Associations among teen-parent relationships, metabolic control, and adjustment to diabetes in adolescents

Sexual Risk Behaviors of Adolescents with Type 1 Diabetes in Comparison with Their Peers

BACKGROUND

Adolescents with type 1 diabetes mellitus (T1D) may differ from peers regarding sexual risk behaviors.

OBJECTIVES

To explore sexual risk behaviors of adolescents with T1D in comparison with peers.

MATERIALS AND METHODS

The subjects were 174 adolescents, 58 adolescents with T1D (mean ± SD age 16.3 ± 2.0 yrs, disease duration 6.7 ± 3.5 yrs and HbA1c:8.0 ± 1.3%) and 116 without (matched 1:2). Anonymous, self-reported questionnaires were used to evaluate sexual education and behaviors.

RESULTS

Fewer adolescents with T1D than those without had a sexual experience (74.1% vs. 87.4%, p = 0.033), with similar age of sexual debut. Among adolescents with T1D, ≥2 risky behaviors were observed less frequently than adolescents without T1D (8.62% vs. 23.27%, p = NS respectively) and in fewer girls than boys in both adolescents with T1D (0% vs. 18.5%, p = NS) and adolescents without T1D (11% vs. 44%, p = 0.022). Adolescents with T1D with ≥2 risky behaviors were older (p = 0.031), younger at first sexual intercourse (p = 0.031), with higher maternal education (p = 0.039). Early sexual debut was associated with higher maternal education (p = 0.014) and HbA1c (p = 0.049). Most adolescents without T1D with ≥2 risky behaviors were boys and older than peers.

CONCLUSIONS

Adolescents with T1D and females were more cautious than adolescents without T1D regarding sex. The associations of increased risky behaviors with male gender, older age, younger age at sexual debut and higher maternal education in adolescents with T1D merit further investigation.

Comorbidity and Factors Affecting Treatment Non-Persistence in ADHD

Objective: The aim of the study was to identify factors for treatment non-persistence in patients with ADHD. Method: Data for 100 patients with ADHD aged 5 to 16 who completed the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version-Korean Version (K-SADS-PL-K) and Korean Wechsler Intelligence Scale for Children (K-WISC) were obtained between 2008 and 2013. Patients were classified as treatment-persistent and treatment-non-persistent based on 6-month follow-up. Sociodemographic data, comorbidities, intelligence quotient (IQ), severity, and social/school functioning were compared. Results: Adolescence and poor parental spousal relationships significantly predicted treatment non-persistence. Although comorbid major depressive disorder and absence of transient tic disorder were associated with treatment non-persistence, there was no difference in overall psychiatric comorbidity. No differences existed for IQ, Clinical Global Impressions-Severity (CGI-S) score, peer relationships, and academic achievement. Conclusion: Lower treatment persistence was associated with adolescence, comorbid depression, absence of tics, and poor parental spousal relationships, but not with symptom severity or impairment of the disorder.

Family Functioning and Medical Adherence Across Children and Adolescents With Chronic Health Conditions: A Meta-Analysis

Objectives

A meta-analysis examined family functioning and medical adherence in children and adolescents with chronic health conditions. Family functioning was evaluated at the level of the family unit, as well as parent-child interactions.

Methods

We conducted literature searches using PubMed, PsycINFO, SCOPUS, Web of Science, and Cochrane. After reviewing 764 articles, 62 studies met eligibility criteria. Pearson's r correlations were the effect size of interest. We conducted both omnibus and domain-specific (e.g., family conflict, cohesion) meta-analyses. Meta-regressions examined whether relevant covariates related to the magnitude of the effect.

Results

The omnibus meta-analysis showed that family functioning was significantly related to medical adherence across a variety of pediatric chronic health conditions. Lower family conflict, greater family cohesion, greater family flexibility, more positive communication, and better family problem-solving were each associated with better adherence. There were no significant differences in the magnitude of the omnibus effect based on child age, measurement features (subjective vs. objective or bioassay adherence; family unit vs. parent-child interactions), or study quality.

Conclusions

Consistent with social-ecological frameworks, findings supported links between family functioning and medical adherence. This study highlights several limitations of the extant research, including absence of a guiding theoretical framework and several methodological weaknesses. We offer clinical and research recommendations for enhancing scientific understanding and promotion of adherence within the family context.

Improving Diabetes-Related Parent-Adolescent Communication With Individualized Feedback

Objective

To pilot a brief individualized feedback intervention to improve the communication skills of parents with an adolescent with type 1 diabetes.

Methods

Parent-adolescent dyads (N = 79) discussed a diabetes-related problem, while an interventionist rated the parent's communication skills to give feedback to the parents. Parents were then randomized to a brief feedback session to target person-centered communication skills or an educational session. Dyads discussed another diabetes care problem to assess for change in communication skills. Independent raters coded parent communication skills from video recordings to rate behaviors in the service of examining possible changes in communication skills. Dyads completed ratings of perceived closeness and empathy after each conversation.

Results

Controlling for overall positive communication at baseline, parents who received feedback showed more improvement in specific person-centered communication skills than parents in the control group. Adolescents in the feedback group reported greater increases in parental empathy and intimacy from pre- to postmanipulation than the control.

Conclusions

The feedback intervention showed preliminary efficacy for increasing person-centered communication skills and perceived empathy and intimacy.

Reduction of hypoglycaemic events with a behavioural intervention: a randomized clinical trial for paediatric patients with Type 1 diabetes mellitus

AIMS

To determine if a low-intensity, clinic-integrated behavioural intervention reduced the incidence of hypoglycaemic events in children with Type 1 diabetes.

METHODS

A total of 390 families with children with Type 1 diabetes were enrolled in a 2-year, randomized clinical trial of a behavioural intervention. The intervention was designed to improve diabetes management practices by targeting the family's diabetes problem-solving skills. Hypoglycaemic events were categorized in two groups: those treated by oral ingestion and those treated by parenteral therapy. Events were self-reported by participants at each clinic visit, which occurred approximately every 3-4 months. Analyses included two-sample t-tests, the mean cumulative function test, and the Cox proportional hazards model for recurrent events to compare the incidence between groups.

RESULTS

Across the entire 2-year study period, the incidence of hypoglycaemic events treated by oral ingestion of glucose-rich foods and events requiring parenteral therapy did not significantly differ between study conditions; however, during the second year of participant enrolment, the incidence of events treated by oral ingestion in the intervention group was 13.6 per 100 person-years compared with 27.3 per 100 patient-years in the control group (P = 0.02). The hazard ratio of these events during the second year was 0.49 (95% CI 0.27-0.90; P = 0.02).

CONCLUSIONS

Our findings suggest the need for a long-term (> 1 year) focus on the implementation of interventions targeting diabetes management in young people. Behavioural interventions targeting problem-solving skills could be considered as practical, non-pharmacological strategies to reduce hypoglycaemia in adolescents with Type 1 diabetes.

Brief Computer-Delivered Intervention to Increase Parental Monitoring in Families of African American Adolescents with Type 1 Diabetes: A Randomized Controlled Trial

BACKGROUND

African American adolescents with type 1 diabetes (T1D) are at elevated risk for poor diabetes management and metabolic control. Parental supervision and monitoring of adolescent diabetes management have been shown to promote better diabetes management among adolescents, but parents typically decrease their oversight during the transition to independent diabetes care.

INTRODUCTION

The purpose of the study was to conduct a randomized clinical trial to test the feasibility and efficacy of a three-session, computer-delivered motivational intervention (The 3Ms) to promote increased parental monitoring among primary caregivers of young African American adolescents with T1D. The intervention was brief and optimized for delivery during routine diabetes clinic visits.

MATERIALS AND METHODS

Sixty-seven adolescents with T1D aged 11-14 and their primary caregiver were randomly assigned to one of three arms: adolescent and parent motivational intervention (Arm 1), adolescent control and parent motivational intervention (Arm 2), or adolescent and parent control (Arm 3). Intervention effects were assessed 1 month after intervention completion.

RESULTS

Parents in Arm 1 and Arm 2 had significant increases in knowledge of the importance of monitoring adolescents' diabetes care. Parents in Arm 2 also had trend to significant increases in direct observation and monitoring of adolescent diabetes care, and adolescents in Arm 2 had significant improvements in glycemic control.

DISCUSSION AND CONCLUSIONS

Findings from the present study provide preliminary support for the efficacy of a brief, computer-delivered parenting intervention for improving family management practices and adolescent health outcomes among African American adolescents with T1D and their caregivers.

Behavioral Assessment and Intervention in Pediatric Diabetes

This article reviews the empirical research literature on behavioral assessment and intervention methods in the context of diabetes mellitus in children and adolescents. The review summarizes the pathophysiology, medical management, and monitoring of pediatric type 1 and type 2 diabetes. Next, the article describes common behavioral barriers to acceptable diabetes management and adequate metabolic control and the role of behavior change agents in evaluation and intervention for these problems. Validated approaches to the assessment of diabetes-specific behavioral problems are described for the measurement of treatment adherence, diabetes-related fears and avoidance behaviors, diabetes-specific social skills, and disease-related stressors. Behavioral interventions that have empirical support are discussed, including treatments that target treatment adherence, social skills, coping skills, family communication and problem solving, anxiety and stress management, and weight control. The article concludes with clinical practice recommendations for behavior change specialists who have the opportunity to work with this population.

Videoconferencing for Teens With Diabetes: Family Matters

BACKGROUND

Adolescence is a developmental period associated with increased difficulty managing diabetes. During adolescence family functioning, including miscarried helping, family conflict, and acceptance of illness, is an important predictor of adherence to treatment recommendations. Multiple barriers exist to receiving behavioral health interventions to address suboptimal adherence. We hypothesized that behavioral family systems therapy-diabetes (BFST-D) delivered via telehealth would yield changes in family functioning that were not significantly different than changes in clinic-based treatment. Furthermore, that BFST-D would significantly improve overall family functioning.

METHODS

Ninety adolescent participants and their parents were randomized to receive BFST-D via telehealth or traditional (Clinic) treatment conditions. Repeated measures ANOVAs were used to assess changes in mean scores across pre, post, and follow-up assessments. Mediation analyses were conducted using methods outlined by Sobel and were confirmed by bootstrapping.

RESULTS

Changes in miscarried helping, family conflict and adjustment to illness were not significantly different across groups. Overall, clinically significant improvements were identified in youth- and parent-reported miscarried helping, family conflict, and acceptance of illness. Reductions in family conflict mediated the relationship between changes in miscarried helping and acceptance of illness. In addition, improvements in family functioning were associated with changes in adherence and glycemic control.

CONCLUSIONS

Results provide strong support for BFST-D (and similar interventions) delivered via telehealth as yielding outcomes no different than clinic-based treatment. In addition, further support was provided for the effectiveness of BFST-D.

Predicting Health Resilience in Pediatric Type 1 Diabetes: A Test of the Resilience Model Framework

OBJECTIVES

This research examined whether individual and family-level factors during the transition from late childhood to early adolescence protected individuals from an increased risk of poor glycemic control across time, which is a predictor of future diabetes-related complications (i.e., health resilience).

METHODS

This longitudinal, multisite study included 239 patients with type 1 diabetes and their caregivers. Glycemic control was based on hemoglobin A1c. Individual and family-level factors included: demographic variables, youth behavioral regulation, adherence (frequency of blood glucose monitoring), diabetes self-management, level of parental support for diabetes autonomy, level of youth mastery and responsibility for diabetes management, and diabetes-related family conflict.

RESULTS

Longitudinal mixed-effects logistic regression indicated that testing blood glucose more frequently, better self-management, and less diabetes-related family conflict were indicators of health resilience.

CONCLUSIONS

Multiple individual and family-level factors predicted risk for future health complications. Future research should develop interventions targeting specific individual and family-level factors to sustain glycemic control within recommended targets, which reduces the risk of developing future health complications during the transition to adolescence and adulthood.

Flexible Lifestyles for Youth (FL3X) behavioural intervention for at-risk adolescents with Type 1 diabetes: a randomized pilot and feasibility trial

AIM

To determine the potential effect sizes for the Flexible Lifestyle for Youth (FL3X) behavioural intervention to improve glycaemic control (HbA(1c)) and quality of life for at-risk adolescents with Type 1 diabetes.

METHODS

Participants [n = 61; age 12-16 years, HbA(1c) 64-119 mmol/mol (8-13%)] were randomized to FL3X (minimum three sessions) or usual care. Effect sizes (Cohen's d), comparing the mean difference between the groups, were calculated.

RESULTS

Study retention (95%), attendance at intervention sessions (87% attended all three sessions) and acceptability were high (100% of the adolescents and 91% of parents would recommend the programme to others). Overall, 41% of participants in the intervention group and 24% of participants in the control group were 'responders' [HbA(1c) decreased by > 6 mmol/mol (0.5%); d = 0.37]. HbA(1c) levels decreased (d = -0.18), diabetes-specific quality of life increased (d = 0.29), but generic quality of life decreased (d = -0.23) in the intervention compared with the control group.

CONCLUSIONS

The FL3X programme merits further study for improving HbA(1c) and diabetes-specific quality of life in adolescents with Type 1 diabetes. (Clinical trials registry no.: NCT01286350).

Annual Psychological Screening in Youth and Young Adults with Type 1 Diabetes

Aim

Youth and young adults with type 1 diabetes are at a great risk for developing depression and diabetes specific distress, therefore, systematic psychological screening is recommended. Routine psychological screening was implemented in Slovene diabetes clinic for children, adolescents and young adults in 2012. One-year results are presented.

Methods

Adolescents and young adults (N = 159, aged 11 – 25 years), attending the obligatory yearly educational outpatient visit at University Children’s Hospital, Ljubljana, Slovenia, were examined using questionnaires measuring depression (depression scale from Slovene version of Trauma Symptom Checklist for Children) and diabetes distress (Diabetes Distress Screening Scale). Six additional items were included to assess the fear of hypoglycemia and family support. Socio-demographic and diabetes-related data were collected. Questionnaires were analyzed by a psychologist, and the patients that scored above cut-off point were invited to an individual psychological assessment.

Results

Of the sample, 1.3 % reached the threshold for elevated depressive symptoms, and 32.7 % reported significant diabetes distress. The need for psychological support from a specialist was expressed by 5.0 %. There were statistically significant associations between all psychological variables; moreover, better glycemic control was associated with lower diabetes distress and better family support. Nine patients (5.7 %) started with psychological treatment according to the referrals after screening.

Conclusions

The results after one year of psychological screening in Slovene type 1 diabetes population displayed small rates of depression and a large proportion of diabetes distress. Only a small percentage of patients attended the offered individual psychological assessment.

Recognizing the psychosocial aspects of type 1 diabetes in adolescents

OBJECTIVE

Considering the ever increasing population of diabetic adolescents and the association of the disease with psychosocial problems throughout its course, depression and/or anxiety and social support from parents are issues of special concern in these patients. The study aimed to identify the depression and anxiety state of diabetic adolescents and its impact on the management of diabetes mellitus (DM).

METHODS

295 adolescents with type 1 DM and their parents attended our study. Psychological distress was assessed using the Children's Depression Inventory and the State-Trait Anxiety Inventory (STAI I-II) for Children, Perceived Social Support from Family (PSS-Fa) scale, Beck Depression Inventory for adults, STAI I-II for adults and the Multidimensional Scale of Perceived Social Support (MSPSS). Records of glycemic measurements, insulin dosage and hemoglobin A1c levels were used as glycemic control parameters.

RESULTS

Depression rate was 12.9%. State (p<0.001) and trait anxiety (p<0.001) levels were high; PSS-Fa (p<0.001) and MSPSS (p<0.006) scores were low in the depressive patients. Positive correlations were noted between depression, PSS-Fa, STAI-I and STAI-II.

CONCLUSION

Therapeutic strategies of DM should include co-existing psychiatric conditions throughout the course of the disease. In diabetic adolescents, PSS-Fa, STAI-I and STAI-II appear to be effective tools in the evaluation of depression.

Family Density and SES Related to Diabetes Management and Glycemic Control in Adolescents With Type 1 Diabetes

OBJECTIVE

Youth with Type 1 diabetes (T1D) from single-parent families have poorer glycemic control; a finding confounded with socioeconomic status (SES). Family density (FD), or youth:adult ratio, may better characterize family risk status.

METHODS

Structural equation modeling assessed the relation of single-parent status, SES, and FD to parenting stress, diabetes-related conflict, parental monitoring, adherence, and glycemic control using cross-sectional parent and youth data (n = 257).

RESULTS

Single-parent status exhibited similar relations as SES and was removed. Lower FD was associated with better glycemic control (β = -.29, p = .014) via less conflict (β = .17, p = .038) and greater adherence (β = -.54, p < .001).

CONCLUSIONS

Beyond SES, FD plays a significant role in adherence and glycemic control via diabetes-related conflict. In contrast, the effects of single-parent status were indistinguishable from those of SES. FD provides distinct information related to adolescent glycemic control.

Balancing parental involvement with adolescent friendly health care in teenagers with diabetes: are we getting it right?

PURPOSE

Current guidance about adolescent-friendly health care emphasizes the benefits of seeing young people alone for confidential consultations. Yet in young people with Type 1 diabetes mellitus (T1DM), parental involvement has been shown to contribute to better diabetes control. This study aimed to better understand how these apparent tensions are reconciled in clinical practice by identifying how frequently adolescents with T1DM are seen alone and exploring parents' opinions about this.

METHODS

A convenience sample of consecutive parents of adolescents (aged 12-21 years) with T1DM was recruited from the outpatient clinic of a specialist diabetes service and asked to complete a 30-item written survey.

RESULTS

A total of 137 surveys were returned from 146 eligible parents (94%) of whom 106 had complete data. Thirteen percent of adolescents with T1DM had ever been seen alone for a confidential consultation with their doctor. The most common concern for parents about confidential care was not being informed about important information, not just about T1DM, but also about common adolescent risk behaviors and mental health states.

DISCUSSION

These findings suggest that young people with T1DM are not being routinely seen alone for confidential care. This could be attributed to: parents or adolescents declining confidential care; clinicians being time-poor and/or lacking the necessary skills; or a culture of uncertainty about the value of confidential care. A discussion is now required about how best to enact adolescent-friendly care in the chronic-illness outpatient setting, where parental involvement is understood to be important for effective chronic illness management.

Functional communication as a predictor of depression and anxiety symptoms among adolescents seeking bariatric surgery

The purpose of the present study was to determine whether functional communication and parent-adolescent relations prospectively predict anxiety and depression symptoms among severely obese adolescents seeking bariatric surgery. Participants included 30 adolescents and their primary caregivers, who presented for enrolment in a study assessing the safety and efficacy of the laparoscopic adjustable gastric band. Adolescents and their caregivers completed questionnaires assessing anxiety and depression symptoms, functional communication, and parent-adolescent relations at baseline and immediately prior to having bariatric surgery. Regression analyses revealed that poorer parent reported functional communication at baseline predicted increases in adolescent reported anxiety and depression symptoms immediately prior to surgery (on average 8.8 months later), above and beyond baseline symptoms. Anxiety and depression symptoms did not predict functional communication over time. Parent-adolescent relations, as reported by the adolescent, were concurrently associated with adolescent reported depression symptoms at baseline, and were concurrently associated with adolescent reported anxiety and depression symptoms, as well as parent reported depression symptoms, immediately prior to surgery. Functional communication may be an important prospective risk factor for the development of anxiety and depression symptoms among severely obese adolescents seeking bariatric surgery, whereas adolescent report of the parent-adolescent relationship appears to be concurrently related to anxiety and depression symptoms. Future research should examine whether specifically targeting communication skills and family relationships within psychological treatment would improve psychosocial functioning among severely obese adolescents.

Autonomy support and responsibility-sharing predict blood glucose monitoring frequency among youth with diabetes

OBJECTIVE

Adolescence poses a number of special challenges for youth and their families managing the Type 1 diabetes medical regimen. Little is known on how family and youth factors and management of the regimen change over the course of early adolescence and predict adherence to the regimen during this developmental period.

METHODS

Youth with Type 1 diabetes (n = 239) and their maternal caregivers completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency (BGMF) at 4 timepoints over a 3-year period.

RESULTS

Autonomy support and BGMF significantly decreased over time and responsibility for the diabetes regimen shifted from the caregiver toward youth over time. Significant changes in perceived family conflict over time differed depending on the reporter. Baseline BGMF, changes in caregiver autonomy support, and changes in responsibility for the regimen significantly predicted changes in BGMF over time.

CONCLUSIONS

This study documents changes in autonomy support, youth responsibility for the diabetes regimen, and BGMF during the transition into early adolescence. Higher levels of caregiver autonomy support preserve BGMF during a developmental period in which BGMF typically deteriorates.

Developmental challenges of adolescents with type 1 diabetes: the role of eating attitudes, family support and fear of negative evaluation

Young people with chronic illnesses including type 1 diabetes mellitus (T1DM) are at increased risk of developing psychological problems during adolescence. The aim of the present study was to explore whether a relationship exists between developmental challenges of adolescence (eating attitudes, family support and fear of negative evaluation) and psychopathology in adolescents with T1DM, and the nature of such a relationship. Sixty-one adolescents with T1DM completed a series of questionnaires assessing illness beliefs, eating attitudes, family support, Fear of Negative Evaluation (FNE) and psychopathology. The study was of a correlational design, and also included a seven-day diabetes management diary in order to collect blood glucose levels over this time. Results demonstrated the relevance of all three developmental challenges. In multiple regression analyses, FNE and eating attitudes independently predicted current levels of depressive symptomatology. Current levels of anxiety were predicted by FNE and family support, but not eating attitudes. The results support the relevance of all three developmental challenges of adolescence to psychopathology in young people with diabetes. These results suggest that in working with adolescents who are having difficulty coping with diabetes; it may be beneficial to focus on the developmental issues that commonly face adolescents.

Behavioral health care for adolescents with poorly controlled diabetes via Skype: does working alliance remain intact?

BACKGROUND

Increasingly various technologies are being tested to deliver behavioral health care. Delivering services via videoconferencing shows promise. Given that the patient-provider relationship is a strong predictor of patient adherence to medical regimens, addressing relationship quality when services are not delivered face-to-face is critical. To that end, we compared the therapeutic alliance when behavioral health care was delivered to youth with poorly controlled type 1 diabetes mellitus (T1DM) and their caregivers in-clinic with the same services delivered via Internet-based videoconferencing (i.e., Skype™).

METHODS

Seventy-one adolescents with poorly controlled T1DM (hemoglobin A1c ≥9%) and one of their caregivers received up to 10 sessions of a family-based behavioral health intervention previously shown to improve adherence to diabetes regimens and family functioning; 32 were randomized to the Skype condition. Youth and caregivers completed the working alliance inventory (WAI), a 36-item measure of therapeutic alliance, at the end of treatment. Additionally, the number of behavioral health sessions completed was tracked.

RESULTS

No significant differences in WAI scores were found for those receiving behavioral health care via Skype versus in-clinic. Youth WAI goal and total scores were significantly associated with the number of sessions completed for those in the clinic group.

CONCLUSION

Behavioral health can be delivered to youth with T1DM via Internet-based videoconferencing without significantly impacting the therapeutic relationship. Thus, for those adolescents with T1DM who require specialized behavioral health care that targets T1DM management, Internet-based teleconferencing represents a viable alternative to clinic-based care.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.

Declining metabolic control and decreasing parental support among families with adolescents with diabetes: the risk of restrictiveness

Background For children with diabetes, metabolic control typically declines across the adolescent years.

OBJECTIVE

The longitudinal interplay between supportive relationships with parents and metabolic control were investigated in families that differ in parents' restrictiveness.

METHOD

The time-dependent links between perceived parental social support and metabolic control were investigated in a sample of 109 German adolescents with diabetes. 3 waves of data were collected at annual intervals; metabolic control (indexed by HbA1c) was assayed by physicians annually.

RESULTS

Family restrictiveness moderated longitudinal associations between metabolic control and perceived social support. For adolescents reporting high family restrictiveness, poorer initial metabolic control predicted greater subsequent declines in perceived parent social support, and lower initial perceived parental social support predicted greater subsequent deterioration in metabolic control.

CONCLUSION

The findings add to the growing body of work suggesting that restrictiveness is a risk factor that exacerbates problems associated with low perceived parental support.

Measurement of diabetes stress in older children and adolescents with type 1 diabetes mellitus

OBJECTIVE

Studies indicate general psychological stress plays a role in the glycemic control of individuals with type 1 diabetes mellitus (T1DM). Disease-specific rather than general measures may be more closely related to measures of health outcomes. Therefore, measurement of diabetes-related stress is needed to advance knowledge of significant relationships between stress and glycemic control. The objective of this study was to evaluate the psychometric properties of a measure of diabetes-related stress for youth with T1DM.

RESEARCH DESIGN AND METHODS

A 65-item diabetes stress questionnaire for youths (DSQY) was previously developed for use with older children and adolescents. The DSQY was completed by 417 youths with T1DM and the results were analyzed to determine the factor structure and psychometric properties of the questionnaire, as well as relationships of diabetes stress with demographic and clinical variables.

RESULTS

A factor analysis of the DSQY yielded an eight-factor solution with acceptable internal consistencies. Significant relationships were observed between glycemic control and stress related to parents and dietary issues. While age and socioeconomic status were unrelated with DSQY scores, higher stress was associated with longer diabetes duration, female gender, and racial/ethnic minority status.

CONCLUSIONS

The DSQY is a reliable and valid measure for assessment of diabetes-specific stress in youths with T1DM.

Quality of life and technology: impact on children and families with diabetes

Ensuring quality of life (QOL) while maintaining glycemic control within targets is an important challenge in type 1 and type 2 diabetes treatment. For children with diabetes, QOL includes enjoying meals, feeling safe in school, and perceiving positive, supportive relationships with parents, siblings, and friends. Yet many treatment-related and psychosocial barriers can interfere with a child's QOL and their ability to manage diabetes effectively. Diabetes management also imposes considerable lifestyle demands that are difficult and often frustrating for children to negotiate at a young age. Recent advances in diabetes medications and technologies have improved glycemic control in children with diabetes. Two widely used technologies are the insulin pump and continuous glucose monitoring (CGM) system. These technologies provide patients with more flexibility in their daily life and information about glucose fluctuations. Several studies report improvements in glycemic control in children with type 1 diabetes using the insulin pump or sensor-augmented pump therapy. Importantly, these technologies may impact QOL for children and families with diabetes, although they are rarely used or studied in the treatment of children with type 2 diabetes. Further, emerging closed loop and web- and phone-based technologies have great potential for supporting diabetes self-management and perhaps QOL. A deeper understanding and appreciation of the impact of diabetes technology on children's and parents' QOL is critical for both the medical and psychological care of diabetes. Thus, the purpose of this review is to discuss the impact of new diabetes technologies on QOL in children, adolescents and families with type 1 diabetes.

Assessment of psychosocial variables by parents of youth with type 1 diabetes mellitus

PURPOSE

To evaluate the impact of type 1 diabetes (T1D) on family functioning and child-rearing practices from parents' point of view, to assess parents' health-related quality of life and to explore the relations between psychosocial variables and diabetes care outcomes in youth with diabetes.

METHODS

This research was part of the cross-sectional multicenter Brazilian Type 1 Diabetes Study, conducted between December 2008 and December 2010 in 28 public clinics of 20 cities across four Brazilian geographical regions. Psychosocial questions were addressed to 1,079 parents of patients with T1D through an interview (89.3% mothers, 52.5% Caucasians, 38.6 ± 7.6 years old). Overall, 72.5% of the families were from low or very low socioeconomic levels. Parents were also submitted to health-related quality of life instruments (EQ-5D+EQ-VAS). Clinical data from the last medical appointment were collected by a physician using standardized chart review forms. The demographic, educational and socioeconomic profiles were also obtained and HbA1c levels registered.

RESULTS

Discomfort and anxiety/depression were the main complaints in EQ-5D, and were significantly more frequent in mothers (37.3% and 53.4%, respectively) than in fathers (25.7% and 32.7%, respectively). The mother was the only parent involved in diabetes care in 50.5% of the cases. The majority of parents (78.5%) mentioned changes in family functioning after the diagnosis, although they neither treated their diabetic children differently from the others (76.3%), nor set prohibitions (69.1%) due to diabetes. The majority was worried about diabetes complications (96.4%) and felt overwhelmed by diabetes care (62.8%). Parents report of overwhelming was significantly associated with anxiety/depression, as measured by the EQ-5D questionnaire. Less than half of the patients had already slept over, and the permission to do it increased as a function of children's age. Nearly half of the parents (52%) admitted to experiencing difficulties in setting limits for their children/adolescents. HbA1c levels in patients from this group (9.7 ± 2.5%) were significantly higher than those of children/adolescents whose parents reported no difficulties towards limit-setting (8.8 ± 2.1%). Parents whose children/adolescents reported the occurrence of hypoglycemic episodes in the last month complained significantly more about anxiety/depression (55.1%) than parents from patients who did not report it (45.7%). Also a significantly greater proportion of parents whose children/adolescents had been hospitalized due to hyperglycemia reported anxiety /depression (58.7%) than those whose children/adolescents had not been hospitalized (49.8%).

CONCLUSIONS

After the diagnosis of T1D, the lifestyle of all family members changes, what interferes with their quality of life. Mothers are still the primary caregivers for children/adolescents with diabetes. Difficulty to set limits for children/adolescents may be a risk for poor metabolic control. The study demonstrates the importance of family context in the adjustment of young patients to T1D. The specific needs of T1D patients and their impact on a family routine must be considered for future improvement on therapy elements and strategies.

Diabetes management and glycemic control in youth with type 1 diabetes: test of a predictive model

The objective of this study was to test a comprehensive model of biologic (pubertal status), family (communication and conflict), and psychological influences (behavioral autonomy) on diabetes management and glycemic control in a sample of youth (N = 226) with type 1 diabetes recruited during late childhood/early adolescence (ages 9-11 years). The study design was a prospective, multisite, multi-method study involving prediction of diabetes management and glycemic control 1 year post-baseline. The primary outcome measures included diabetes management behaviors based on the Diabetes Self-Management Profile (DSMP) administered separately to mothers and youth and glycemic control measured by glycated hemoglobin (HbA1c) obtained by blood samples and analyzed by a central laboratory to ensure standardization. Our hypothesized predictive model received partial support based on structural equation modeling analyses. Family conflict predicted less adequate glycemic control 1 year later (p < 0.05). Higher conflict predicted less adequate diabetes management and less adequate glycemic control. More advanced pubertal status also predicted less adequate glycemic control, but behavioral autonomy did not. Family conflict is an important, potentially clinically significant influence on glycemic control that should be considered in primary and secondary prevention in the management of type 1 diabetes in youth.

Clinic-integrated behavioral intervention for families of youth with type 1 diabetes: randomized clinical trial

OBJECTIVE

To test the effect on diabetes management outcomes of a low-intensity, clinic-integrated behavioral intervention for families of youth with type 1 diabetes.

METHODS

Families (n = 390) obtaining care for type 1 diabetes participated in a 2-year randomized clinical trial of a clinic-integrated behavioral intervention designed to improve family diabetes management practices. Measurement of hemoglobin A1c, the primary outcome, was obtained at each clinic visit and analyzed centrally. Blood glucose meter data were downloaded at each visit. Adherence was assessed by using a semistructured interview at baseline, mid-study, and follow-up. Analyses included 2-sample t tests at predefined time intervals and mixed-effect linear-quadratic models to assess for difference in change in outcomes across the study duration.

RESULTS

A significant overall intervention effect on change in glycemic control from baseline was observed at the 24-month interval (P = .03). The mixed-effect model showed a significant intervention by age interaction (P < .001). Among participants aged 12 to 14, a significant effect on glycemic control was observed (P = .009 for change from baseline to 24-month interval; P = .035 for mixed-effect model across study duration), but there was no effect among those aged 9 to 11. There was no intervention effect on child or parent report of adherence; however, associations of change in adherence with change in glycemic control were weak.

CONCLUSIONS

This clinic-integrated behavioral intervention was effective in preventing the deterioration in glycemic control evident during adolescence, offering a potential model for integrating medical and behavioral sciences in clinical care.

Parenting goals: Predictors of parent involvement in disease management of children with type 1 diabetes

The purpose of this study was to develop a measure of diabetes-specific parenting goals for parents of children with type 1 diabetes and to examine whether parenting goals predict a change in parenting involvement in disease management. An independent sample of primary caretakers of 87 children aged 10 to 16 years with type 1 diabetes completed the measure of parenting goals (diabetes-specific and general goals); both parent and child completed measures of parent responsibility for diabetes management at baseline and 6 months. Parents ranked diabetes-specific parenting goals as more important than general parenting goals, and rankings were moderately stable over time. Parenting goals were related to parent responsibility for diabetes management. The relative ranking of diabetes-specific parenting goals predicted changes in parent involvement over 6 months, with baseline ranking of goals predicting more parental involvement at follow-up. Parenting goals may play an important role in family management of type 1 diabetes.

Health-related quality of life changes of children and adolescents with chronic disease after participation in therapeutic recreation camping program

Background

The principals of therapeutic recreation underpin a camping program for children and adolescents living with chronic disease. This study aimed to evaluate the campers' health-related quality of life (HRQoL) before and after the program.

Method

We used the Hungarian version of Kidscreen-52 questionnaire to assess HRQoL. The study sample (n = 115) consisted of children and adolescents aged 10-18 (Mean Age: 13,34; SD: 2,20) collected two months before and two months after camp with the following illnesses: oncology patients (n = 32), diabetes (n = 55) and juvenile immune arthritis (JIA) (n = 28). Repeated measures of multivariate analysis of variance (MANOVA) evaluated pre and post camp changes. We used the Reliable Change Index (RCI) to calculate all the 10 subscales of clinically significant changes.

Results

The Self-perception subscale showed significant positive change from pre camp to post camp with small effect size. Autonomy scores showed time related decline as well as significant time and age group interaction: children under 14 years of age showed a significant moderate effect size decrease on the Autonomy subscale. 32 children (27.8%) showed clinically significant improvement (RCI > 1.96) at least on one subscale. All positive changes were independent of the type of disease, age, gender, and previous camp experience.

Conclusion

The therapeutic recreation camping program had a positive impact on HRQoL of children and adolescents living with cancer, diabetes mellitus and JIA. The experience enhanced their self-perception in all age groups and reduced the autonomy of children under 14 years of age. This study is an innovative use of the KIDSCREEN-52 questionnaire to measure the outcome effectiveness of a psychosocial rehabilitation program and to assess and compare HRQoL of children living with different chronic diseases.

The influence of diabetes upon adolescent and young adult development: A qualitative study

It is not clear how developmentally appropriate healthcare services for adolescents (11-15) and young adults (16-25) should be provided.

AIMS

First, to describe and understand the influence of diabetes upon psychosocial development and second, to highlight the implications for healthcare teams.

DESIGN

Given the heterogeneity of findings, lack of conceptual clarity and lack of quantitative measures, qualitative semi-structured interviews were used, to define more clearly the constructs significant to young people.

METHODS

People aged 16-25 registered with one secondary care diabetes service, across two districts in north-east England were contacted. Nineteen interviews were conducted and analysed using a Framework Approach.

RESULTS

Diabetes can impact upon personal identity and self-concept. Peer support can buffer from negative effects, especially if young people control the disclosure of their diabetes. In coming to rely more on peers, participants continue to value the safe base of their family, especially at times of change and challenge. A key challenge appears to be coming to terms with risk and mortality.

CONCLUSIONS

Health care services need to support young people with self-care but must also understand and respond to the social and personal complexities of growing-up with a long-term health condition. Psychologists may have a role in promoting and supporting such an approach.

Blood glucose monitoring and glycemic control in adolescence: contribution of diabetes-specific responsibility and family conflict

PURPOSE

To examine age and time trends in responsibility for diabetes management tasks and diabetes-specific family conflict and their relationship to blood glucose monitoring (BGM) frequency and blood glucose control (HbA1c).

METHODS

A sample of 147 adolescents (mean = 15.5 +/- 1.4 years) with type 1 diabetes and their caregivers completed measures of diabetes-specific responsibility and family conflict at baseline and 6 months. BGM frequency and HbA1c were measured during outpatient clinic appointments.

RESULTS

Responsibility for diabetes management tasks shifted from caregivers to adolescents with increasing age by adolescent and caregiver report. Diabetes-specific conflict was stable. Similar trends in responsibility and conflict were seen over the 6-month follow-up period. Less frequent BGM and higher HbA1c were also observed with increasing adolescent age. Multivariate analyses demonstrated adolescents taking greater responsibility for management tasks and experiencing greater family conflict at baseline reported lower BGM at 6 months. Family, demographic, psychosocial, and disease-specific variables accounted for 26% of the variance in BGM frequency by both adolescent and caregiver report. Adolescents reporting greater diabetes-specific family conflict at baseline experienced higher HbA1c values at 6 months. Variables accounted for 23% and 28% of the variance in HBA1c by adolescent and caregiver report respectively.

CONCLUSIONS

Diabetes-specific responsibility and conflict have important implications for improving disease outcomes. Interventions targeting responsibility and conflict (i.e., reducing conflict while keeping caregivers involved in diabetes management) may help prevent the deterioration in BGM and HbA1c frequently seen during adolescence.

Glycemic control, coping, and internalizing and externalizing symptoms in adolescents with type 1 diabetes: a cross-lagged longitudinal approach

OBJECTIVE

This study examines how active coping and withdrawal, psychological (internalizing and externalizing) symptoms, and glycemic control (A1C values) influence each other across time in adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

One hundred and nine adolescents participated in a four-wave longitudinal study spanning four years (mean age at Time 1 was 13.77). Patients were visited at home and completed questionnaires measuring coping and psychological symptoms. The treating physicians were contacted to obtain A1C values. Cross-lagged path analysis from a structural equation modeling approach was used for data analysis.

RESULTS

Clinically meaningful pathways between coping and glycemic control were found across time. Active coping prospectively predicted lower A1C levels, which, in turn, predicted active coping. Higher A1C levels and higher psychological symptoms consistently predicted avoidance coping across time. Finally, psychological symptomatology constituted an important link in the observed longitudinal chain of effects. More specifically, higher A1C values and symptomatology at Time 1 positively predicted withdrawal at Time 2, which, in turn, positively predicted symptomatology at Time 3. Next, symptomatology at Time 3 positively predicted higher A1C values at Time 4, thus coming full circle.

CONCLUSIONS

Coping with everyday stress, psychological symptoms, and glycemic control were interrelated across time. Evidence was obtained for reciprocal pathways and mutually reinforcing mechanisms, indicating the need to monitor coping strategies and psychological symptoms along with glycemic control in optimizing clinical care in adolescents with type 1 diabetes.

Parent involvement is associated with early success in obesity treatment

OBJECTIVE

The study examined the influence of parent involvement and family factors on body mass index (BMI) change in a pediatric obesity treatment program.

METHODS

A total of 104 children and their caregivers were examined during a 12-week obesity intervention. Participants (mean age = 11.42 years; SD = 2.83) and their caregivers completed measures of family environment and depression prior to enrollment. Children's BMI and parental involvement were rated weekly during the intervention. Logistic regressions were conducted to examine the role of sociodemographic factors, family characteristics, and parent involvement on weight.

RESULTS

Children with the lowest parent involvement were less likely to lose any weight or have clinically significant (>or=2 kg) weight loss. Demographics and family factors did not predict BMI change. Parent involvement related to ethnicity, absences and physical activity.

CONCLUSIONS

Parental involvement may be helpful in identifying who is likely to do well in a weight loss program.

Family therapy for adolescents with poorly controlled diabetes: initial test of clinical significance

OBJECTIVE

We examined a structured family therapy approach in promoting clinically meaningful improvements in parent-adolescent conflict in adolescents with poorly controlled diabetes.

METHOD

Eighteen adolescents with poorly controlled diabetes and their parent(s) participated in 10 sessions of home-based Behavioral Family Systems Therapy (BFST). Outcome comparisons were made using a sample of adolescents with poorly controlled diabetes (n = 40) from a previous study. Clinically significant improvements were determined by calculating SD differences between treatment and comparison groups on measures of diabetes-related and general parent-adolescent conflict.

RESULTS

Home-based BFST produced change in diabetes-related family conflict ranging from 1/3 to 1/2 SD and general family conflict ranging from 1/3 to 3/4 SD.

CONCLUSIONS

BFST produced change in family conflict, a variable shown through previous research to relate to treatment adherence in adolescents with diabetes. The test of clinical significance represents an example of a method useful for pediatric research.

Psychosocial problems in adolescents with type 1 diabetes mellitus

Adolescents with diabetes are at increased risk of developing psychiatric (10-20%) or eating disorders (8-30%), as well as substance abuse (25-50%), leading to non-compliance with treatment and deterioration of diabetic control. At high risk are female adolescents with family problems and other comorbid disorders. Impaired cognitive function has also been reported among children with diabetes, mainly in boys, and especially in those with early diabetes diagnosis (< 5 years), or with episodes of severe hypoglycaemia or prolonged hyperglycaemia. Type 1 diabetes mellitus contributes to the development of problems in parent-child relationships and employment difficulties, and negatively affects the quality of life. However, insulin pumps appear to improve patients' metabolic control and lifestyle. The contributions of family and friends to the quality of metabolic control and emotional support are also crucial. In addition, the role of the primary-care provider is important in identifying patients at high risk of developing psychosocial disorders and referring them on to health specialists. At high risk are patients in mid-adolescence with comorbid disorders, low socioeconomic status or parental health problems. Multisystem therapy, involving the medical team, school personnel, family and peer group, is also essential. The present review focuses on the prevalence of nutritional and psychosocial problems among adolescents with diabetes, and the risk factors for its development, and emphasizes specific goals in their management and prevention.

Effects of coping skills training in school-age children with type 1 diabetes

Children with type 1 diabetes are at risk for negative psychosocial and physiological outcomes, particularly as they enter adolescence. The purpose of this randomized trial (n = 82) was to determine the effects, mediators, and moderators of a coping skills training intervention (n = 53) for school-aged children compared to general diabetes education (n = 29). Both groups improved over time, reporting lower impact of diabetes, better coping with diabetes, better diabetes self-efficacy, fewer depressive symptoms, and less parental control. Treatment modality (pump vs. injections) moderated intervention efficacy on select outcomes. Findings suggest that group-based interventions may be beneficial for this age group.

Parent-adolescent discrepancies in adolescents' competence and the balance of adolescent autonomy and adolescent and parent well-being in the context of Type 1 diabetes

This study examined whether intrafamily discrepancies in perceptions of the adolescent's competence and independence were associated with autonomy and well-being for adolescents and parents. The ways in which mothers and fathers consistently differed from their adolescent across measures of independence and competence regarding Type 1 diabetes, a stressful context for families, were examined with the latent discrepancy model. A sample of 185 adolescents (mean age = 12.5 years, SD = 1.3), their mothers, and participating fathers completed measures of the adolescent's independence in completing diabetes tasks, problems with diabetes management, adherence to the medical regimen, measures of well-being, and metabolic control. The latent discrepancy model was conducted via structural equation modeling that generated latent discrepancies from the adolescent for mothers and fathers. Both mothers and fathers viewed the adolescent's competence more negatively than did the adolescent. These discrepancies related to more parental encouragement of independence and adolescent autonomy but also to poorer metabolic control and poorer parental psychosocial well-being. The results are interpreted within a developmental perspective that views discrepancies as reflecting normative developmental processes of autonomy but as being associated with disruptions in well-being in the short term.

Racial/ethnic differences in teen and parent perspectives toward depression treatment

PURPOSE

There are significant racial/ethnic disparities in youth access to and use of appropriate depression treatment. Although there is a growing literature on racial/ethnic differences in treatment preference among adults, we know very little about whether these differences persist for adolescents and whether parents have an influence on their teens' treatment perspectives.

METHODS

Teens and parents from a sample of primary care settings were interviewed at baseline and 6 months. We used bivarate and regression analyses to describe racial/ethnic differences in teen and parent depression knowledge and treatment preference and to assess the impact of parental views on teen perspectives.

RESULTS

Latino and African American teens had lower average scores on antidepressant knowledge (p < .01) and counseling knowledge than white teens (p < .01). These racial/ethnic differences were greater among parents (p < .001). Parent antidepressant knowledge had an impact on teen knowledge when teens reported turning to them for advice (beta = 0.20, p < .05). Teen knowledge about medication (odds ratio [OR] = 1.16, p < .01) and counseling (OR = 1.26, p < .001) were associated with a willingness to seek active treatment.

CONCLUSIONS

Racial/ethnic differences in depression treatment knowledge persist, but are more pronounced for parents than teens. Talking to parents who have more knowledge about depression treatment is associated with more teen knowledge and that knowledge is associated with greater willingness to seek depression treatment. Research is needed on the content and type of conversations that parents and teens have about depression treatment, and if there are differences by race/ethnicity.

Development and validation of the collaborative parent involvement scale for youths with type 1 diabetes

OBJECTIVE

To develop and test a youth-report measure of collaborative parent involvement in type 1 diabetes management.

METHODS

Initial item development and testing were conducted with 81 youths; scale refinement and validation were conducted with 122 youths from four geographic regions. Descriptive statistics, Cronbach's alpha, and factor analyses were conducted to select items comprising the scale. Correlations with parenting style and parent diabetes responsibility were examined. Multiple regression analyses examining associations with quality of life, adherence, and glycemic control were conducted to assess concurrent validity.

RESULTS

The measure demonstrated strong internal consistency. It was modestly associated with parenting style, but not with parent responsibility for diabetes management. A consistent pattern of associations with quality of life and adherence provide support for the measure's concurrent validity.

CONCLUSIONS

This brief youth-report measure of parent collaborative involvement assesses a unique dimension of parent involvement in diabetes management associated with important youth outcomes.

Short-term effects of coping skills training in school-age children with type 1 diabetes

OBJECTIVE

Little is known about the use of psychosocial interventions in children younger than adolescence with type 1 diabetes (T1D) and their parents. We report preliminary short-term outcomes of a randomized controlled trial of coping skills training (CST) compared with group education (GE) in school-aged children with T1D and their parents.

METHODS

One hundred and eleven children (range = 8-12 yr) with T1D for at least 6 months (3.71 +/- 2.91 yr) were randomized to CST (55.6% female (F); 81.5% white (W)) or GE (69.7% F; 90.9% W). Children and parents (n = 87) who completed the intervention, baseline, 1- and 3-month data are included. Children completed measures of self-efficacy, coping, and quality of life; parents completed measures of family functioning (adaptability and cohesion), diabetes-related conflict, parent depression, and parent coping. Metabolic control was assessed with glycosylated hemoglobin A1c. Mixed-model repeated measures anova was used to analyze the data.

RESULTS

CST and GE group composition was generally comparable. Children had good psychosocial adaptation and metabolic status. CST parents reported significantly more improvement in family adaptability compared with GE parents, and a trend was seen indicating that CST children showed greater improvement in life satisfaction than GE children. Effect sizes for this short-term follow-up period were small, but group participants were receptive to the intervention and reported positive gains.

CONCLUSIONS

In these preliminary results, CST and GE were more similar than different across multiple measure of psychosocial adaptation, although CST showed promising statistical trends for more adaptive family functioning and greater life satisfaction. Longer term follow-up is underway.

Role of parental monitoring in understanding the benefits of parental acceptance on adolescent adherence and metabolic control of type 1 diabetes

OBJECTIVE

This study examined 1) whether the benefits of mothers' and fathers' accepting relationships with their adolescents regarding diabetes control were due to parental monitoring and 2) how parents together may provide sufficient acceptance and monitoring for diabetes management.

RESEARCH DESIGN AND METHODS

Adolescents aged 10-14 years with type 1 diabetes (n = 185) and their mothers (n = 185) and fathers (n = 145) completed assessments of parental acceptance and monitoring of diabetes tasks. Adolescents completed a modified version of the Self-Care Inventory (1) to measure adherence. A1C scores were used as a marker of glycemic control.

RESULTS

Mediational analyses revealed that the benefits of adolescents' reports of fathers' acceptance on A1C and mothers' and fathers' acceptance on better adherence were partially mediated by monitoring. Both mothers' and fathers' monitoring and fathers' acceptance had independent effects in predicting adherence. However, only fathers' monitoring had an independent effect on A1C. The effect of fathers' monitoring on A1C occurred as fathers were monitoring at a lower level than mothers. Mothers' and fathers' reports of their own acceptance and monitoring were not associated with A1C or adherence.

CONCLUSIONS

Results reveal the importance of fathers' acceptance and monitoring in diabetes management, a role that should be encouraged, despite the little attention it has received.

Randomized, controlled trial of Behavioral Family Systems Therapy for Diabetes: maintenance and generalization of effects on parent-adolescent communication

We report a randomized trial of a revised Behavioral Family Systems Therapy for Diabetes (BFST-D) intervention. Families of 104 adolescents with diabetes were randomized to standard care (SC) or to 6 months of an educational support group (ES) or BFST-D. Family communication and problem-solving skills were assessed at 0, 6, 12, and 18 months by independent rating of videotaped family problem-solving discussions. BFST-D improved individual communication of adolescents and mothers, but not fathers. BFST-D significantly improved quality of family interaction compared to SC (10 of 12 comparisons) and ES (6 of 12 comparisons). Changes in family communication were differentially associated with changes in glycemic control, adherence, and family conflict. BFST-D improved family communication and problem solving relative to SC and modestly relative to ES.

The parental monitoring of diabetes care scale: development, reliability and validity of a scale to evaluate parental supervision of adolescent illness management

PURPOSE

Monitoring of adolescents' behavior and whereabouts has been repeatedly identified as an important predictor of adolescent behavioral outcomes. However, to date, measures of parental supervision and monitoring are lacking in the chronic illness literature. The present study describes development and initial evaluation of a measure of parental monitoring of the illness management of adolescents with diabetes: the Parental Monitoring of Diabetes Care scale (PMDC).

METHODS

Ninety-nine parents of 12-18-year-old children with type 1 diabetes completed the PMDC. Measures of illness management and metabolic control were also obtained.

RESULTS

The PMDC demonstrated good internal consistency (alpha coefficient = .81) and test-rest reliability (ICC = .80). Supporting the instrument's construct validity, confirmatory factor analysis indicated that a five subdomain structure had an acceptable fit to the data, [chi(2) (181.65)/df (126) = 1.44, Bollen-Stine chi(2) = 165.03, p = .32, comparative fit index (CFI) = .91, and root-mean-square error of approximation = .07]. In structural equation models, parental monitoring as assessed by the PMDC had a significant direct effect on adolescent diabetes management, accounting for 38% of the variance. Parental monitoring also had a significant indirect effect on metabolic control.

CONCLUSIONS

The PMDC represents an important first step in the development of measures of parental monitoring for use with adolescents with chronic medical conditions.