DESCRIPTION (provided by applicant): Parental depression presents a significant risk for psychopathology in offspring of depressed parents. Early adolescence may be an especially important developmental period to study parent-child interactions in families of depressed parents, as this developmental period is associated with increasing rates for depression and the emergence of a strong gender difference in risk for depression. To better understand the mechanisms underlying this transmission of parental depression, the proposed study will use a global coding system to compare videotaped interactions between depressed mother-child dyads and non-depressed mother-child dyads. Mothers and children will engage in two 15-minute videotaped discussions, one of which will focus on a pleasant activity they have recently shared, and a second around a mutually agreed-upon family stress associated with depression. The interactions will be coded with the Iowa Family Interaction Rating System for individual and dyadic variables in both mothers and adolescents. Associations between the mothers' diagnostic status, [fathers' depressive symtoms, marital conflict,] communication variables, and adolescents' outcomes will be examined. Moreover, the role of stress and coping in the relationship between mothers and adolescents will be examined by looking at associations between communication styles and coping responses, as well as the relationship between coping responses and child functioning. Results of this study will inform future preventive interventions with families to help reduce the incidence of depression and other disorders in adolescent offspring of depressed mothers.

DESCRIPTION (provided by applicant): The goal of this Mentored Patient-Oriented Research Career Development Award (K23) is to understand the risk and protective factors predicting adolescents'adjustment to type 1 diabetes (T1D). Adolescents with T1D are at risk for poor adjustment, including both physiological (i.e., poor metabolic control) and psychosocial outcomes (e.g., depressive symptoms, poor quality of life). The overarching framework guiding this research is the Transactional Stress and Coping Model, which views chronic illness as a potential stressor to which children and families attempt to adapt. Child adjustment is thought to be mediated by child and family adaptational processes and moderated by demographic and illness variables. The proposed study uses a multi-method, prospective approach to examine the effects of three broad categories of risk and protective factors as predictors of adolescents'physiological and psychosocial adjustment to the illness over 12 months: a) Coping Strategies (primary control, secondary control, and disengagement coping);b) Family Functioning (maternal involvement, parent-child conflict);and c) Maternal Adjustment (symptoms of depression and anxiety). The K23 Award will be conducted at Yale University with a multidisciplinary team of mentors, consisting of a primary mentor, Margaret Grey, Dr.PH, RN, and two secondary mentors, William Tamborlane, MD, and Alan Delamater, PhD. Each of these mentors are experts in their respective fields and will be able to provide the applicant with additional instruction and experience in: (1) the pathophysiology of T1D in adolescents;(2) translating the applicant's previous research on risk and protective factors in children and adolescents to longitudinal research in adolescents with T1D;and (3) advanced manuscript and grant writing skills. The acquisition of these skills will prepare the applicant to build a research career focused on developing family-based cognitive-behavioral preventive interventions for children and adolescents at risk for negative psychosocial and physical outcomes, particularly adolescents with chronic pediatric conditions, such as T1D. RELEVANCE (See instructions): This study has the potential to greatly improve the quality of life in adolescents with chronic illness and their families. It is expected that the study to follow will be a pilot and feasibility study of a family-based cognitive-behavioral preventive intervention for adolescents with Tl D and their mothers, focusing on improving adolescents'use of adaptive coping, relieving parents'distress, and promoting the best parenting behaviors. PUBLIC HEALTH RELEVANCE: This study has the potential to greatly improve the quality of life in adolescents with chronic illness and their families. It is expected that the study to follow will be a pilot and feasibility study of a family-based cognitive behavioral preventive intervention for adolescents with Tl D and their mothers, focusing on improving adolescents'use of adaptive coping, relieving parents'distress, and promoting the best parenting behaviors.

DESCRIPTION (provided by applicant): The goal of this Mentored Patient-Oriented Research Career Development Award (K23) is to understand the risk and protective factors predicting adolescents' adjustment to type 1 diabetes (T1D). Adolescents with T1D are at risk for poor adjustment, including both physiological (i.e., poor metabolic control) and psychosocial outcomes (e.g., depressive symptoms, poor quality of life). The overarching framework guiding this research is the Transactional Stress and Coping Model, which views chronic illness as a potential stressor to which children and families attempt to adapt. Child adjustment is thought to be mediated by child and family adaptational processes and moderated by demographic and illness variables. The proposed study uses a multi-method, prospective approach to examine the effects of three broad categories of risk and protective factors as predictors of adolescents' physiological and psychosocial adjustment to the illness over 12 months: a) Coping Strategies (primary control, secondary control, and disengagement coping); b) Family Functioning (maternal involvement, parent-child conflict); and c) Maternal Adjustment (symptoms of depression and anxiety). The K23 Award will be conducted at Yale University with a multidisciplinary team of mentors, consisting of a primary mentor, Margaret Grey, Dr.PH, RN, and two secondary mentors, William Tamborlane, MD, and Alan Delamater, PhD. Each of these mentors are experts in their respective fields and will be able to provide the applicant with additional instruction and experience in: (1) the pathophysiology of T1D in adolescents; (2) translating the applicant's previous research on risk and protective factors in children and adolescents to longitudinal research in adolescents with T1D; and (3) advanced manuscript and grant writing skills. The acquisition of these skills will prepare the applicant to build a research career focused on developing family-based cognitive-behavioral preventive interventions for children and adolescents at risk for negative psychosocial and physical outcomes, particularly adolescents with chronic pediatric conditions, such as T1D. RELEVANCE (See instructions): This study has the potential to greatly improve the quality of life in adolescents with chronic illness and their families. It is expected that the study to follow will be a pilot and feasibility study of a family-based cognitive-behavioral preventive intervention for adolescents with Tl D and their mothers, focusing on improving adolescents' use of adaptive coping, relieving parents' distress, and promoting the best parenting behaviors.

DESCRIPTION (provided by applicant): Problems with adherence in adolescents with type 1 diabetes are common - occurring at rates as high as 93% - and have serious health consequences, including suboptimal glycemic control and risk for later complications. Yet, previous interventions to improve adherence in adolescents with type 1 diabetes have only shown modest to moderate effects, and many have been time-intensive and expensive. Thus, there is a need for novel interventions to improve adherence in adolescents with type 1 diabetes. Increasing positive affect (e.g., feeling happy, cheerful, proud) has been shown to promote adherence to treatment recommendations in adult populations. We propose to develop, revise, and pilot test a positive psychology intervention for adolescents with type 1 diabetes aimed at increasing motivation for adherence. This innovative intervention would induce positive affect in adolescents (age 13-17) through tailored exercises in gratitude, self-affirmation, small gifts, and parent affirmations to promote adherence. Specifically, we aim to increase the frequency of blood glucose monitoring, which is one of the best indicators of adherence and is strongly linked to glycemic control. We will also explore the use of technology, by developing and comparing telephone-administered vs. automated text- messaging versions of the intervention, to determine which mode of delivery is more appealing and convenient for adolescents. The study will be conducted by a multidisciplinary team, consisting of Sarah Jaser, PhD, a pediatric psychologist, and two collaborators, Robin Whittemore, PhD, APRN, a nurse researcher, and Stuart Weinzimer, MD, a pediatric endocrinologist. We believe that this low-cost positive psychology intervention has the potential to increase adolescents' motivation for performing blood glucose monitoring without adding to the burden of treatment management. Results from the proposed study will provide the basis for a large scale randomized clinical trial of the intervention.

Summary Adolescents with type 1 diabetes (T1D) are at increased risk for problems with adherence and suboptimal glycemic control, and novel approaches are needed to improve outcomes in this high-risk population. The majority of adolescents obtain insufficient sleep (defined as <8 hours/night), and in our data, sleep disturbance was significantly associated with poorer adherence and predicted greater problems with quality of life and worse glycemic control. Yet, no interventions have addressed sleep in youth with T1D. Working from a biopsychosocial and contextual model of sleep, we propose to tailor a sleep-promoting intervention to meet the needs of adolescents with T1D by conducting interviews with to identify the barriers and facilitators to adequate sleep specific to this population. We will then develop and pilot test a brief, behavioral sleep-promoting intervention, building on successful interventions in other populations, including components such as limiting caffeine, establishing a media curfew, and positive bedtime routines, while addressing the needs unique to adolescents with T1D, such as fear of hypoglycemia. The study will be conducted by a multidisciplinary team, consisting of Sarah Jaser, PhD, a pediatric psychologist, Beth Malow, MD, MS, a neurologist with specialty in sleep medicine, Cindy Lybarger, MSN, APRN, CDE, a nurse practitioner and certified diabetes educator, and Jill Simmons, MD, a pediatric endocrinologist. Sleep is a potentially modifiable risk factor that may have both a physiological and behavioral impact on diabetes outcomes. Given the strong associations between sleep and diabetes outcomes in our preliminary data, and accumulating evidence indicating the impact of insufficient sleep on insulin sensitivity, behavior, and mood, there is reason to believe that a sleep-promoting intervention has the potential to improve outcomes in adolescents with T1D indirectly by improving self-management and directly through its effect on metabolic function and glycemic control. Therefore, the proposed study offers a novel approach to improve glycemic control, adherence, and quality of life in adolescents with T1D.

Summary Adolescents with type 1 diabetes (T1D) are at increased risk for problems with adherence and suboptimal glycemic control, and novel approaches are needed to improve outcomes in this high-risk population. The majority of adolescents obtain insufficient sleep (defined as <8 hours/night), and in our data, sleep disturbance was significantly associated with poorer adherence and predicted greater problems with quality of life and worse glycemic control. Yet, no interventions have addressed sleep in youth with T1D. Working from a biopsychosocial and contextual model of sleep, we propose to tailor a sleep-promoting intervention to meet the needs of adolescents with T1D by conducting interviews with to identify the barriers and facilitators to adequate sleep specific to this population. We will then develop and pilot test a brief, behavioral sleep-promoting intervention, building on successful interventions in other populations, including components such as limiting caffeine, establishing a media curfew, and positive bedtime routines, while addressing the needs unique to adolescents with T1D, such as fear of hypoglycemia. The study will be conducted by a multidisciplinary team, consisting of Sarah Jaser, PhD, a pediatric psychologist, Beth Malow, MD, MS, a neurologist with specialty in sleep medicine, Cindy Lybarger, MSN, APRN, CDE, a nurse practitioner and certified diabetes educator, and Jill Simmons, MD, a pediatric endocrinologist. Sleep is a potentially modifiable risk factor that may have both a physiological and behavioral impact on diabetes outcomes. Given the strong associations between sleep and diabetes outcomes in our preliminary data, and accumulating evidence indicating the impact of insufficient sleep on insulin sensitivity, behavior, and mood, there is reason to believe that a sleep-promoting intervention has the potential to improve outcomes in adolescents with T1D indirectly by improving self-management and directly through its effect on metabolic function and glycemic control. Therefore, the proposed study offers a novel approach to improve glycemic control, adherence, and quality of life in adolescents with T1D.

ABSTRACT Mothers of adolescents with type 1 diabetes experience high levels of depressive symptoms, which impair their ability to monitor and manage diabetes treatment effectively. Given that adolescents are a high-risk population for suboptimal glycemic control ? with only 17% meeting treatment goals - there is a critical need for novel interventions to improve outcomes in adolescents with T1D. Yet, previous behavioral interventions for youth with diabetes have not directly targeted maternal depressive symptoms. Building on effective interventions to treat depression in adults, and our own pilot work in this population, the proposed study will use a rigorous approach to evaluate the efficacy of a cognitive-behavioral intervention for mothers of adolescents with type 1 diabetes to promote the use of adaptive coping strategies and positive parenting practices. Results from our pilot study indicated significant intervention effects on adolescents? quality of life and depressive symptoms. In addition, adolescents whose mothers received the intervention demonstrated promising improvements in glycemic control, and we found support for the effect of the intervention on mediating variables, with large effects on maternal depressive symptoms and family conflict. The revised aims of this study are to: 1) evaluate the effects of the Communication & Coping intervention on diabetes-related outcomes; 2) evaluate the effects of the Communication & Coping intervention on psychosocial outcomes; and 3) explore the differential impact of the intervention across demographic factors. Mothers who are randomized to the Communication & Coping Intervention will receive individual cognitive-behavioral therapy sessions by phone, as well as access to a Facebook group to augment the material covered in calls and provide social support. Mothers randomized to the Attention Control condition will receive educational materials and phone check-ins, as well as a Facebook group with educational posts. Adolescents and their mothers will be assessed at baseline and again post- intervention, at 3 months, 6 months, and 12 months. We hypothesize that the adolescents of mothers who receive the intervention will demonstrate improvements in diabetes outcomes (i.e., glycemic control, adherence), as well as psychosocial outcomes (i.e., improved quality of life, fewer depressive symptoms) compared to those in the attention control condition. This approach is innovative by targeting maternal depressive symptoms and the quality of parental involvement in mothers of adolescents with type 1 diabetes. Responding to the American Diabetes Association?s call to address the psychosocial needs of people with diabetes and their family members, the proposed project has the potential to improve outcomes in both adolescents with type 1 diabetes and their mothers.

PROJECT SUMMARY Meta-analytic studies have identified small but significant deficits in neurocognitive functioning in children with type 1 diabetes (T1D) compared to their peers without diabetes, especially in the areas of memory, learning, and executive function skills. Further, neuroimaging studies consistently observe differences in brain structures and brain development in children with T1D, particularly brain white matter microstructure. Evidence suggests that factors such as age of onset, diabetic ketoacidosis (DKA) at time of onset, and exposure to chronic hyperglycemia or severe hypoglycemia may increase risk or severity of these deficits but findings are mixed, and many studies were limited by the inclusion of older adolescents or adults with T1D, small samples or cross-sectional designs. Thus, a large prospective study of young children with T1D followed over time with rigorous assessment and follow-up is needed to identify modifiable risk and protective factors for neurocognitive complications in this population. This U34 planning award will provide the time and resources needed to prepare for an observational, longitudinal cohort study of young children with T1D (age 6 to 10 years at enrollment), and a comparison group of children without diabetes. We will establish contracts with other clinical research centers, obtain data needed to develop neuroimaging harmonization plans, and finalize the protocols, including neuroimaging and neurocognitive testing. Our multidisciplinary team includes a pediatric psychologist, a pediatric neurologist, a pediatric endocrinologist, and a pediatric neuroradiologist; experts in imaging science and harmonization of imaging data, as well as a biostatistician experienced in analyses with imaging data, and a researcher using a novel mobile phone-based method to capture child function in real- time, called ecological momentary assessment. The Children's Diabetes Program (CDP) Vanderbilt University Medical Center serves a large, diverse population of children with T1D and has a strong history of multicenter collaborations with other pediatric diabetes centers. The proposed project will assess hypothesized risk factors (age of onset, DKA at presentation and glycemic control), as well as potentially modifiable protective factors (child sleep quality, caregiver distress, and use of diabetes devices). In addition, we will optimize imaging protocols and processing tools to allow for harmonization of neuroimaging data across sites and scanners for the most robust analysis. This project has the potential to influence standards of clinical care for children with T1D and to pinpoint critical periods for prevention and intervention to improve brain health and function.

PROJECT SUMMARY Adolescents with type 1 diabetes (T1D) struggle to meet treatment goals ? only 17% met the target for glycemic control in a recent national study ? and many adolescents experience high levels of diabetes distress related to the daily demands of diabetes care. Yet, previous interventions to improve glycemic control in adolescents with type 1 diabetes have only shown modest to moderate effects, and many have been time- intensive and expensive. Thus, there is a need for novel interventions to improve outcomes in adolescents with T1D. Increasing positive affect, or pleasurable engagement with the environment (e.g., feeling happy, cheerful, proud), has been shown to promote the use of more adaptive coping strategies to manage stress. Thus, the proposed study is based on the premise that, by boosting positive affect in teens with diabetes, we will enhance the use of adaptive coping strategies and reduce diabetes distress, thereby improving glycemic control in adolescents. Through an iterative series of pilot studies, our research team adapted a behavioral intervention using a positive psychology framework that we demonstrated to be feasible and acceptable for adolescents with T1D. This intervention is aimed at inducing positive affect in adolescents (age 13-17) through empirically-validated, tailored exercises in gratitude, self-affirmation, and caregiver affirmations. In our pilot studies, the intervention had promising effects on adolescents' quality of life, diabetes-related stress, and family conflict, all of which are closely linked with diabetes distress. We now plan to evaluate the efficacy of the intervention in a multisite, randomized controlled trial. The aims of this study are to 1) evaluate the effects of a positive psychology intervention for adolescents (age 13-17) and their caregivers on glycemic control; 2) evaluate the effects of the intervention on diabetes distress, coping, and self-care behavior; and 3) explore the differential impact of intervention effects across demographic and treatment variables. We plan to randomize 200 adolescent-caregiver dyads to the Positive Affect + Education intervention (n=100) or the Education only intervention (n=100) from two clinical sites (Vanderbilt University Medical Center and Children's National Medical Center). By employing a positive psychology framework, we propose an innovative approach to treat diabetes distress and improve glycemic outcomes. We believe this novel intervention has the potential to improve outcomes in adolescents with T1D, and the use of automated text messaging to deliver the intervention offers possibilities for wide dissemination.