Non-adherence to diabetes treatment regimens and less than optimal glycemic control, which have been consistently reported for pediatric patients with type 1 diabetes, puts children and adolescents at potential risk for future health complications (Delamater, 2006
; Helgeson, Honcharuk, Becker, Escobar, & Siminerio, 2011
; Hood, Peterson, Rohan, & Drotar, 2009
). The increased prevalence of non-adherence and problematic self-management are of special concern in adolescents with type 1 diabetes because adolescents assume increasing responsibility for the management of their condition at a time of decreasing parental monitoring that occurs during this developmental transition (Anderson, Ho, Brackett, Finkelstein, & Laffel, 1997
). Problematic self-management for type 1 diabetes and deterioration in glycemic control during adolescence have led to a research focus on the identification of individual differences in risk and protective factors that affect self-management. One such factor is executive functioning. Executive functioning is a multidimensional construct that encompasses the abilities to initiate, plan, organize, and sustain future-oriented problem solving in working memory, as well as the ability to shift cognitive set and modulate emotions and behavior via appropriate inhibitory control (Gioia, Isquith, Guy, & Kenworthy, 2000
). Executive functioning includes two primary domains that measure related, but different, factors. These are behavioral regulation, defined as abilities to inhibit, shift, and sustain emotional control, and metacognition, defined as abilities to initiate, plan, organize, monitor, and working memory (Gioia et al., 2000
The potential clinical relevance of executive functioning to facilitate adolescents’ management of type 1 diabetes stems from the multifaceted demands of diabetes treatment, which requires a range of competencies in executive functioning such as planning, problem solving, monitoring, organizing, as well as ongoing regulation of behavior and emotions to achieve effective insulin management, dietary intake, and exercise (Wing, Epstein, Nowalk, & Lamparski, 1986
). Executive functioning is potentially relevant for diabetes management at various ages but may be particularly crucial during early adolescence when increased self-management for diabetes is required (Bagner, Williams, Geffken, Silverstein, & Storch, 2007
). Young adolescents demonstrate potential vulnerabilities in cognitive capacities that could interfere with their management of the complex tasks involved in diabetes management (Wysocki, 2000
). For example, recent research has described the neurobiological immaturity of younger adolescents in areas that are related to executive functioning, such as the ability to regulate strong emotion (Dahl, 2004
), and increased reward seeking in the presence of peers (Steinberg, 2007
), which could both interfere with diabetes management. For example, adolescents with problematic behavioral regulation might be more likely to get upset if their blood sugar levels are not within the targeted range and may cause them to avoid monitoring their blood sugar levels in the future. Children with less adequate behavioral regulation might also have difficulty inhibiting certain behaviors (e.g., activities with peers) that would interfere with their adherence to treatment. Such data underscore the need for studies of how changes in executive functioning among youth with type 1 diabetes that transition to adolescence relate to changes in their diabetes self-management.
Several studies have found a relation between executive functioning, as measured by the Behavioral Rating Inventory of Executive Functioning (BRIEF) (Gioia et al., 2000
) treatment adherence, and/or self-management in children and adolescents with type 1 diabetes. Bagner et al. (2007)
described a significant relation between overall executive functioning and adherence in a sample of youth (aged 8–19 years) with type 1 diabetes. Graziano et al. (2011)
noted a significant relation among specific measures of executive functioning (e.g., emotional regulation), adherence, and glycemic control for male adolescents (aged 12–18 years). Finally, McNally, Rohan, Pendley, Delamater, & Drotar (2010)
found that a higher level of executive functioning related to diabetes self-management also mediated the effects on glycemic control.
However, all these studies had limitations. The most important limitation was that the cross-sectional designs precluded description of changes in executive functioning over time and limited inferences that could be drawn concerning the impact of changes in executive functioning on diabetes management. Bagner et al. (2007)
included a wide age range (8–19 years) and did not control for age-related differences in executive functioning. Moreover, children on insulin pump therapy were excluded, and glycemic control was not assessed. McNally et al.'s (2010)
study of 9–11-year-olds used only the composite score of the BRIEF. The two subscales of the composite executive functioning score, behavioral regulation and metacognition, which assess different domains of executive functioning, were not analyzed in addition to the global executive functioning score.
To our knowledge, no study has assessed changes in executive functioning including behavioral regulation and metacognition and the relation to changes in diabetes self-management in a relatively homogeneous (by age) sample of youth studied at the onset of adolescence. Early adolescence was chosen as a focus of the study because it is an important time in the development of psychological autonomy and changes in parent–adolescent communication concerning decision making, and illness management (Steinberg & Silverberg, 1986
). Research has indicated that psychological autonomy and diabetes-related autonomy undergo a rapid increase in early adolescence after a period of relative stability during the school-age period (Steinberg & Silverberg, 1986
; Wysocki et al., 1996a
). Young adolescents are also in the process of learning lifelong strategies of health behaviors, including diabetes self-management, which make this an opportune time for preventive intervention (Williams, Holmbeck, & Greenley, 2002
To address these needs, the goals of our study were to (1) describe changes in executive functioning during two years in youth with type 1 diabetes, and (2) document the relation of change in executive functioning to changes in self-management and glycemic control. We studied overall executive functioning, as well as the two separate domains of executive functioning: (1) behavioral regulation (ability to shift cognitive set and moderate emotions and behaviors via emotional control), and (2) metacognition (ability to monitor, initiate, plan, and organize future-oriented problem solving and working memory). We were interested in determining whether these two factors of the multidimensional construct of executive functioning would have comparable relations with self-management and glycemic control.
Our primary hypotheses were that changes in overall executive functioning would predict changes in self-management. Moreover, we expected that the Behavioral Regulation Index and Metacognition Index of the BRIEF would each predict changes in self-management and glycemic control in adolescents with type 1 diabetes. More precisely, we expected that positive changes in behavioral regulation and metacognition would predict positive changes in self-management, which in turn would relate to better glycemic control.