Parent-adolescent communication and psychological symptoms among adolescents with chronically ill parents

OBJECTIVE: To examine the psychological adjustment of adolescents living with a chronically ill parent and the relationship between psychological symptoms and communication with both their healthy and ill parents. METHOD: Adolescents, healthy parents, and ill parents from 38 families completed questionnaires regarding adolescent psychological symptoms, including posttraumatic stress symptoms, and parent-adolescent communication. RESULTS: Adolescent anxiety, depression, and behavior problems were within the subclinical ranges while approximately one-third of adolescents reported clinical levels of posttraumatic stress symptoms. Openness, but not problems, in communication between adolescents and their parents varied as a function of the parent's health status (healthy or ill) and parent sex. Adolescents reported poorer communication with healthy mothers; however only the quality of communication with healthy parents was related to adolescent psychological symptoms. CONCLUSIONS: Many adolescents with severely ill parents appear to experience clinically significant posttraumatic stress symptoms, therefore assessment for these symptoms in this population is important. Communication with a healthy parent may serve significant and unique functions for adolescents with ill parents, making communication between adolescents and their healthy parent a potentially useful target for clinical intervention.     

An exploration of social cognitive theory mediators of father-son communication about sex

OBJECTIVES: R.E.A.L. MEN (responsible, empowered, aware, living) is an HIV prevention project developed for fathers and their sons. The primary aim of R.E.A.L. MEN was to test the efficacy of an intervention to promote delay of sexual intercourse among 11- to 14-year-old adolescents and to enhance the father's role as a sexuality educator. In this article, we report the outcomes related to father-son communication about sex and the results of an exploratory analysis to test the hypothesis that the intervention effect on father-son communication about sex-related topics is mediated by the social cognitive variables of self-efficacy and outcome expectations. METHODS: Two hundred seventy-seven fathers and their sons enrolled in the study. Fathers randomized to the intervention group attended seven group sessions, and their sons attended the final session with them. Fathers and sons completed baseline and 3-, 6-, and 12-month follow-up assessments. The fathers who completed the 3-month follow-up assessment were included in the mediation analyses described in this article. RESULTS: All the participants were male, most were African American (97%), and most fathers and sons reported residing in the same household. The mean age of father participants was 40.5 years; most had graduated from high school, and about 60% reported a yearly income over 30,000 dollars. Based on the results of mediation analyses, the data supported a mediation model that suggests that the effect of the intervention on father-son communication was mediated by differences in self-efficacy. A mediation effect for outcome expectations was weak and could not be validated using additional tests. CONCLUSIONS: The mediation analysis provides some understanding of the role of self-efficacy and outcome expectations in promoting behavioral change. Understanding the active components of interventions can help refine the interventions to eliminate nonfunctioning components and enhance the active components leading to more streamlined programs.     

Child routines and youths' adherence to treatment for type 1 diabetes

OBJECTIVE: Type 1 diabetes (T1DM) is a chronic life-threatening disease that requires strict adherence to daily treatment tasks. Although necessary for survival, children who present with behavior problems tend to show problems complying with the treatment regimen, thereby increasing their risk for morbidity and premature mortality. The risk of poor treatment adherence is hypothesized to be lower for these children, however, if they engage in more routine behaviors. Given the potential clinical implications, this hypothesis and two theoretical models proposed to elucidate the underlying psychological process for the role of child routines in treatment adherence were evaluated empirically. The first model hypothesized that child routines protect (moderator variable) behaviorally problematic children from poor treatment adherence, whereas the alternative model hypothesized that child routines mediate the relation between childhood behavior problems and poor treatment adherence. METHODS: Parents of T1DM patients (N = 111) ranging from 6 to 16 years of age (M = 12 years) reported on their child's behavior problems, routine behaviors, and adherence to treatment for T1DM using standardized measures. Baron and Kenny's statistical procedures for testing moderation and mediation hypotheses were used to evaluate the proposed models. RESULTS: Regression analyses did not support the moderation hypothesis but did support the hypothesis that engaging in child routines mediates the relation between childhood behavior problems and poor treatment adherence. CONCLUSIONS: Parents of behaviorally problematic children diagnosed with T1DM might be advised to instill routines in their child's daily activities to increase the likelihood of treatment adherence, and thereby reduce the risk of morbidity and early mortality. Implications for clinical interventions are discussed.     

The relationship between parent-reported social support and adherence to medical treatment in families of adolescents with type 1 diabetes

OBJECTIVE: To investigate the relationships between both mother-reported spousal support and social network support, and mother-adolescent diabetes-related conflict, discrepancies in decision-making autonomy (DDMA), and adolescent adherence to diabetes treatment. METHOD: Fifty-one mothers of adolescents with IDDM completed self-report measures of social support, diabetes-related conflict, and adolescent autonomy for diabetes care. Analyses tested conflict and DDMA as mediators between mother-reported social support and adolescent adherence to treatment. RESULTS: Increased levels of mother-adolescent conflict were associated with poorer treatment adherence and both mother-reported diabetes-related conflict and DDMA predicted adolescents' glycemic control. Higher levels of mother-reported spousal support were associated with less conflict and greater adherence to treatment. Sobel's test indicated a statistical trend for conflict as a mediator between spousal support and adolescent treatment adherence (p < .07). DDMA did not predict mother-adolescent conflict and did not emerge as a mediator between mother-reported social support and adolescent adherence. CONCLUSIONS: This study highlights the role of spousal support for mothers of adolescents with IDDM and indicates that the level of spousal support mothers receive may play an important role in the health care behaviors of their adolescents.     

Health beliefs and regimen adherence in minority adolescents with type 1 diabetes

OBJECTIVE: To examine the appraisal of short- and long-term diabetes health risk and adherence, determine whether health risk predicts adherence and glycemic control in an ethnic minority sample, and determine whether perceptions of personal risk differ from risk to others. METHODS: Seventy-four youths with type 1 diabetes (ages 11-16) completed measures of risk perception and regimen adherence during their clinic visit; parents completed a measure of their children's adherence. Glycosylated hemoglobin A1c level was measured as part of the clinic visit. RESULTS: Regression analyses predicting parental report and self-reported adherence from appraisal of risk yielded nonsignificant results; perceived short-term complications to self predicted glycemic control. Appraisal of risk was higher for short- and long-term complications occurring to someone else with diabetes than to self. Greater risk for short-term complications than for long-term complications to self and other was found. CONCLUSIONS: The distinction between long-term and short-term complications and complications occurring to ones' self or someone else with diabetes was supported. Assessment of perceived risks for short-term complications is important for this age group and should be addressed in interventions to improve adherence.     

Parenting styles, regimen adherence, and glycemic control in 4- to 10-year-old children with diabetes

OBJECTIVE: To examine relationships among parenting styles, regimen adherence, and glycemic control for preschool and elementary school children who have Type I diabetes. METHODS: Parents of 55 children with diabetes completed parenting style and regimen adherence questionnaires. Glycosylated hemoglobin results were collected by chart review. RESULTS: Parental warmth was associated with better adherence ratings. Regression analyses showed that parental warmth explained 27% of the variance in adherence ratings. Parental restrictiveness was associated with worse glycemic control in univariate analyses. However, only Black ethnicity, not adherence or parenting variables, predicted glycemic control. Black ethnicity and lower socioeconomic status (SES) were associated with more parental restrictiveness and worse glycemic control. CONCLUSIONS: These results suggest that authoritative parenting, characterized by support and affection, may be advantageous for the regimen adherence and glycemic control of school-age and younger children with diabetes. Demographic characteristics are important and require further study in this context.     

Barriers to regimen adherence among persons with insulin-dependent diabetes

The present study was designed to assess the frequency of different barriers to adherence among persons with insulin-dependent diabetes mellitus (IDDM) and to determine the relationship between such barriers and adherence to insulin injection, glucose testing, and dietary and exercise components of the regimen. The behavior analytic model was used to develop a Barriers to Adherence Scale for adults and adolescents with IDDM. Sixty-five outpatient subjects were then interviewed in their home and reassessed 6 months later. Subjects reported the greatest number of barriers to dietary and exercise adherence and the fewest barriers to insulin injections. Females reported more barriers than males, but age was not associated with barriers scores. Self-report measures of adherence revealed consistent relationships between barriers and all areas of regimen adherence assessed. Adherence indices based on self-monitoring and dietary recall data correlated less consistently with barriers scores. We conclude that the behavior analytic model has great potential for use in the development of psychosocial assessment procedures for diabetes.This study was supported by Grants 28318 and 35524 from the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases.     

A longitudinal analysis of adherence and health status in childhood diabetes.

Applied structural equation modeling to a longitudinal data set of 193 youngsters with insulin-dependent diabetes mellitus assessed on two occasions, an average of 1.65 years apart. Six adherence constructs, Injection, Exercise, Diet Type, Testing-Eating Frequency, Calories Consumed, and Concentrated Sweets, were quantified from 24-hr recall interviews conducted with mother and child. Glycemic control was indexed by glycosylated hemoglobin (HA1C); lipid metabolism was indexed by fasting triglyceride levels (TRIG). The relationship of each adherence construct to metabolic control was tested separately. Patient age and disease duration served as exogenous variables in all models. Testing-Eating Frequency was associated with HA1C and Injection was associated with TRIG; in both cases better adherence was associated with better metabolic control. However, the standardized regression weights and variance accounted for were small. Patient age was a predictor of both adherence and metabolic control; older youngsters were less adherent and were in worse metabolic control. Inspection of models for younger versus older children suggested that age-homogeneous models improved prediction, but adherence and metabolic control linkages remained weak. Suggestions for refining the model are provided.     

Prediction of adherence and control in diabetes

This study aims to predict adherence to diabetic treatment regimens and sustained diabetic control. During two clinic visits that were 2 months apart, 63 adult outpatients completed measures of diabetic history, current treatment, diabetic control, adherence, and self-efficacy about adherence to treatment. Results showed that self-efficacy was a significant predictor of later adherence to diabetes treatment even after past levels of adherence were taken into account. Posttest levels of adherence in turn were significantly associated with posttest %HbA₁c after control for illness severity. A stepwise multiple regression to predict %HbA₁c at post entered pretest measures of diabetic control, treatment type, and self-efficacy, which together predicted 50% of the variance. Results are related to self-efficacy theory and implications for practice are discussed.This research was conducted as partial fulfillment of the requirements for a Bachelor of Arts degree by the second author. Dr Wilson was then with the University of Sydney.     

Case study: feasibility of multisystemic therapy as a treatment for urban adolescents with poorly controlled type 1 diabetes

OBJECTIVE: To determine the feasibility of using multisystemic therapy (MST), an intensive, home-based psychotherapy, to improve poor metabolic control among four adolescents with type 1 diabetes. METHOD: A multiple baseline, repeated measures design was used. Blood glucose readings were obtained every 2 weeks during a baseline period, a 7-month intervention, and a month-long postintervention period. Glycosylated hemoglobin (GHb) was measured at baseline and follow-up and was contrasted between two participants who received MST and two participants who did not receive the intervention. RESULTS: Intervention participants showed improvements in health status, as well as fewer hospitalizations and emergency room visits. CONCLUSIONS: Findings from this case study suggest that MST has the potential to improve treatment adherence and metabolic control among teens with poorly controlled type 1 diabetes.     

The relation between family factors and metabolic control: the role of diabetes adherence

OBJECTIVES: To examine family factors as predictors of metabolic control in children with type 1 diabetes and determine whether adherence behaviors mediate this relationship. METHOD: Participants were 109 children (ages 8-18) and a parent. Measures of diabetes-specific family functioning and an adherence interview were completed. Glycosylated hemoglobin (HbA1c) was the index of metabolic control. RESULTS: Family functioning and adherence were strongly associated with metabolic control. Combined with demographic information, these constructs accounted for 49% of the variance in metabolic control. Age moderated the relation between aspects of family functioning and HbA1c. Path analyses suggest that adherence mediates the relationship between family functioning and metabolic control. CONCLUSIONS: Family functioning and adherence behaviors are strongly related to a child's health status. Assessment of diabetes-specific family functioning, in addition to adherence, is an important factor in understanding metabolic control.     

Response to hypo- and hyperglycemia in adolescents with type I diabetes

OBJECTIVE: To assess the appropriateness of adolescents' responses to hypo- and hyperglycemia and to examine the relationship of patient age, gender, diabetes duration, diabetes knowledge, parental supervision, and glycemic control to response appropriateness. METHODS: We assessed 125 adolescents' responses to daily episodes of hypo- and hyperglycemia by 24-hour recall interviews; responses were coded for type and appropriateness. RESULTS: Adolescents responded inappropriately to 38% of hypoglycemic and 29% of hyperglycemic episodes. Parental supervision of blood glucose testing did not increase the likelihood of an appropriate response; in the case of hyperglycemic episodes, it appeared to be counterproductive. Adolescents who responded inappropriately to hyperglycemia were also older but not different from those who responded appropriately by gender, disease duration, diabetes knowledge, or glycemic control. CONCLUSIONS: Health providers and family members may underestimate adolescents' difficulty managing hypo- and hyperglycemia appropriately. The presence of parental supervision does not ensure an appropriate response; parents may be particularly misinformed about the management of hyperglycemia.     

A follow-up study of adherence and glycemic control among Hong Kong youths with diabetes

OBJECTIVE: To extend longitudinally an earlier study of the pathway from symptoms of emotional distress (ED) through self-efficacy (SE) and adherence to glycemic control (GC) in youths with diabetes, and to examine the contribution of different specific adherence behaviors to changes in GC. METHODS: Fifty-six Hong Kong youths with diabetes received a follow-up evaluation 12-24 months after initial participation. ED, SE, self-reported adherence to medical regimen (SRA), and GC were assessed at both evaluations. RESULTS: The pathway from ED to SE to SRA to GC was replicated. Participants' SRA to regular checks on blood glucose levels, and taking steps to maintain levels in the recommended range, explained significant variance in changes in GC. CONCLUSIONS: The model offers strategies to enhance health care in youths with diabetes. Findings support the importance of adherence to the medical regimen but emphasize the complexity of the relationship between adherence behaviors and GC. Self-regulatory behaviors, rather than compliance with fixed instructions, appear to have the most impact on GC.     

Attributions of adolescents with type 1 diabetes related to performing diabetes care around friends and peers: the moderating role of friend support

OBJECTIVE: To examine the relationships among negative attributions of friend and peer reactions to diabetes management in social situations, anticipated adherence difficulties, friend support, diabetes stress, and metabolic control. METHODS: A sample of 102 adolescents with Type 1 diabetes completed instruments measuring attribution of friend and peer reactions, anticipated adherence, friend support, and diabetes stress. Metabolic control was measured by the percentage of hemoglobin A1c. RESULTS: Structural equation modeling demonstrated an excellent fit of two models depicting the mediating role of anticipated adherence difficulties and diabetes stress on the relationship between negative attributions of friend (first model) and peer (second model) reactions and metabolic control. Friend support was found to moderate the path between diabetes stress and metabolic control in an unexpected manner. That is, as friend support increased, so did the relationship between stress and metabolic control. CONCLUSIONS: Adolescents who make negative attributions about reactions of friends and/or non friend peers are likely to find adherence difficult in social situations and have increased stress, with the latter associated with metabolic control. Results are discussed in terms of a social information processing model of adjustment.     

Discrepancies between mother and adolescent perceptions of diabetes-related decision-making autonomy and their relationship to diabetes-related conflict and adherence to treatment

OBJECTIVE: To document the relationship between discrepancies in mother and adolescent perceptions of diabetes-related decision-making autonomy, diabetes-related conflict, and regimen adherence. METHODS: The sample was composed of 82 mother-adolescent dyads. Measures included adolescent and mother reports of diabetes-related decision-making autonomy, diabetes-related conflict, and regimen adherence. Nurses' reports of adherence and number of glucose tests performed each day were also obtained. RESULTS: Discrepancies between mother and adolescent perceptions of decision-making autonomy were related to greater maternal report of diabetes-related conflict. In particular, when adolescents reported that they were more in charge of decisions than reported by their mothers, mothers reported more conflict. Discrepancies between mother and adolescent perceptions of decision-making autonomy were not related to regimen adherence. CONCLUSIONS: The findings suggest that discrepancies between mother and adolescent perceptions of diabetes-related decision-making autonomy may be a potentially important area for intervention.     

Cultural factors and patients'' adherence to lifestyle measures

BACKGROUND: Non-adherence to preventive and therapeutic lifestyle recommendations among patients at high risk of cardiovascular disease is more prevalent and varied than previously thought. The problem needs to be addressed by those who are involved in the care of these patients. AIM: To measure adherence and barriers of complying with lifestyle recommendations among patients with high cardiovascular risk factors. DESIGN OF STUDY: Prospective study. SETTING: Six family-practice health centres in Kuwait. METHOD: Data are from 334 Kuwaiti adult males and females with hypertension, type 2 diabetes, or both, who completed a routine clinic visit in one of six family practice centres. Trained staff used a structured questionnaire to obtain a detailed medical history regarding exercise habits and barriers to compliance with diet and exercise programmes. Clinical criteria assessed were height, weight, and the control of blood pressure and blood sugar. RESULTS: From the study sample, 63.5% of patients reported that they were not adhering to any diet regimen, 64.4% were not participating in regular exercise, and 90.4% were overweight and obese. The main barriers to adherence to diet were unwillingness (48.6%), difficulty adhering to a diet different from that of the rest of the family (30.2%), and social gatherings (13.7%). The main barriers to adherence to exercise were lack of time (39.0%), coexisting diseases (35.6%), and adverse weather conditions (27.8%). Factors interfering with adherence to lifestyle measures among the total sample were traditional Kuwaiti food, which is high in fat and calories (79.9%), stress (70.7%), a high consumption of fast food (54.5%), high frequency of social gatherings (59.6%), abundance of maids (54.1%), and excessive use of cars (83.8%). CONCLUSION: The majority of individuals in the sample were overweight, did not engage in recommended levels of physical activity, and did not follow dietary recommendations. Additional cultural and demographic variables need to be considered to improve adherence to lifestyle measures.     

Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: I. The influence of patient coping and adjustment

An onset cohort of adolescents and children with insulin-dependent diabetes mellitus was studied over a 4-year period. Individual patient psychosocial and demographic factors were assessed at study inception and used to examine aspects of adherence over the follow-up. We found that initial assessment of patient coping (defense level, adaptive strength, and locus of control) and adjustment at study inception were predictive of the level of patient adherence to diabetic regimen over the 4 years of study. Psychosocial variables predicted adherence outcomes independent of patient age. This was found for three domains of adherence, i.e., diet, insulin adjustment, and metabolic monitoring, and for the composite index derived from the separate adherence scales. Preadolescents (ages 9-12) at study entry were more adherent than patients who were already adolescent (ages 13-16) when diagnosed. Using multiple regression, three factors (age, adjustment, ego defense level) accounted for 47% of the variance in adherence. No factors were predictive of change in adherence during the follow-up. Thus, psychosocial characteristics of diabetic children assessed shortly after diagnosis predicted typical or average adherence over a 4-year period. Identification of such characteristics may be useful in developing strategies for intervention early in the course of illness.     

Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: II. Immediate and long-term linkages with the family milieu

Cross-sectional and longitudinal findings drawn from a 4-year longitudinal study of an onset cohort of preadolescents and early adolescents with insulin-dependent diabetes and their families are presented. Patient and parent perceptions of the family environment near the time of diagnosis are used to examine patterns of adherence in the first year of illness as well as over the four follow-up years. We found that family conflict, cohesion, and organization were strongly associated with independently rated first-year adherence levels. The strongest predictor of longer term adherence was family conflict, as experienced by the patients. In addition, parents' and youngsters' perceptions of family cohesion predicted improved adherence as well as overall higher levels of patient adherence. The findings are discussed with respect to the clinical implications of discovering those family characteristics that can, shortly after diagnosis, predict short- and long-term adherence. In addition, we present planned investigations intended to further clarify paths from family perceptions to individual diabetes behaviors.     

Brief report: a cognitive behavioral intervention for distressed adolescents with type I diabetes

OBJECTIVE: To examine the impact of a cognitive behavioral intervention for distressed adolescents with Type I diabetes. METHODS: Six youths with elevated levels of anxiety, anger, or diabetes stress received training in cognitive restructuring and problem solving in individual sessions. A multiple baseline design across participants was used. Treatment effectiveness was assessed through measures of anxiety, anger expression, and diabetes stress. RESULTS: Four youths displayed some improvement on one or more variables for which they had elevated levels during baseline, while others showed no impact. CONCLUSIONS: Cognitive behavioral interventions show some promise for distressed youths with Type I diabetes. Individual youths responded to treatment differently. Further research is needed in developing procedures to better meet the needs of youths, improve youth participation, and enhance treatment effectiveness.