Involving children and adolescents in the decision to initiate the use of a continuous glucose monitoring (CGM) device is necessary to achieve maximum clinical benefit, explains Victoria A. Miller, PhD. “If youth are not directly involved in the decision to start the device, they may be less successful with it, which would lead to a missed opportunity to receive the clinical benefits of consistent CGM device use,” Dr. Miller says.

Laying the Groundwork for Increased Responsibility

For a study published in Diabetes Care, Dr. Miller and colleagues sought to identify factors that facilitate long-term use of CGM. They examined whether youth involvement in the decision to start CGM predicted device use and whether this relationship was mediated by CGM self-efficacy and satisfaction. “This study supports my prior research, which demonstrated that greater youth involvement in discussions with parents about type 1 diabetes (T1D) management is associated with improved treatment adherence,” Dr. Miller notes. “Being empowered to participate in such decisions lays the groundwork for increased responsibility and effective self-management as children mature.”

In this study, parent-child dyads from an academic endocrinology clinic completed assessments prior to initiating CGM, including a measure of the child’s involvement in the decision to start. Two months into CGM use, young people completed measures of CGM self-efficacy and satisfaction. Adherence to CGM use between weeks 5 and 12 was assessed via a cloud-based data repository. Hypotheses were tested with linear, mixed effects models.

Empowering Young Patients

CGM use in 108 dyads (youth mean age, 13.4; 73% white) was positively predicted in a baseline parent report of youth involvement in the CGM decision. In addition, this relationship was mediated by the youths’ perception of CGM self-efficacy and hassle. When youth shared their opinions about CGM with parents and participated in the decision to start, they perceived higher self-efficacy and lower hassle at the 2-month follow-up, which predicted more days of use (Figure). This pattern held in models adjusting for youth race, sex, and family income. “This finding is consistent with prior research showing the importance of self-efficacy for successful diabetes management in youth,” Dr. Miller notes.

The qualitative data that the team are working on suggest that some parents may put pressure on their children to agree to start the device, which may backfire if a child is hesitant or feels as if they don’t have ownership over the decision, she adds. “There are multiple ways to engage youth in discussions about CGM, such as asking about their questions or concerns, showing them the device in the physician’s office, and asking their opinions about whether or not they wish to proceed,” Dr. Miller says. “These actions can go a long way in helping young people feel empowered regarding decisions about their T1D management and their general overall health.”

Important Implications

Dr. Miller suggests that future research in this area should target more racially and ethnically diverse samples to determine whether and how processes related to CGM decision making differ in more vulnerable subgroups of youth with T1D. “We are also in the process of documenting additional analyses from the study, focused on semi-structured interviews with a random subset of youth and parents at both baseline and follow-up. This will give us a more in-depth understanding of their experiences with decision making and device use,” she adds. “In addition, future research can expand on this study by developing and evaluating intervention strategies to enhance youth involvement about other T1D-related decisions.”

The most important message Dr. Miller seeks to convey to endocrinologists and pediatricians is that children and adolescents should be the primary drivers of the decision about whether to start CGM. “Young people who were more involved in the decision used the device more consistently, which is important to achieving maximum clinical benefits of CGM,” she explains. “For many families, the decision about CGM was discussed and revisited over a long period before deciding to use the device.”