Journal of Pediatric Psychology, Vol. 25, No. 1, 2000, pp. 23-33
© 2000 Society of Pediatric Psychology
Randomized, Controlled Trial of Behavior Therapy for Families of Adolescents With Insulin-Dependent Diabetes Mellitus
1 Nemours Children's Clinic, 2 University of Florida, 3 Washington University School of Medicine, 4 St. Louis Children's Hospital
All correspondence should be sent to Tim Wysocki, Nemours Children's Clinic, 807 Nira Street, Jacksonville, Florida 32207. E-mail: twysocki{at}nemours.org .
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Abstract |
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Objective: To describe the short-term results of a controlled trial of Behavioral Family Systems Therapy (BFST) for families of adolescents with diabetes.
Methods: We randomized 119 families of adolescents with diabetes to 3 months' treatment with either BFST, an education and support Group (ES), or current therapy (CT). Family relationships, psychological adjustment to diabetes, treatment adherence and diabetic control were assessed at baseline, after 3 months of treatment (reported here), and 6 and 12 months later.
Results: Compared with CT and ES, BFST yielded more improvement in parent-adolescent relations and reduced diabetes-specific conflict. Effects on psychological adjustment to diabetes and diabetic control were less robust and depended on the adolescent's age and gender. There were no effects on treatment adherence.
Conclusions: BFST yielded some improvement in parent-adolescent relationships; its effects on diabetes outcomes depended on the adolescent's age and gender. Factors mediating the effectiveness of BFST must be clarified.
Key words: behavior therapy; family therapy; adolescents; diabetes.
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Introduction |
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Treatment of insulin-dependent diabetes mellitus (IDDM) is designed to maintain near-normal blood glucose levels (DCCT Research Group, 1994
).
The regimen includes several daily insulin injections, self-monitoring of
blood glucose, a prescribed meal plan, regular exercise, and problem-solving
tactics to regulate blood glucose. Adaptation to IDDM is often more difficult
during adolescence when family communication and conflict resolution tend to
deteriorate. The treatment burden pervades daily life, complicating other
challenges of adolescence, and the regimen often becomes the focus of
parent-adolescent conflict.
Family conflict has been associated with adolescents' treatment adherence
and diabetic control in cross-sectional studies
(Anderson, Miller, Auslander, &
Santiago, 1981; Marteau,
Bloch, & Baum, 1987). Because similar associations have been
found in longitudinal studies, we may infer that family conflict may be
related causally to poor diabetes outcomes
(Gustafsson, Cederblad, Ludvigsson, &
Lundin, 1987; Hauser et al.,
1990). Other studies point to parent-adolescent conflict
specifically as a correlate of poor diabetes outcomes
(Bobrow, AvRuskin, & Siller,
1985; Miller-Johnson et al.,
1994; Wysocki,
1993). The association between parent-adolescent relationships and
family conflict may be bi-directional, but it is plausible that a treatment
targeting family communication and conflict resolution could improve
adaptation to IDDM, treatment adherence, and diabetic control. A few studies
support the effectiveness of family therapy with this population, but none was
a well-controlled trial of treatments that target parent-adolescent
communication (Ryden et al.,
1994; Snyder,
1987).
Robin and Foster's (1989)
behavioral family systems model suggests promising research directions,
portraying parent-adolescent conflict as a product of the clash between the
adolescent's need for autonomy and parental needs to maintain stability. They
argue that parent-adolescent conflict is modulated by four factors: family
problem-solving skills; family communication; the degree to which family
members hold extreme beliefs about one another; and the extent of family
structural or systemic anomalies. They have validated several assessment tools
based on the model (Prinz,
1977; Robin, Koepke, &
Moye, 1990) and behavioral family systems therapy (BFST), an
intervention targeting their central constructs. The model is supported by
studies confirming the benefits of BFST and similar therapies (e.g.
Barkley, Guevremont, Anastopoulos, &
Fletcher, 1992; Foster, Prinz,
& O'Leary, 1983; Guerney,
Coufal, & Vogelsong, 1981). Since BFST reduces
parent-adolescent conflict, it could help families of adolescents to cope with
IDDM by improving their communication and conflict resolution skills. Such
improvements could enhance parental social supports for diabetes self-care,
reduce overall family stress and clarify responsibility for diabetes tasks
(Wysocki et al., 1997). This
paper compares the short-term outcomes of three treatments: current medical
therapy alone or augmented by ten sessions of participation in either BFST or
an educational support group.
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Method |
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Participants
The sampling plan was designed to recruit families who were appropriate candidates for BFST. The enrollment criteria were designed to ensure that parent-adolescent conflict in each family might be expected to impede management of diabetes. Because we considered severe psychopathology to be a contraindication for BFST, families with recent treatment for certain psychiatric diagnoses were excluded. Enrollment was limited to adolescents with adequately stable family structure to enable completion of the various study requirements.
Adolescents with IDDM and their parents were recruited in St. Louis, Missouri, or Jacksonville, Florida. Recruitment included an initial confirmation of eligibility based on demographic factors followed by a screening process to ensure that enrolled families had at least moderate levels of parent-adolescent conflict. Initially, 380 families were contacted about the study and to verify that the adolescent met these criteria: age between 12 years (an age at which parent-adolescent conflict often increases) and 16.75 years (to ensure that adolescents lived at home during the 15-month study); IDDM for at least 1 year; no other major chronic diseases; no mental retardation; no incarceration, foster care, or residential psychiatric treatment; and absence of diagnoses of psychosis, major depression, or substance abuse disorder in parents or adolescents during the prior 6 months. Families were not asked to report on psychiatric diagnoses prior to that point in time. Parents or step-parents living with the patient were required to participate in the study and other adult caregivers were allowed to participate. Of the 380 families contacted, 28 did not meet all of the demographic enrollment criteria. The 174 families who denied interest in the study cited time constraints (41%), travel distance (17%), minimal parent-adolescent conflict (33%), and other factors (9%) as reasons for not participating.
Eligible, interested families (n = 178) then signed an approved
informed consent form and completed two screening tools: the Conflict Behavior
Questionnaire (CBQ; Prinz, Foster, Kent,
& O'Leary, 1979) and the Diabetes Responsibility and Conflict
Scale (DRC; Rubin, Young-Hyman, &
Peyrot, 1989). This was done to limit study enrollment to families
reporting parent-adolescent conflict at levels that could impede family
management of IDDM. In consultation with the authors of these tools, we
identified cutoff scores that were expected to exclude 60% of families (CBQ
> 5; DRC > 24). Only families in which at least one family member
obtained scores above these cutoffs on one or both scales were eligible to
enroll. Of 132 families exceeding this criterion, 119 (90%) enrolled in the
study. The CBQ was used only for pre-enrollment screening purposes, while the
DRC was also treated as an outcome measure. Participants included 119
adolescents, 117 female caregivers, and 82 male caregivers. The 46 families
excluded by the screening procedure did not differ demographically from those
who enrolled. The apparent enrollment rate of 31% (119 of 380 contacted) is
artifically low as the denominator includes families who were ineligible
demographically (n = 28), who failed the conflict screening criterion
(n = 46), or who reported minimal parent-adolescent conflict as a
reason for refusing to participate (n = 58). With these families
eliminated from consideration, the enrollment rate is 52% (119 of 228 families
enrolled). No patients received mental health services from any of the
researchers other than those received in this project.
Measures
Participants completed a baseline evaluation and follow-up evaluations
scheduled at posttreatment (3 months), and at 6 and 12 months after the
conclusion of treatment. This article reports only results of the baseline and
3-month (immediate posttreatment) evaluations. Each evaluation included
collection of interview, questionnaire, and biochemical data; order of
administration of instruments was counterbalanced among families. A research
assistant administered questionnaires at evaluation sessions; the research
assistant completed telephone interviews during the 2 weeks preceding each of
the four evaluations. A detailed procedural manual promoted equivalence of
methods across the two sites. Measures were chosen to provide varied
perspectives of the family processes targeted by BFST and of the general and
diabetes-specific outcomes expected to be affected by changes in those
factors. The following are the specific measures used.
Demographic Factors. Parents reported the patient's age, gender,
race, duration of IDDM, family composition, family size, and the information
needed for measuring socioeconomic status (SES) with the Hollingshead
Four-Factor Index of Social Status
(Hollingshead, 1975). Tanner
stage information was retrieved from each adolescent's medical record.
Demographic data were updated at follow-up evaluations.
General Parent-Adolescent Relationships. The Parent-Adolescent
Relationship Questionnaire (PARQ; Robin et
al., 1990) assesses the primary constructs in the behavioral
family systems model. It yields 16 subscales that load on three factors: Overt
Conflict/Skill Deficits; Extreme Beliefs; and Family Structure, with higher
scores indicative of worse family relations. There are separate forms for
adolescents (314 items) and parents (280 items), and the normative group
included 314 adolescents and 427 parents. Internal consistency based on the
present sample ranged from.73 to.89 for the three scales and did not differ
among adolescents, mothers, and fathers.
The Issues Checklist (IC) obtains ratings of the frequency and intensity of
recent conflicts around 44 issues (Prinz
et al., 1979). It yields scores for the number of conflict items
endorsed and for conflict frequency and intensity. Higher scores indicate more
parent-adolescent conflict. Internal consistency based on the present sample
was.74 for adolescents,.72 for mothers, and.79 for fathers.
Montemayor and Hanson's
(1985) telephone recall
interview was used to collect participants' descriptions of conflict
situations that occurred in the prior day. The topic, participants, intensity,
duration, and manner of conflict resolution (negotiation, withdrawal, and
authoritarian parental action) were recorded. Higher scores are less
favorable. This study yielded significant correlations between parents and
youths for frequency (r =.68), intensity (r =.57), and
duration (r =.53) of conflict events.
IDDM-Specific Psychological Adjustment. The Teen Adjustment to
Diabetes Scale (TADS) is a 21-item Likert-type scale with parallel parent and
adolescent forms that measures adolescents' behavioral, affective, and
attitudinal adjustment to IDDM (Wysocki,
1993). Higher scores indicate more favorable adjustment to IDDM.
Internal consistency, calculated from data obtained from the present sample,
was.81 for adolescents,.87 for mothers, and.88 for fathers.
The DRC (Rubin et al.,
1989) assesses parent-child conflict over 15 IDDM tasks. Higher
scores indicate more conflict about the diabetes regimen. Internal consistency
based on the present sample was.92 for adolescents,.86 for mothers, and.89 for
fathers.
IDDM Treatment Adherence. Parents and teens were interviewed
separately during three 20-30 min telephone interviews over 2 weeks to elicit
their recall of IDDM self-care during the prior day. The 24-Hour Recall
Interview (Johnson, 1995)
yields reliable and valid scores for five adherence factors: Diet Composition,
Diet Amount, Insulin, Testing and Eating Frequency, and Exercise. Higher
scores indicate worse adherence. Each interview began with assessment of IDDM
treatment adherence and then of teen-parent conflict using the Montemayor and
Hanson (1985) method.
The 14-item Self-Care Inventory (SCI) validated by Greco et al.
(1990) was used to sample
adherence over a longer interval than is captured by the recall interviews.
Higher scores indicate better treatment adherence. Internal consistency based
on the present sample was.76 for adolescents,.81 for mothers, and.82 for
fathers.
Health Status. At each evaluation, a 3 cc venous blood sample was collected from each patient for glycated hemoglobin (GHb) assays to index recent diabetic control. A regression equation, based on concurrent measurements on 56 split samples, was used to enable treatment of all results as if they had been obtained from one laboratory (i.e., GHbSt. Louis = 1.007[GHbJacksonville] -.032). The normal range for the assay is about 6%-8% and higher values indicate poorer metabolic control.
Parents reported hospitalizations, emergency room visits, and contacts with other mental health professionals at the 3-month evaluation. These reports were verified by chart review or contact with the pertinent health professionals when possible. The study did not include collection of pre-enrollment measures of these variables.
Procedure
After the baseline evaluation, the research assistant at the opposing
center randomly assigned each family to one of the three conditions described
below. Randomization was stratified by the adolescent's gender and treatment
center so that each center enrolled a similar number of boys and girls into
the three groups.
Current Therapy (CT). Patients in the CT group (and in the other groups) continued in standard therapy for IDDM directed by their physicians, including examination by a physician and GHb assay three or more times annually; two or more daily injections of mixed intermediate and short-acting insulins; home blood glucose monitoring and recording of test results; IDDM self-management training; a prescribed diet; physical exercise; and annual evaluation for long-term diabetic complications.
Education and Support (ES). In the first 12 weeks of the study, ES
families attended 10 group meetings emphasizing diabetes education and social
support. The meetings were designed to emulate a common mental health service
for families of chronically ill adolescents and to serve as a "best
alternative therapy" comparison. A master's level social worker with
extensive diabetes experience and a master's level health educator served as
group facilitators. Panels of two to five families began and completed a
10-session series together, attended by the parents and adolescent with
diabetes. Session content was organized around the chapters of the American
Diabetes Association's Diabetes Support Groups for Young Adults: A
Facilitator's Manual
(1990). The same materials and
session outlines were used at both sites, and the two facilitators conferred
weekly by telephone to ensure consistency of the intervention. Family
communication and conflict resolution skills were excluded from session
content. Each session included a 45-min educational presentation by a diabetes
professional on one of the 10 topics, followed by 45 minutes of family
interaction about that topic led by the facilitator.
Behavioral Family Systems Therapy (BFST). Adolescents and parents
in this group received 10 sessions of Robin and Foster's
(1989) BFST. Sessions were
conducted by one of two licensed psychologists who each received about 150
hours of training and supervised BFST experience and were certified as
proficient by Dr. Robin. Extensive efforts ensured that each psychologist's
technical proficiency was maintained throughout the study; every BFST session
was audiotaped and rated by either Dr. Robin or one of the project
psychologists, and feedback from these ratings was provided in weekly
conference calls. These ratings verified excellent treatment fidelity
throughout the study. Neither psychologist demonstrated any consistent or
significant departure from prescribed therapy content or delivery. A detailed
therapy manual supplemented the guidelines offered by Robin and Foster
(24) and included session
outlines, educational handouts, and homework assignments used at both sites.
BFST consisted of four therapy components matched to families' treatment needs
as identified by the project psychologists based on study data and family
interaction in sessions: Problem-solving training provided families
with a behavioral contracting approach to conflict resolution with training in
problem definition, generation of alternative solutions, group decision
making, planning, implementation and monitoring of the selected solution, and
renegotiation or refinement of ineffective solutions. Communication skills
training included instructions, feedback, modeling, and rehearsal
targeting common parent-adolescent communication problems. Cognitive
restructuring was used to identify and change family members' exaggerated
beliefs, attitudes, and attributions that may have impeded effective
parent-adolescent communication and conflict resolution. Functional and
structural family therapy interventions targeted anomalous family
systemic characteristics (e.g., weak parental coalitions; cross-generational
coalitions) that may have impeded effective problem solving and
communication.
Families received an individualized BFST treatment plan designed by the three project psychologists in accord with the results of baseline assessments and observation of family interactions. Sessions consisted of family problem-solving discussions and focused on IDDM-specific or general conflictual issues as appropriate for each family. The psychologist used standard behavior therapy techniques of instructions, feedback, modeling, and rehearsal. Behavioral homework was assigned at each session and reviewed at the next session. Families were asked to practice the targeted skills at home and to apply them to new problems.
Participation Incentives and Intervention Adherence
To promote adherence to the study requirements, we paid families $100 ($50
each for the parents and adolescent) upon completing each evaluation. The ES
and BFST families could earn another $100 if they completed all 10 treatment
sessions. The 3-month follow-ups were completed by 115 families (96%). All 10
treatment sessions were completed by 87% of BFST families and 91% of ES
families. Psychological services outside of the study were received by five CT
families (22 sessions), three ES families (21 sessions), and no BFST families.
There were no psychiatric admissions.
Data Reduction
To reduce the number of statistical comparisons, clarify data presentation,
and decrease measurement error, we calculated family composite scores by
summing and averaging the scores of individual family members (e.g.
Hanson, Henggeler, & Burghen,
1987). This was justified conceptually since all family members
reported on the same family behaviors and, in each case, there were
significant positive correlations (range.45 to.83) between family members'
scores. This reduced the number of univariate tests from 45 to 21, reducing
both the risk of Type I error and variability in some measures. Our
conclusions did not differ when we analyzed individual family members.
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Results |
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Sampling and Randomization
The sampling plan was designed to enroll families with parent-adolescent relationship difficulties that were severe enough to impede family management of diabetes. With the assay used for this study, a GHb level of 10% was considered indicative of good diabetic control. This criterion was exceeded by 73% of the enrolled adolescents, indicating that most were in poor or fair diabetic control. Mean scores for normative nondistressed families were exceeded by a substantial percentage of enrolled families on study measures for which these data were available. The percentage of families in which at least one family member's baseline scores exceeded the normative mean by one standard deviation or more were CBQ: 74%; DRC: 64%; PARQ Overt Conflict/Skill Deficits: 27%; PARQ Extreme Beliefs: 21%; PARQ Family Structure: 29%; and IC Number of Items Endorsed: 28%. For those measures without such a normative comparison group, 32% of the sample had SCI scores below 42, indicative of average adherence below 50% for each of the 14 diabetes management tasks, whereas on the TADS, 29% of the sample had scores below 63, indicative of poor emotional or social adjustment to 21 diabetes-related challenges. A total of 31 families (26%) did not meet any of these criteria, and these families were distributed equally among the three groups. Taken as a whole, these data suggest that the distributions of scores for the study sample were shifted in the direction of more frequent and severe parent-adolescent conflict and poorer adaptation to diabetes, confirming that a clinically appropriate sample of families was enrolled.
Table I describes the three groups at baseline with respect to the adolescents' age, duration of IDDM, gender, race, GHb level, Tanner stage, family size and composition, and parental socioeconomic status. Despite careful randomization, the three treatment groups differed at baseline on several demographic dimensions. The BFST group included significantly fewer intact families (Kruskal-Wallis H = 7.05; p <.03) and more single-parent families (Kruskal-Wallis H = 7.27; p <.03) than did the other two groups. The divorce rate for the CT group was significantly lower than that for either the ES or BFST groups (Kruskal-Wallis H = 5.47; p <.05).
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Table II shows that these demographic differences were accompanied by baseline differences in several measures, indicating greater conflict and poorer adaptation to IDDM among BFST families. Analyses of variance (ANOVA) with treatment group (degrees of freedom = 2, 116) as the between-subjects factor were conducted for family composite baseline scores on the PARQ, DRC, IC, SCI, TADS, and Recall Interviews and for GHb values. A significant main effect for groups, in each case indicative of less favorable status for the BFST group compared with one or both of the other two groups, was obtained on the following measures: PARQ Skill Deficits/Overt Conflict scale (F = 4.43; p <.02), IC Intensity scale (F = 3.19; p <.05), DRC (F = 3.61; p <.03), TADS (F = 3.08; p <.05), SCI (F = 3.29; p <.05), Recall Interview Testing/Eating Frequency (F = 4.03; p <.03) and Diet Amount (F = 3.71; p <.03) factors, and Recall Interview scores for duration of conflict events (F = 3.15; p <.05). Subsequent analyses were designed to compensate for these pretreatment group differences as described below.
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Statistical Analysis Strategy
Initial analyses consisted of repeated measures analyses of variance
(MANOVA) and analyses of covariance (ANCOVA) using the baseline values of the
outcome measures as the covariates and with group, adolescent age, and gender
as between-subjects factors. The MANOVA revealed no significant group x time
interactions for any measure. The ANCOVA yielded no significant main effects
at the 3-month follow-up when baseline values of the outcome measures served
as covariates.
Pretreatment inequality of the groups may impede discrimination of true
treatment effects from those due to regression toward the mean. With such
baseline differences, interpretation of statistical analyses may be impeded by
strong correlations between the baseline value of a variable and the magnitude
of change in that variable (Fleiss,
1986). This problem can be countered by treating baseline scores
as covariates (Llabre, Spitzer, Saab,
Ironson, & Schneiderman, 1991). Hence, ANCOVAs for
post-treatment change in each primary outcome measure were completed, using
the baseline value of the outcome measure as a covariate. This approach
controlled statistically for the baseline differences between groups, reducing
the influence of correlations between baseline status and change scores.
Because inspection of the data showed differences as a function of the age and
gender of the adolescent, all analyses treated the youth's age group (older.
[> 14.3 yrs] versus younger [< 14.3 yrs] based on a median split in
order to equate sample size) and gender as additional between-subjects
factors. Table II shows the
mean (± 1 SD) family composite scores on each measure at baseline and
3-month follow-up.
Measures of General Parent-Adolescent Relationships
The ANCOVA revealed a significant main effect for groups on mean change
from baseline to posttreatment in family composite scores on the PARQ Overt
Conflict and Skill Deficits scale, F(2, 103) = 2.98, p
=.050, and the Extreme Beliefs scale, F(2, 103) = 5.45, p
=.006, but no significant difference between groups on the Family Structure
scale. Post-hoc analyses using the Scheffe test showed that the BFST group
improved more on the Overt Conflict/Skill Deficits scale than the CT, but not
the ES, group. On the Extreme Beliefs scale, the BFST group had significantly
greater improvement than either the CT or ES groups. Neither the group x age,
group x gender, nor group x age x gender interaction effects were significant
for any of the three PARQ factor scores.
The ANCOVA revealed a significant main effect for groups on change in the IC scores for number of items endorsed, F(2, 103) = 4.75, p =.011, and conflict intensity, F(2, 103 = 3.99, p =.022, but no effect on conflict frequency, possibly due to excessive variability in that measure. Post-hoc analyses confirmed greater reduction in number of items and conflict intensity for BFST families than for either CT or ES families. No age or gender interaction effects were significant for any IC score. No group or interaction effects were significant for family conflict reported during recall interviews.
IDDM-Specific Psychological Adjustment
The ANCOVA revealed a significant main effect for groups on change in DRC
family composite scores favoring the BFST group, F(2, 103) = 3.08,
p =.049, indicative of decreased IDDM-specific conflict. There were
no significant age or gender interactions.
The ANCOVA analysis of change in family composite scores on the TADS revealed no significant main effects for groups, but significant group x gender, F(2, 103) = 3.35, p =.039, and group x age x gender, F(2, 103) = 3.18, p =.046, interaction effects were obtained, as shown in Table III. Older boys showed improved adjustment to IDDM (e.g., higher TADS scores) after treatment with BFST and worse adjustment following treatment with ES, whereas older girls demonstrated the opposite treatment effects.
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IDDM Treatment Adherence
No significant main or interaction effects were obtained for either the SCI
family composite score or the five factor scores obtained with the 24-Hour
Recall Interview.
Health Status Measures
The ANCOVA revealed no significant main effects for groups on baseline to
3-month change in GHb levels. However, significant group x age, F(2,
103) = 3.34, p =.041, and group x gender x age, F(2, 103) =
3.72, p =.028, interaction effects were obtained. Older adolescents
in the BFST group demonstrated a mean increase in GHb of 1.51%, whereas
younger adolescents displayed a.89% decrease, indicative of improved metabolic
control. The significant group x age x gender interaction effect is presented
in Table III, which shows that,
among BFST participants, older girls demonstrated a 2.19% increase in GHb,
while substantial decreases occurred for younger girls (-1.40%) and moderate
decreases were found for both younger (-.60%) and older (-.54%) boys. A
variety of analyses designed to explore pretreatment differences between older
girls and other participants failed to reveal any meaningful differences that
might have mediated these significant group x age x gender interactions.
There were no significant effects on the low frequencies of hospital admissions (2) or emergency room visits (5) reported at the 3-month follow-up evaluation.
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Discussion |
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This article compares the short-term benefits of BFST compared with continued current medical therapy or participation in a diabetes support group with a large, clinically relevant sample of families of adolescents with diabetes. The average GHb level of the study patients indicated very poor diabetic control, and the sample had generally unfavorable status on a variety of measures of parent-adolescent relationships and adaptation to diabetes. This study advances the methodology of previous trials of psychological treatments for families of youths with IDDM (Rubin & Peyrot, 1992
) by
using multiple well-validated outcome measures and two appropriate comparison
groups. In addition to these important features, the study goals went beyond
those of conventional treatment outcome studies by attempting to show that
change in a clinically relevant process (parent-adolescent relationships)
yielded changes in disease-related functioning and health status. Despite careful randomization, the three groups differed at baseline along many clinically meaningful dimensions, impeding the confirmation of clear treatment effects. Conventional MANOVA and ANCOVA methods did not confirm treatment benefits for BFST; ANCOVA treating the baseline values of the outcome measures as covariates enabled statistical control of these pretreatment differences. These analyses revealed significant between-group effects favoring BFST in terms of changes in several family composite scores on the PARQ, IC, and DRC, suggesting that BFST yielded some improvements in parent-adolescent relationships. Change in diabetes-specific outcomes such as GHb and TADS scores was less robust and depended on the age and gender of the adolescent. Older adolescent girls tended to deteriorate along these dimensions after BFST, whereas boys and younger girls derived benefits. There were no main or interaction effects obtained on measures of treatment adherence or parent-adolescent conflict derived from recall interviews.
Given the analytic problems inherent in evaluation of change scores, particularly with substantial group differences at baseline, the results of the ANCOVA analyses should be interpreted very cautiously. Although treatment of the baseline outcome measures enabled some degree of statistical control over these complications, the groups may have differed qualitatively despite this statistical manipulation. This report offers only suggestive evidence in support of the use of BFST with this population. The failure of the present randomization illustrates the importance of stratification based on key outcome variables in order to increase the probability of pretreatment equivalence of the groups.
This study expands the research literature on psychological interventions
for this population. Previous studies supporting the efficacy of family
therapy for youths with IDDM (Ryden et
al., 1994; Snyder,
1987) lacked the large sample size, comparison groups, and
multimodal assessment methods used in this study. The Diabetes Control and
Complications Trial (DCCT Research Group,
1994) showed that long-term maintenance of near-normal blood
glucose levels reduces the onset and progression of diabetic complications by
50%-75%. Those results were achieved with intensified use of available medical
tools, suggesting that translation of the DCCT findings into clinical practice
may depend on the validation of interventions for promoting adaptation to this
more demanding treatment.
This study suggests some promise for BFST in this regard, and the results
suggest avenues for further research to increase the impact of BFST on
diabetes outcomes. Targeting families of younger adolescents with BFST to
prevent, rather than remedy, family conflict around IDDM may be more
effective. Others have also reported greater effectiveness of behavioral
interventions among younger, or more recently diagnosed, children with IDDM
(Delamater et al., 1990;
Kaplan, Chadwick, & Schimmel,
1985). Further, the realization of benefits in important diabetes
outcomes may require BFST sessions targeted specifically at each family's
unique barriers to adequate treatment adherence and diabetic control. Clearly,
giving families general skills that improve parent-adolescent relationships
does not guarantee that those skills will be applied to enhance family coping
with diabetes. Other possibilities for improving the diabetes-specific impact
of BFST might include integrating it with other effective intervention
strategies such as multifamily support groups
(Satin, LaGreca, Zigo, & Skyler,
1989), training in use of blood glucose data for diabetes problem
solving (Anderson, Wolf, Burkhart, Cornell,
& Bacon, 1989; Delamater et
al., 1990), employing a longer duration of intervention
(Delamater et al., 1990), and
implementing regularly occurring "booster" sessions
(Foster et al., 1983). Our
findings provide reason for optimism that further research on BFST can yield a
disseminable and broadly applicable intervention that can improve family
adaptation to IDDM.
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Acknowledgments |
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This work was supported by grant 1-RO1-DK43802 "Behavior Therapy for Families of Diabetic Adolescents" awarded by the National Institutes of Health (National Institute of Diabetes, Digestive and Kidney Diseases) to the first author and by the Pediatric and General Clinical Research Centers of Washington University (RR06021 and RR00036). We thank the following physicians and their respective clinic staffs for their assistance in recruiting families for this study: Thomas Aceto, George Bright, Dominique Darmaun, Myrto Frangos, John Galgani, Luigi Garibaldi, Santosh Gupta, Morey Haymond, Nelly Mauras, Robert Miller, and Patricia Wolff. We also thank Arthur L. Robin, PhD, and Diana Guthrie, PhD, for their consultation in intervention design and evaluation. A detailed BFST Treatment Implementation Manual can be obtained by sending a $20 check or money order payable to the Nemours Children's Clinic to Tim Wysocki, PhD, Nemours Children's Clinic, 807 Nira Street, Jacksonville, FL 32207.
Received September 2, 1997; revision received February 24, 1998; revision received July 23, 1998; revision received December 13, 1998; accepted December 29, 1998
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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