Management and Family Burdens Endorsed by Parents of Youth <7 Years Old With Type 1 Diabetes

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1 721938DSTXXX / Journal of Diabetes Science and TechnologyHarrington et al research-article2017 Original Article Management and Family Burdens Endorsed by Parents of Youth <7 Years Old With Type 1 Diabetes Journal of Diabetes Science and Technology 2017, Vol. 11(5) Diabetes Technology Society Reprints and permissions: sagepub.com/journalspermissions.nav DOI: journals.sagepub.com/home/dst Kara R. Harrington, PhD 1, Claire T. Boyle, MS 2, Kellee M. Miller, PhD 2, Marisa E. Hilliard, PhD 3, Barbara J. Anderson, PhD 3, Michelle Van Name, MD 4, Linda A. DiMeglio, MD, MPH 5, and Lori M. Laffel, MD, MPH 1, for the T1D Exchange Clinic Network Abstract Background: This study investigated unique burdens experienced by parents of young children with type 1 diabetes in the context of contemporary diabetes management. Methods: Self-report surveys and medical record information from the T1D Exchange clinic registry were used. Parental burden and family impact scores were tabulated across demographic and clinical characteristics, overall and according to age group (<4, 4-<6, and 6-<7 years). Results: The mean age of the 597 children was 5.2 ± 1.2 years (n = 111 <4 years, n = <6 years, and n = <7 years) and mean duration of diabetes was 2.4 ± 1.1 years. Mean hemoglobin A1c was 8.2% ± 1.1%. Approximately one-third (31%) reported their child was currently using CGM and over half (58%) reported using insulin pumps. The most frequently endorsed parent-reported burdens of diabetes were worrying about child having a low blood sugar (74%), about the future and possibility of serious complications (70%), and feeling upset when their child s diabetes management is off track (61%). Areas endorsed for negative family impact were diminished amount or quality of sleep for family members (59%) and need for flexible working arrangements to help care for their child (55%). Conclusions: Substantial burdens remain for parents of young children with type 1 diabetes, despite the availability of advanced technologies for diabetes management. Keywords type 1 diabetes, young children, Problem Areas in Diabetes Survey, Family Impact Survey, T1D Exchange Clinic Registry Parents of young children with type 1 diabetes face significant stress and burden. 1,2 A majority, if not all, of diabetes management is the responsibility of the parents, and there are many challenges to diabetes management in children aged 7 and under. Young children are rapidly emerging in the realms of physical, cognitive, social, and emotional development. These changes impact the interaction between children and their caregivers as they navigate diabetes management. In addition, primary caregivers of young children need to trust others with diabetes management responsibilities as the child is introduced to child care and school settings. 3 Each developmental stage of young childhood has unique challenges and issues pertaining to diabetes management. Given this, it is important to consider the experience of parents caring for children with type 1 diabetes at different developmental stages. There is ample evidence that suggests parents of young children with type 1 diabetes experience emotional distress while caring for their child. 4-7 There have been calls for research to refine our knowledge of parental burden and distress to inform the design of interventions for families of young children with type 1 diabetes. 8,9 Parental coping strategies and distress have 1 Joslin Diabetes Center, Boston, MA, USA 2 Jaeb Center for Health Research, Tampa, FL, USA 3 Baylor College of Medicine and Texas Children s Hospital, Houston, TX, USA 4 Yale School of Medicine, New Haven, CT, USA 5 Indiana University School of Medicine, Indianapolis, IN, USA Corresponding Author: Claire T. Boyle, MS, Jaeb Center for Health Research, Amberly Dr, Ste 350, Tampa, FL 33647, USA. T1DStats6@jaeb.org Note: This article has been substantially revised from the original submission, which was published in the OnlineFirst section of JDST in February 2017.

2 Harrington et al 981 implications for treatment adherence, quality of life, and family functioning. Interventions have been developed to help parents cope with caring for young children with type 1 diabetes However, few of these psychosocial interventions have been focused on the adoption of advanced diabetes technology in very young children. Diabetes technologies have improved substantially in the past several decades, with tools such as smart insulin pumps with bolus calculators and continuous glucose monitors (CGMs). Along with these technical advancements come new challenges and possible burdens, especially for young children and their families. For example, it can be difficult for parents to find real estate on their small children s bodies to attach and secure devices, and other caregivers need to be educated on these devices. 15,16 Thus, it is important to ascertain typical burdens and stresses of parents of young children with diabetes in the contemporary diabetes management era. It is also important to understand how the burdens reported by parents are impacted by use or nonuse of different diabetes technologies, as well as by other demographic factors, such as socioeconomic status. The aim of this study was to understand present-day burdens experienced by parents caring for their young child with type 1 diabetes. We investigated the burden reported by families with children in different age groups, toddlers (under 4 years), preschoolers (4-<6 years), and school age children (6-<7 years) to understand the unique burdens and family impacts at different developmental stages. Children in toddlerhood have limited verbal abilities which make it difficult to convey symptoms, preschool children are entering the school environment for the first time, and school age children and their parents need to establish new relationships with caregivers and rely on them more due to the longer days spent at school. All of these factors may have an impact on reported diabetes burdens. We anticipated that parents of young children with type 1 diabetes would report significant burdens and distress, highlighting the need to explore the factors related to burden and distress and ultimately identify approaches to overcome the challenges reported by parents of young children with type 1 diabetes, especially with potential burdens associated with advanced diabetes technologies. Methods The T1D Exchange Clinic Registry (T1D Exchange) includes 74 endocrinology practices based in the United States, including 58 centers serving youth with type 1 diabetes (see Supplemental Materials). To date, over participants have been enrolled in the registry, and details of the enrollment process, eligibility criteria, and baseline data collection have been previously reported. 17 Data were collected for the clinic registry central database from medical records in addition to questionnaires completed by parents of the young children enrolled in the registry. 17 This report includes 597 young children enrolled in the registry since February 1, 2015, aged less than 7 years with a clinical diagnosis of type 1 diabetes for at least 1 year, whose parent/guardian completed the two surveys assessing the main constructs of interest in this study: parental burden and family impact (described below). Demographic, socioeconomic, and diabetes management factors were obtained from parent/guardian questionnaires. Insulin pump and CGM use were reported by parent/guardian and confirmed by clinic report. The most recent hemoglobin A1c (HbA1c) measurement within 6 months prior to registry enrollment (mean duration of HbA1c measurement prior to enrollment was 7 days) was obtained from the clinic medical record. HbA1c values were measured by point-of-care device or local laboratory. Occurrences of diabetic ketoacidosis (DKA) and severe hypoglycemia (SH) during the 3 months prior to enrollment were reported by parent/guardian. DKA was defined by occurrence of ketoacidosis diagnosed by a doctor requiring a visit to hospital, emergency room, or other health care facility. SH was defined as hypoglycemia resulting in seizure or loss of consciousness. The Problem Areas in Diabetes Survey Parent Revised version (PAID-PR) 18 measures the degree of burden experienced by the parents while managing their child with type 1 diabetes. Parents/guardians were asked to rate their agreement with 18 statements regarding the burden of diabetesrelated issues using a 0 (agree) to 4 (disagree) Likert-type scale. Total score for each participant was the mean of all nonmissing responses reversed scored then multiplied by 25 for a total possible score of 100, with higher scores representing higher parental burden. The Family Impact Survey (FIS) 19 measures a different kind of burden, how often diabetes impacted family life in the past year. Parents were asked to rate how often diabetes negatively affected areas such as school, work, finances, and well-being using a 0 (almost never) to 3 (almost always) Likert-type scale, which was scored for each participant as the mean of all nonmissing responses multiplied by 33.3 for a total score out of 100. Higher FIS scores represent more negative impact of diabetes on the family. Parents had the option of selecting not applicable for any of the responses on the FIS. These values were excluded from tabulations and calculations of the total score. Statistical Analyses For both the PAID-PR and FIS, the mean total score was tabulated according to various demographic and clinical characteristics. The amount of burden and the degree of negative family impact for the individual responses to the PAID-PR and FIS surveys were tabulated overall and according to age group (<4, 4-<6, and 6-<7 years), with presentation of percentages of the sample endorsing various burdens or family impacts. The associations between each mean total score and demographic and clinical characteristics were

3 982 Journal of Diabetes Science and Technology 11(5) Table 1. Cohort Characteristics. Overall N = 597 Ages <4 n = 111 Ages 4-<6 n = 291 Ages 6-<7 n = 195 Age in years 5.2 ± ± ± ± 0.3 Child gender female 277 (46%) 51 (46%) 137 (47%) 89 (46%) Race/ethnicity White non-hispanic 446 (76%) 92 (84%) 214 (75%) 140 (74%) Other 138 (24%) 17 (16%) 71 (25%) 50 (26%) Annual household income $75, (52%) 51 (52%) 129 (50%) 94 (56%) Highest level of parent education High school/ged or less 242 (41%) 32 (29%) 130 (46%) 80 (42%) Associate s or bachelor s degree 195 (33%) 48 (44%) 83 (29%) 64 (33%) Master s, professional, or doctorate degree 148 (25%) 29 (27%) 71 (25%) 48 (25%) Duration of diabetes in years 2.4 ± ± ± ± <3 years 450 (75%) 109 (98%) 223 (77%) 118 (61%) 3-<7 years 147 (25%) 2 (2%) 68 (23%) 77 (39%) Frequency of self-monitoring blood glucose per day 7.1 ± ± ± ± times per day 431 (72%) 82 (74%) 209 (72%) 140 (72%) Current continuous glucose monitor user 185 (31%) 44 (40%) 91 (31%) 50 (26%) Current pump user 337 (58%) 71 (65%) 162 (58%) 104 (56%) Most recent HbA1c 8.2 ± ± ± ± 1.2 <7.5% 144 (24%) 25 (23%) 69 (24%) 50 (26%) Occurrence of at least one SH event in the past 3 months a 42 (7%) 4 (4%) 19 (7%) 19 (10%) Occurrence of at least one DKA event in the past 3 months a 31 (5%) 7 (6%) 16 (5%) 8 (4%) GED, general education development; SD, standard deviation. a Occurrence of at least one severe hypoglycemia (SH) event in the past 3 months resulting in seizure or loss of consciousness, and occurrence of at least one diabetic ketoacidosis (DKA) event in the past 3 months. assessed overall and according to age group (<4, 4-<6, and 6-<7 years) using t-tests or the Wilcoxon Rank-Sum procedure (or Kruskal-Wallis if >2 levels) as appropriate. An unadjusted linear regression model was used to determine the association with HbA1c. Data analyses were performed using SAS version 9.4 (2011 SAS Institute Inc, Cary, NC). All s are two-sided, and due to multiple comparisons only s <.01 were considered statistically significant. Results Participant Characteristics The mean age of the 597 children was 5.2 ± 1.2 years (n = 111 <4 years, n = <6 years, and n = <7 years) and mean duration of diabetes was 2.4 ± 1.1 years. Mean HbA1c was 8.2% ± 1.1%. Approximately one-third (31%) were identified as current CGM users and more than half (58%) were using insulin pumps. Additional cohort characteristics are shown in Table 1. Survey Tabulations Figures 1 and 2 show the areas in which parents feel most burdened by or experience high negative family impact from their young child s diabetes for each age group. Overall, most parents reported the largest burden of diabetes related to worrying about their child having a low blood sugar (74%). Other areas in which parents felt most burdened by diabetes involved worrying about the future and the possibility of serious complications for their child (70%), feeling upset when their child s diabetes management is off track (61%), worrying that their child will not be taken care of when away from home (57%), and feeling upset when their child s blood sugars are out of range (54%). Parents felt least burdened about their child being excluded from activities/ events because of diabetes (13%), having difficulty dealing with school staff (12%), their child being deprived regarding food and meals (11%), and feeling discouraged with their child s diabetes treatment plan (5%). Areas in which parents experienced frequent negative family impact were diminished amount or quality of sleep for family members (59%) and the need for flexible working arrangements to help care for their child (55%). Problems with regular school attendance (7%), negative impact of diabetes on school performance (5%), and the inability to participate in activities or trips (5%) were the areas in which parents reported the lowest impact on their family life. Parental Burden Results The mean total PAID score was 45.7 ± 18.9 overall, 46.9 ± 18.6 for parents of children <4 years, 47.0 ± 18.6 for parents of children 4-<6 years, and 43.2 ± 19.4 for parents of children

4 Harrington et al 983 Figure 1. Areas parents report most burden. Solid black bars represent <4 years old. Solid white bars represent 4-<6 years old. Black-and-white striped bars represent 6-<7 years old. Figure 2. Areas parents report greatest negative family impact. Solid black bars represent <4 years old. Solid white bars represent 4-<6 years old. Black-and-white striped bars represent 6-<7 years old. aged 6-<7 years (P =.12, Table 2a). The mean total PAID score was not significantly different between parents of females and parents of males (45.2 ± 17.8 vs 46.2 ± 19.9 for females and males, respectively; P =.50), but when stratified by age group, there was a trend toward lower PAID scores in parents of female toddlers compared with parents of male toddlers (42.7 ± 17.8 vs 50.5 ± 18.6, P =.05; Table 2a). Overall, there was a trend toward higher PAID scores in parents with less education and earning less than $75,000 annually (P =.07 and P =.05, respectively), but this trend was not seen when stratified by age group (Table 2a). A higher PAID score was seen among parents of non-white children overall and in the 6-<7-year age group (p<0.01 for both). Mean total PAID scores did not differ among parents of participants using a pump versus injections for insulin delivery (P =.87) or among CGM users versus nonusers (P =.82) when assessed for the overall cohort or when stratified by age group. No significant difference in mean PAID scores was seen among parents of children achieving glycemic target of HbA1c <7.5% versus HbA1c 7.5% (43.9 ± 17.6 vs 46.5 ± 19.3, P =.51), or who had at least one SH event versus no event (47.5 ± 24.3 vs 45.6 ± 18.5, P =.41). A trend toward higher PAID scores was seen in parents of participants who had at least one DKA event versus no event (52.0 ± 19.7 vs 45.4 ± 18.8, P =.06). Results were similar when stratified by age group. Family Impact Results The mean total FIS score was 27.2 ± 19.2 overall, 29.9 ± 19.8 for parents of children <4 years, 28.0 ± 20.5 for parents of children 4-<6 years, and 24.4 ± 16.4 for parents of children aged 6-<7 years (P =.10, Table 2b). The mean total FIS score was not significantly different between parents of females and parents of males (26.0 ± 17.6 vs 28.2 ± 20.5 for females and males, respectively; P =.41, Table 2b).

5 984 Journal of Diabetes Science and Technology 11(5) Table 2a. Mean Problem Areas in Diabetes (PAID) Score According to Demographic and Clinical Characteristics. Overall, N = 597 Ages <4 years, n = 111 Ages 4-<6 years, n = 291 Ages 6-<7 years, n = 195 Mean PAID score Mean PAID score Mean PAID score Mean PAID score Age in years.12 <4 years old 46.9 ± <6 years old 47.0 ± <7 years old 43.2 ± 19.4 Gender Female 45.2 ± ± ± ± 18.2 Male 46.2 ± ± ± ± 20.1 Race/ethnicity < <.01 White non-hispanic 44.8 ± ± ± ± 18.9 Other 49.0 ± ± ± ± 19.5 Annual household income <$75, ± ± ± ± 20.7 $75, ± ± ± ± 18.7 Highest level of parent education High school/ged or less 47.0 ± ± ± ± 21.6 Associate s or bachelor s degree 46.5 ± ± ± ± 18.0 Master s, professional, or doctorate degree 43.1 ± ± ± ± 16.8 Duration of diabetes in years a <3 years 45.7 ± ± ± ± <7 years 46.0 ± ± ± ± 17.8 Reported frequency of self-monitoring blood glucose per day <6 times per day 43.8 ± ± ± ± times per day 46.5 ± ± ± ± 18.8 Continuous glucose monitor user Yes 46.0 ± ± ± ± 19.0 No 45.6 ± ± ± ± 19.5 Pump user Yes 45.6 ± ± ± ± 17.5 No 45.1 ± ± ± ± 21.8 Most recent HbA1c b <7.5% 43.9 ± ± ± ± % 46.5 ± ± ± ± 20.0 Occurrence of at least one SH event in the past 3 months c,d Yes 47.5 ± 24.3 No 45.6 ± 18.5 Occurrence of at least one DKA event in the past 3 months c,d Yes 52.0 ± 19.7 No 45.4 ± 18.8 GED, general education development; SD, standard deviation. a Comparison of total score according to diabetes duration was not completed for the <4-year age group due to small sample size. b Categories are for display purposes only; the is from analyzing as continuous. c The number of participants with events was too small to perform analyses stratified by age. d Occurrence of at least one severe hypoglycemia (SH) event in the past 3 months resulting in seizure or loss of consciousness, and occurrence of at least one diabetic ketoacidosis (DKA) event in the past 3 months. A trend toward higher family impact of diabetes among households earning <$75,000 annually was seen overall (P =.09) and in the 6-<7-year age group (P =.06) (Table 2b). No differences were seen with regards to race/ethnicity or parental education. There was a trend toward higher total FIS score among both parents of children using a CGM compared to non- CGM users (29.3 ± 18.3 vs 26.2 ± 19.6, P =.01) and among parents of children using a pump compared to multiple daily injections (28.2 ± 18.8 vs 25.3 ± 19.1, P =.03). The trend toward higher FIS scores among parents of pump users was also seen in the <4 year and 6-<7-year age groups (P =.03 and.05, respectively). No significant difference in mean FIS scores was seen among parents of children achieving glycemic target HbA1c of <7.5% versus HbA1c 7.5% (27.5 ± 18.9 vs 27.0 ± 19.3, P =.24), who had at least one SH event versus no event (34.9 ± 28.6 vs 26.6 ± 18.2, P =.21), or who had at least one DKA event versus no event (34.5 ± 24.9 vs 26.8 ± 18.8, P =.14). Results were similar when stratified by age group.

6 Harrington et al 985 Table 2b. Mean Family Impact Survey (FIS) Score According to Demographic and Clinical Characteristics. Overall, N = 586 Ages <4 years, n = 108 Ages 4-<6 years, n = 286 Ages 6-<7 years, n = 192 Mean FIS Score Mean FIS Score Mean FIS Score Mean FIS Score Age in years.10 <4 years old 29.9 ± <6 years old 28.0 ± <7 years old 24.4 ± 16.4 Gender Female 26.0 ± ± ± ± 16.3 Male 28.2 ± ± ± ± 16.5 Race/ethnicity White non-hispanic 26.6 ± ± ± ± 16.5 Other 29.2 ± ± ± ± 15.9 Annual household income <$75, ± ± ± ± 18.7 $75, ± ± ± ± 15.1 Highest level of parent education High school/ged or less 27.5 ± ± ± ± 17.4 Associate s or bachelor s degree 27.7 ± ± ± ± 16.5 Master s, professional, or doctorate degree 25.9 ± ± ± ± 14.9 Duration of diabetes in years a <3 years 26.6 ± ± ± ± <7 years 29.0 ± ± ± ± 17.2 Frequency of self-monitoring blood glucose per day <6 times per day 25.6 ± ± ± ± times per day 27.8 ± ± ± ± 15.8 Continuous glucose monitor user Yes 29.3 ± ± ± ± 15.6 No 26.2 ± ± ± ± 16.6 Pump user Yes 28.2 ± ± ± ± 15.8 No 25.3 ± ± ± ± 17.2 Most recent HbA1c b <7.5% 27.5 ± ± ± ± % 27.0 ± ± ± ± 16.4 Occurrence of at least one SH event in the past 3 months c,d Yes 34.9 ± 28.6 No 26.6 ± 18.2 Occurrence of at least one DKA event in the past 3 months c,d Yes 34.5 ± 24.9 No 26.8 ± 18.8 GED, general education development; SD, standard deviation. a Comparison of total score according to diabetes duration was not completed for the <4-year age group due to small sample size. b Categories are for display purposes only; the is from analyzing as continuous. c The number of participants with events was too small to perform analyses stratified by age. d Occurrence of at least one severe hypoglycemia (SH) event in the past 3 months resulting in seizure or loss of consciousness, and occurrence of at least one diabetic ketoacidosis (DKA) event in the past 3 months. Conclusions Data for this study were collected from the largest published national (United States) sample of young children under age 7 using previously validated surveys, and the sample was drawn from multiple diabetes treatment centers in geographically diverse areas, which contribute to both the validity and the generalizability of the results. Parents endorsed substantial burdens relating to hypoglycemia, managing blood sugars, and potential complications of poor diabetes management. Notably, only 5% of parents reported feeling discouraged about their child s diabetes treatment plan, suggesting adequate support from their multidisciplinary treatment teams. In terms of family impact, parents reported sleep issues and the need for flexible work arrangements as significant factors. The age span of 3-<7 encompasses many dynamic changes and developmental stages and so it was originally thought burden may be different in each age group, however, our results suggest there is no significant difference in terms of type and frequency of burden between the age periods of toddler, preschoolers, and school aged children. The most common concern endorsed by parents of young children with diabetes was fear of their child having a low blood glucose, which is supported by findings in previous literature. 20

7 986 Journal of Diabetes Science and Technology 11(5) It is important to recognize this as a very common concern in families of young children with type 1 diabetes, as parents may direct their child s diabetes management toward hyperglycemia to reduce risk for hypoglycemia. For example, this worry may impact the behavior of parents of young children, who may reduce insulin doses to alleviate fears of a hypoglycemic event. Thus, providers can address such parental worries in efforts to achieve target glycemic control. Parents also expressed concerns about the long-term impact of type 1 diabetes for their children, with 70% endorsing worry about potential long-term complications. Thus, parents seem to worry about both hypoglycemia and hyperglycemia, feel upset when numbers are off track or out of range, and worry that their child will not be taken care of when the child is not in their care. If a vast majority of parents are worried about both the short- and long-term risks of diabetes, any indication that the child is not in range may cause worry and add to diabetes burden. These parents recognize they are responsible for their child s diabetes care and that, coupled with knowledge of the implications of out of range blood glucose values, can make taking care of diabetes in their young child an arduous task. Sleep interference was also endorsed in these surveys and has been a consistent theme in the literature The sleep quality of both parents and children can be compromised due to the need for diabetes care overnight. Parents who use CGM or remote monitoring technology may check glucose levels on devices frequently. This type of technology may help manage parental fear of hypoglycemia, but may lead to disruption of sleep to check a glucose value and give a corrective dose or low glucose treatment as needed. There were two demographic findings for both diabetes burden and family impact. Higher parental burden was reported among parents of children who are non-white. Minority families may be under additional stress, which may increase diabetes burden. 25 There was also a trend toward higher parental burden among parents with lower education, and a trend toward both higher parental burden and negative family impact among families with lower incomes. Diabetes burden may have a greater impact on families with fewer resources. For example, parents who have less income may experience financial stress due to missed work time and additional medical expenses. The FIS suggested that families who use insulin pumps and CGMs experience more negative impact from their child s diabetes. However, given the cross-sectional nature of these data, we cannot determine causality. In other words, we cannot determine whether families for whom diabetes has a greater negative family impact turn to technology to alleviate the burden, or if wearing advanced diabetes technology devices creates more burden. Future longitudinal research can help assess these associations. There are a few limitations to consider when interpreting the results of this study. First, this was a cross sectional study; thus no causal inferences can be drawn from the results. Second, surveys were self-reported. It is possible that parents who enrolled their child in the registry and completed the entry survey differ in their degree of diabetes-related burden or family impact from parents who chose not to enroll or complete the survey. Further studies using multiple methods of reporting such as survey and qualitative methodology may help to clarify findings with numerous possible interpretations. Third, we chose to conduct the analysis in three different age groups due to the diversity in developmental skills observed across this young age range. A major goal of this study was to understand parents perceptions of burden, and subgrouping the analysis helped us to accomplish this goal. However, the subgroups contained relatively small numbers of respondents; therefore, detecting statistical significance within the different subgroups becomes more challenging. Finally, advanced diabetes technologies are evolving at a rapid pace. During the course of our data collection there was a significant evolution in CGM technology with the advent of remote monitoring and connectivity to cell phones in There may be variability in the results in terms of parental burden and family impact due to some parents having access to newer technology. Indeed, the generalizability of these results will continue to be challenged due to the rapid evolution of technology. This investigation highlights that all families of young children with diabetes experience diabetes related burden and report that diabetes has impact on their family life. Behavioral interventions need to be developed and available to all families that focus on helping the parents of young children understand how usual developmental challenges at different stages impact diabetes management of a young child. Intervention components need to provide strategies, skills, and support integrated into routine care to support parental quality of life related to diabetes management. These interventions must also provide guidance to parents implementing advanced diabetes treatments and technologies. Such interventions may have a positive impact on parents and ultimately on diabetes outcomes for young children with type 1 diabetes. Abbreviations CGM, continuous glucose monitor; DKA, diabetic ketoacidosis; FIS, Family Impact Survey; HbA1c, hemoglobin A1c; PAID-PR, Problem Areas in Diabetes Survey Parent Revised version; SH, severe hypoglycemia; T1D Exchange, T1D Exchange Clinic Registry. Authors Note This article has been substantially revised from the original submission, which was published in the OnlineFirst section of the Journal of Diabetes Science and Technology in February Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

8 Harrington et al 987 Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported through the Leona M. and Harry B. Helmsley Charitable Trust. MV received support from the National Institutes of Health grant K12-DK MEH and BJA also received support from the National Institute of Diabetes and Digestive and Kidney Disease, K References 1. Patton SR, Dolan LM, Smith LB, Thomas IH, Powers SW. Pediatric parenting stress and its relation to depressive symptoms and fear of hypoglycemia in parents of young children with type 1 diabetes mellitus. J Clin Psychol Med Settings. 2011;18(4): Piazza-Waggoner C, Modi AC, Powers SW, Williams LB, Dolan LM, Patton SR. Observational assessment of family functioning in families with children who have type 1 diabetes mellitus. J Dev Behav Pediatr. 2008;29(2): Herbert LJ, Clary L, Owen V, Monaghan M, Alvarez V, Streisand R. 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