Type 1 diabetes management can be challenging for children and their families. To address psychosocial concerns for parents of youth with type 1 diabetes, we developed two parent-focused interventions to reduce their diabetes distress and fear of hypoglycemia. Our team conducted several of these interventions during the early stages of the COVID-19 pandemic and recognized a need to make timely adjustments to our interventions. In this viewpoint article, we describe our experience conducting these manualized treatment groups during the pandemic, the range of challenges and concerns specific to COVID-19 that parents expressed, and how we adjusted our approach to better address parents' treatment needs.

Objective: There is a complex and bidirectional relationship between parent/guardian wellbeing and child physical and mental health. The role of a pediatric psychologist in this relationship has historically emphasized working with the parent as an agent of change to disseminate evidence-based skills and techniques toward improving child functioning. Increasingly, the role a pediatric psychologist can play in directly impacting the health and wellbeing of the parent/guardian of the identified patient is being explored, especially with expanded integration of behavioral health into primary care and medical home models that approach child health through a holistic, preventative lens. Furthermore, parents of children with acute/chronic illness are at increased risk of mental health concerns themselves; thus, considering parent functioning as its own outcome when working with pediatric patients may confer additional benefits in optimizing family adjustment. Method: Articles inclusive of topics on screening, early intervention, treatment, and program development targeting the parent/guardian of pediatric patients were considered for this issue. Results: This Special Issue includes 10 articles highlighting novel interventions targeting parent well-being in primary care and medical subspecialty settings using a range of service delivery modalities. Additionally, this issue explores the ethical, logistical, and systems considerations that can pose challenges to responding to parent mental health needs within the pediatric health care system, which pediatric psychology as a field is still learning to negotiate. Conclusions: This issue highlights clinical practice approaches and novel research in which the primary target of intervention is the caregiver of a pediatric patient. Implications for Impact Statement: The aim of this Special Issue is to contribute to the research base for pediatric psychology providers with regards to models and methodology for parent/guardian specific screening and intervention in the pediatric health care system. Ethical issues in addressing caregivers as the primary point of intervention also are explored while promoting a holistic family care model.

Objective: This paper reports on the initial outcomes of a new mHealth intervention to reduce diabetes distress (DD) in families of school-age children living with type 1 diabetes (T1D) entitled, ‘Remedy to Diabetes Distress’ (R2D2). Methods: We randomized 34 families (mean child age = 10 ± 1.4 years; 53% male, 85% White, mean HbA1c = 7.24 ± 0.71%) to one of three delivery arms differing only by number of telehealth visits over a 10-week period: zero visits = self-guided (SG), three visits = enhanced self-guided (ESG), or eight visits = video visits (VV). All families had 24 × 7 access to digital treatment materials for 10 weeks. We examined the feasibility and acceptability of R2D2. We used the Problem Areas in Diabetes-Child (PPAIDC and PAIDC, parent and child, respectively) to examine treatment effects by time and delivery arm. We performed sensitivity analyses to characterize families who responded to R2D2. Results: It was feasible for families to access R2D2 mHealth content independently, though attendance at telehealth visits was variable. Parents and children reported high satisfaction scores. There were significant pre-post reductions in PPAIDC (p = 0.026) and PAIDC (p = 0.026) scores but no differences by delivery arm. There were no differences in child age, sex, race, or pre-treatment HbA1c for responders versus non-responders, though families who responded reported higher PPAID-C scores pre-treatment (p = 0.01) and tended to report shorter diabetes duration (p = 0.08). Conclusions: Initial results support the acceptability and treatment effects of R2D2 regardless of the frequency of adjunctive virtual visits. Characterizing responders may help to identify families who could benefit from R2D2 in the future.

Background: Type 1 diabetes (T1D) management requires following a complex and constant regimen relying on child or caregiver behaviors, skills, and knowledge. Psychological factors such as diabetes distress (DD), depression, and burnout are pertinent considerations in the treatment of pediatric T1D. Approximately 40% of youth and 61% of caregivers experience DD. Implementation of DD screening as part of clinical best practice is recommended and may facilitate treatment referral, perhaps leading to improved health or well-being for youth with T1D and their caregivers. By building on existing institutional infrastructure when available, screening via digital health platforms (applications, or “apps”) may allow for timely screening of, and response to, DD. Objective: This work details the creation, implementation, and refinement of a process to screen for DD in youth and their caregivers in the context of routine T1D care using a digital health platform. Methods: DD screening was implemented in an outpatient endocrinology clinic over 1 year as part of a larger screen-to-treat trial for children aged 8‐12.99 years and their caregivers. Validated measures were sent via digital health platform to be completed prior to the clinic visit. Results were initially reviewed manually, but a digital best practice alert (BPA) was later built to notify staff of elevated scores. Families experiencing DD received resources sent via the digital health platform. For this secondary analysis, child demographics and glycated hemoglobin A_1c (HbA_1c) were collected. Results: During the screening period, absolute completion rates were 36.78% and 38.83%, with adjusted screening rates at 52.02% and 54.48%, for children and caregivers, respectively. A total of 21 children (mean HbA_1c 8.04%, SD 1.39%) and 26 caregivers (child mean HbA_1c 8.04%, SD 1.72%) reported elevated DD. Prior to BPA development, resources were sent to all but 1 family. After BPA implementation, all families were sent resources. Conclusions: Early findings indicate that DD education, screening, and response can be integrated via digital platforms in a freestanding outpatient endocrinology clinic, thereby facilitating timely treatment referral and provision of resources for those identified with distress. Notably, in the observed 1-year screening period, screening rates were low, and barriers to implementation were identified. While some implementation challenges were iteratively addressed, there is a need for future quality improvement initiatives to improve screening rates and the identification of, or response to, DD in our pediatric patients and their families.

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.

Parents of young children with type 1 diabetes (T1D) are vulnerable to experiencing fear of hypoglycemia (FH), an emotional condition that includes persistent and intense worry about hypoglycemia and/or use of unhealthful behaviors to avoid hypoglycemia. Despite greater uptake of continuous glucose monitors (CGMs) and automated insulin delivery systems, FH remains prevalent and under-addressed in parents of young children. As such, we developed Reducing Emotional Distress for Childhood Hypoglycemia in Parents (REDCHiP), a video-based telehealth intervention designed to reduce FH in parents by providing T1D education and teaching parents how to apply evidence-based strategies from cognitive behavioral therapy and behavioral parent training in their child's daily T1D care. This study aimed to compare the REDCHiP intervention to a novel attention control condition (ATTN) to better isolate treatment effects for REDCHiP based on parents' FH and diabetes distress. This was a multisite randomized controlled trial. We enrolled 197 families and randomized 183 to either REDCHiP or ATTN. Both REDCHiP and ATTN parents completed 10 video-based telehealth sessions. Our primary outcome was changes in parental FH; secondary outcomes included changes in parental diabetes distress and children's glycated hemoglobin A1c (HbA1c). We used a series of mixed-effects models and logistic regression to evaluate treatment effects. Parents in REDCHiP and ATTN attended >95% of sessions with high treatment fidelity. FH and diabetes distress decreased significantly over time in both REDCHiP and ATTN. Treatment-slope effects slightly favored REDCHiP but were not statistically significant for FH (P=.09) or distress (P=.06). However, parents receiving REDCHiP were significantly less likely to report clinically elevated diabetes distress over time compared to ATTN (P=.02). Child HbA1c showed a small, nonsignificant reduction over time (P=.06). Parents with elevated depressive symptoms consistently reported higher FH and distress across all time points. REDCHiP demonstrated high feasibility, acceptability, and potential clinical relevance in reducing diabetes distress among parents of young children with T1D. While overall treatment effects were modest, use of an attention control condition represents a meaningful advancement in trial rigor for pediatric behavioral interventions. Future adaptations of REDCHiP may enhance its impact, particularly for parents experiencing comorbid depressive symptoms.