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.     

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.     

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.     

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.     

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.     

Pathways from emotional adjustment to glycemic control in youths with diabetes in Hong Kong

OBJECTIVE: To examine factors that influence emotional adjustment, adherence to diabetic care, and glycemic control in Hong Kong youths with insulin-dependent diabetes mellitus (IDDM). METHODS: Seventy youths, their mothers, and matched controls provided information on health beliefs, authoritarian parenting style, parent-child conflict, emotional adjustment, and adherence to medical regimen. Glycosylated hemoglobin levels were obtained to measure glycemic control. RESULTS: Predictors explained 34% of the variance in emotional adjustment and 39% of the variance in glycemic control. The data supported a pathway from emotional adjustment to self-efficacy to adherence behaviors to glycemic control. In contrast to Western culture and consistent with prediction, parenting style did not associate with negative outcomes, and even relatively low levels of parent-child conflict correlated negatively with emotional adjustment in this culture. CONCLUSIONS: Management of conflict and self-efficacy enhancing interactions are suggested interventions to enhance adherence to diabetic care in Hong Kong youths with IDDM.     

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.     

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.     

Gender differences in adherence and metabolic control in urban youth with poorly controlled type 1 diabetes: the mediating role of mental health symptoms

OBJECTIVE: To examine gender differences in adherence and metabolic control and test the mediating role of mental health symptoms in a sample of predominantly African-American, low-income youth with chronically poor metabolic control. METHODS: Baseline questionnaire data from an intervention study were collected from 119 youth and their primary caregiver. RESULTS: Boys had worse adherence than girls, but there were no gender differences in hemoglobin A1C (HbA1C). Boys had more externalizing symptoms, whereas girls had more anxiety; there were no gender differences in depression. Externalizing symptoms were associated with poor adherence and metabolic control. Although anxiety was correlated with poor adherence, this relationship was not significant in the invariate analysis. Results of structural equation modeling (SEM) suggested that externalizing symptoms mediated the relationship between gender and adherence. CONCLUSIONS: Results suggest that gender differences in adherence may be attributed, in part, to gender differences in externalizing symptoms in urban youth with poor metabolic control. Interventions targeting these symptoms may be necessary to improve adherence and HbA1C in both boys and girls.     

Impact of family environment and support on adherence,metabolic control,and quality of life in adolescents with diabetes

Background: Diabetes is a common disease in pediatric populations. Family functioning has been related to child adaptation to diabetes. Purpose: To determine the impact of family factors on diabetes, particularly the influence of family support and family environment on adherence to treatment, quality of life, and metabolic control in Portuguese adolescents with type 1 diabetes, taking in consideration age, sex, duration of disease, and social class. Method: This study used a cross-sectional design. A sample of 157 Portuguese diabetic patients filled disease-specific measures on adherence and quality of life and family functioning measures. Hypotheses were that family support and an organized family environment (high cohesion and low conflict) would be positively associated with better adherence, metabolic control, and quality of life. Results: This study’s results confirmed that adherence was predicted by family support for females and lower-class patients while metabolic control was predicted by family conflict for upper-class patients. Quality of life was predicted by lack of family conflict and family social support for both males and females as well as lower-class patients. Conclusion: The results highlight the importance of studying family variables in adolescents’ diabetes care within the wider cultural factors affecting the patient.     

Self-classification as an adult in patients with type 1 diabetes: relationships with glycemic control and illness coping

Objective

Previous community research has demonstrated the link between adult self-classification and health behaviors. The present study investigated the extent to which individuals with type 1 diabetes (ages 18–30 years) classified themselves as adults as compared with individuals without diabetes. Adult self-classification was examined in relation to illness coping and glycemic control.

Methods

A total of 194 patients and 287 control individuals participated. Adult self-classification was assessed using a single item, coping was assessed using the Diabetes Coping Measure, and glycemic control was determined by HbA_1c values.

Results

Compared with control participants, more patients classified themselves as adults. Furthermore, adult self-classification was positively related to glycemic control. Structural equation modeling indicated that coping mediated the relationship between adult self-classification and glycemic control.

Conclusion

Individuals with diabetes classified themselves as adults more often than did their peers without diabetes, possibly due to their need to master their lives when confronted with diabetes. Adult self-classification appeared to function as a resource for glycemic control through its relationship with specific coping strategies.

Practice implications

The present study underscores the need to assess adult self-classification in individuals with diabetes. Our findings call for a developmentally tailored transition from pediatric to adult care.     

Effects of behavioral family systems therapy for diabetes on adolescents' family relationships, treatment adherence, and metabolic control

BACKGROUND: Behavioral family systems therapy (BFST) for adolescents with diabetes has improved family relationships and communication, but effects on adherence and metabolic control were weak. We evaluated a revised intervention, BFST for diabetes (BFST-D). METHODS: One hundred and four families were randomized to standard care (SC) or to 12 sessions of either an educational support group (ES) or a BFST-D over 6 months. Family relationships, adherence, glycosylated hemoglobin (HbA1c), and health care utilization were measured at baseline and after treatment. RESULTS: BFST-D significantly improved family conflict and adherence compared to SC and ES, especially among those with baseline HbA1c > or = 9.0%. BFST-D and ES significantly improved HbA1c compared to SC among those with baseline HbA1c > or = 9.0%. CONCLUSIONS: The revised intervention (BFST-D) improved family conflict and treatment adherence significantly, while both ES and BFST-D reduced HbA1c significantly, particularly among adolescents with poor metabolic control. Clinical translation of BFST-D requires further study.     

Social support and personal models of diabetes as predictors of self-care and well-being: a longitudinal study of adolescents with diabetes

OBJECTIVES: To examine whether peer support and illness representation mediate the link between family support, self-management and well-being. METHOD: Fifty-two adolescents (12-18 years old) with Type I diabetes were recruited and followed over 6 months, completing assessments of self-management, well-being, and social support. RESULTS: Perceived impact of diabetes and supportive family and friends were prospectively predictive of participants' well-being measures. Although support from family and friends was predictive of better dietary self-care, this relationship was mediated by personal model beliefs. In particular, beliefs about the effectiveness of the diabetes treatment regimen to control diabetes was predictive of better dietary self-care. CONCLUSIONS: Both friends and family are important to support adolescents as they live with and manage their diabetes. Personal models of diabetes are important determinants of both dietary self-care and well-being. In addition, personal models may serve to mediate the relationship between social support and dietary behavior.     

Psychological functioning of children with insulin-dependent diabetes mellitus: a longitudinal study

Assessed school-age youth repeatedly over the first 6 years of their insulin-dependent diabetes mellitus (IDDM) to determine self-perceived psychological adjustment. After the first year of IDDM, Ss exhibited a mild increase in depressive symptoms. Anxiety decreased for boys but increased for girls over the duration of IDDM. In contrast, self-esteem remained stable regardless of rehospitalizations or degree of metabolic control. Ss' adjustment shortly after IDDM onset, as reflected by levels of depression, anxiety, and self-esteem, were predictors of later adjustment. In general, Ss found the implications of IDDM more upsetting and the regimen more difficult with time, and girls were more upset by their illness than boys. The degree to which children were upset by the implications and management of IDDM varied as a function of their anxiety and depression.     

Peer and family support in children and adolescents with type 1 diabetes

OBJECTIVE: To examine social support and peer and family involvement in relation to diabetes management within a developmental context. METHODS: Sixty-eight youths ages 8 to 17 diagnosed with type 1 diabetes participated. This study represents the phase 1 data from a multisystemic, home-based intervention. Data included parent and youth report of disease management and conflict, youth-reported perceptions of support, peer participation in the intervention, and HbA1c. RESULTS: Adolescents perceived greater diabetes-related peer support than did school-age children. Perceived peer and family support were not correlated with metabolic control. Peer participation in the intervention was correlated with metabolic control. CONCLUSIONS: There is a developmental shift in perceptions of peer support. Increased perceptions of peer and family support overall may not result in improved metabolic control. Social support interventions should focus on the types of support that are most highly associated with positive health outcomes.     

Brief report: disordered eating and psychosocial factors in adolescent females with type 1 diabetes mellitus

OBJECTIVE: To evaluate whether insulin pump therapy [continuous subcutaneous insulin infusion (CSII)] is associated with a lower frequency of disordered eating, better glycemic control, and improved quality of life and self-efficacy compared to multiple daily injections (MDI) in adolescent females with type 1 diabetes mellitus (T1DM). METHODS: This cross-sectional study included 22 adolescent females using CSII and 47 adolescent females using MDI who completed standardized questionnaires measuring disordered eating, quality of life, and self-efficacy. Most recent glycosylated hemoglobin (HbA1(c)) and measures of personal characteristics were drawn from medical records. RESULTS: The CSII group exhibited better glycemic control and reported higher quality of life and more self-efficacy. However, the groups did not differ significantly on disordered eating behaviors and attitudes. CONCLUSION: Insulin pump therapy may provide a means for improving glycemic control, quality of life, and self-efficacy in adolescent females with type 1 diabetes.     

Fathers’ and mothers’ attachment styles,couple conflict,parenting quality,and children’s behavior problems: an intervention test of mediation

ABSTRACT

A diverse sample of 239 primarily low-income couples participated in a random controlled trial of the Supporting Father Involvement couples group intervention. In this report, we examined the value of adding measures of fathers’ attachment style and parenting to mothers’ measures in order to explain variations in children’s behavior problems. We also tested the hypothesis that the link between intervention-induced reductions in couple conflict and reductions in anxious/harsh parenting can be explained by intervention effects on parents’ attachment insecurity or on anxiety and depression. Fathers’ attachment security and parenting behavior added significantly to mothers’ in accounting for children’s internalizing and externalizing problem behaviors. Fathers’ anxious attachment style and anxiety/depression mediated the link between post-intervention reductions in parental conflict and anxious/harsh parenting. For mothers, only improvements in attachment security accounted for those links. The findings support the need for attachment researchers to consider the contributions of both parents to their children’s development.     

Glycemic control in youth with type 1 diabetes: family predictors and mediators

OBJECTIVE: This study examined predictive and mediated relationships among youth perception of critical parenting, Child Behavior Checklist Externalizing Subscale (CBCL) externalizing problem scores, adherence, and (hemoglobin A(1c) HbA(1c)), in youth with type 1 diabetes from low socioeconomic status families. METHODS: Caregiver/youth dyads (n = 120) completed diabetes specific measures of family functioning regarding diabetes management and structured adherence interviews. Parents completed the CBCL, while assays of youth HbA(1c) were performed. Analyses were conducted using hierarchical linear regression. RESULTS: Combined measures predicted 44% of the variance in HbA(1c). Adherence partially mediated critical parenting and HbA(1c), while critical parenting and adherence mediated CBCL externalizing problem scores and HbA(1c). CBCL externalizing problem scores did not mediate critical parenting and HbA1(c). CONCLUSIONS: The presence of youth perceptions of critical parenting and youth externalizing behavior problems may interfere with adherence, leading to increases in HbA(1c).