Initiatives to promote effective self-care skills in children and adolescents with diabetes mellitus

Intensive management of type 1 diabetes mellitus (TIDM) is increasingly becoming the 'ideal' standard of care for pediatric patients at diabetes centers across the world. This 'ideal' standard is based on two landmark studies that documented that keeping blood glucose levels as close to normal as possible and achieving this as early as possible in the disease course helps to prevent or delay the devastating long-term complications of TIDM. Simultaneously, initiatives supplemental to the medical care of young patients with diabetes that are attempting to improve the self-care behavior and glycemic control of young patients with diabetes have been implemented. There is consensus among recent meta-analyses and critical reviews of these interventions that their overall impact on glycemic control is modest to moderate at best. Because of the need for healthcare cost containment and allocation of resources, we have attempted to identify the components of these different initiatives that have the potential to be practical, cost saving, and integrated into the routine clinical care of diabetes. Interventions based on coping-skills training, motivational interviewing, behavioral family systems therapy, and multisysternic therapy models require the expertise of a highly trained mental healthcare professional. Moreover, none of these interventions has yet been implemented or evaluated within the ongoing context of routine ambulatory diabetes care. Finally, each of these interventions requires additional time commitments from young patients with diabetes and their families. The Care Ambassador intervention and programs based on the Family Teamwork intervention do not require highly trained, expensive staff for delivery and have been successfully integrated into routine pediatric diabetes-care settings. Moreover, the Care Ambassador model has also been shown to reduce expensive adverse outcomes across a broad spectrum of youth with diabetes. Finally, telehealth interventions for youth with diabetes may hold great potential as a lower-cost intervention to supplement routine diabetes care and to optimize glycemic control for pediatric patients; however, we await the rigorous evaluation of the application of telehealth interventions across a range of outpatient pediatric diabetes-care settings. Pediatric diabetes care requires an environment of supportive, collaborative communication grounded in realistic expectations for youths. Thus, ongoing evaluations of outcomes of these various interventions are needed within multiple healthcare settings.