Journal of Pediatric Psychology, Vol. 26, No. 1, 2001, pp. 61-66
© 2001 Society of Pediatric Psychology
Brief Report: A Cognitive Behavioral Intervention for Distressed Adolescents With Type I Diabetes
1 University of Wisconsin-Milwaukee, 2 Children's Hospital of Wisconsin, 3 Medical College of Wisconsin
All correspondence should be sent to Anthony Hains, Department of Educational Psychology, P.O. Box 413, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin 53201. E-mail: aahains{at}uwm.edu .
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Abstract |
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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.
Key words: cognitive behavioral interventions; Type I diabetes.
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Introduction |
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Many children and adolescents display adjustment problems with the onset of diabetes; however, these reactions dissipate for most of them within 1 year (Northam, Anderson, Adler, Werther, & Warne, 1996
). Unfortunately, early psychological problems in
response to diabetes persist over time for some youths and have clinically
relevant consequences for later functioning, adherence, and metabolic control
(Jacobson et al., 1990).
Jacobson et al. (1990) suggest
that intervention programs for problems in coping and adjustment beyond
existing services should receive increased emphasis.
Cognitive behavioral interventions have promise for youths with diabetes.
Identification and modification of negative cognitions, and the development of
more adaptive problem solving and functional coping, are central to the
intervention process (Kane & Kendall,
1989). Recent intervention efforts focusing on youths with chronic
illness have shown increases in family communication and problem solving in
youths with Type I diabetes (Wysocki et
al., 1999) and improvement in anxiety, coping, and perceived
functional disability in adolescents with cystic fibrosis
(Hains, Davies, Behrens, & Biller,
1997).
This study examined the impact of a cognitive behavioral intervention for
youths with Type I diabetes using a multiple baseline design. The study
extends previous work by including only youths who displayed evidence of
metabolic control problems and who scored above designated levels of emotional
distress. Impact of treatment was examined on diabetes stress, and, for those
in the clinical range at baseline, on manifest anxiety and anger expression.
Manifest anxiety was chosen as a dependent variable in order to assess the
impact of the intervention on dispositional anxiety rather than on transitory
or state anxiety. The use of manifest anxiety is also consistent with past
intervention research with anxious children
(Kane & Kendall, 1989).
Anger expression was included because anecdotal reports in other research
indicated anger issues were brought up by participating youths with chronic
illness (Hains et al.,
1997).
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Method |
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Participants
Six adolescents with Type I diabetes who were out-patients at a children's hospital in a large Midwestern city participated in the study. Three youths (Kris, 12; Wendy, 15; and Amy, 13) were female, and three were male (Alan, 18; Thomas, 13; and David, 14) (names are fictitious). Patients who were in special education classes or diagnosed with psychotic disorders were excluded from the study.
Initially, 14 youths met the criteria for inclusion in the study (described below) and gave consent to participate. However, five dropped out before the treatment began, due to time constraints or lack of interest. Three others dropped out after the initiation of treatment. Two youths claimed a lack of interest in continuing, and the third dropped out because of a family crisis. Three of these eight youths who dropped out were minority youths (two were African American and one was Latino). All participants completing the study were European-American except for Kris, who was Latino. In addition, youths who did not complete the intervention had higher hemoglobin A1c scores (a mean of 12) than the youths who completed the study (mean of 10).
Assessment Measures
Anxiety, anger expression, and diabetes stress were measured during
baseline, before each treatment session, and at a 3-month follow-up.
Anxiety was assessed by the Revised Children's Manifest Anxiety Scale
(RCMAS; Reynolds & Richman,
1985). A total score from this 37-item questionnaire, ranging from
0 to 28 (higher levels indicating greater anxiety), was used in this study.
Anger expression was measured by the State-Trait Anger Expression
Inventory (STAXI; Spielberger,
1988), a 44-item inventory that forms six scales. For this study,
only one scale was used: Anger Expression (AX/EX), a general frequency index
of anger expression. Scores range from 0 to 72. Higher scores indicate greater
levels of expressed anger. Diabetes-specific stress was examined by
the Diabetes Stress Questionnaire (DSQ;
Boardway, Delamater, Tomakowsky, &
Gutai, 1993), a 65-item self-report instrument assessing the
degree of everyday stress for adolescents that is related to diabetes (e.g.,
conflicts with parents over adherence). The measure yields a composite scaled
score, with higher scores indicating higher levels of stress.
Procedure
This study was approved by the Institutional Review Board, and informed
consent was obtained from all parents and youths. Two criteria for inclusion
were used. First, members of the diabetes treatment team referred patients who
had problems with metabolic control, identified as hemoglobin A1c greater than
9.0 at last clinic visit. Although the relationship between metabolic control
and psychosocial distress is complex, there is evidence of a relationship
between these variables (McQuaid &
Nassau, 1999). A brief description of the study was presented to
eligible families by a nurse practitioner during their clinic visit. Families
who expressed interest were given a more detailed description by a graduate
student in counseling psychology. If parents and youths were interested, then
the youths were asked to complete the RCMAS, the STAXI, and the DSQ. If a
youth's scores on any of these inventories were above the designated cutoffs,
the youth was invited to participate in the study. The designated score for
the RCMAS and STAXI was a T score 
60 (one standard deviation
above the mean) for the youth's gender and age group. For the DSQ, the
designated score was 85. This score was set based on research by Boardway et
al. (1993), who reported mean
scores ranging from 81 to 86 (across pre-post-, and follow-up periods) in an
untreated group of youths in a stress management study.
A multiple baseline across-subjects design
(Barlow & Hersen, 1984) was
used to assess treatment impact. Baseline data were taken on anxiety, anger,
and diabetes stress on all youths. The intervention is initiated with one
youth while the others remain in baseline. Then another youth begins training
while the remainder continue in baseline. This process continues until all
youths receive the intervention. The experimenter is assured that the
treatment is effective for an individual when a change in the dependent
variable(s) appears in a participant receiving treatment and no change occurs
in the participants for whom treatment has not yet begun.
After being recruited, youths were given a set of assessment instruments and were asked to return them the following week. Upon return, the instruments were scored and a decision was made whether to maintain a particular youth in baseline or to begin the intervention. If a youth remained in baseline, then a new set of instruments was mailed to the youth. Assessment instruments were examined upon return, and if the youth's scores on those instruments for which he or she was initially elevated remained fairly stable at or above the designated cutoff, then the youth was called to schedule the first intervention session. If a youth scored at or above the designated cutoff on more than one instrument, we waited until at least one of the scores was stable during baseline in order to begin treatment.
Although youths were reminded to return the assessment instruments once a week, rate of return was variable. Across participating youths, assessments were returned on average every 15.9 days. Consequently, baseline data points are defined in terms of number of assessments instead of number of weeks. One vouth (Kris) began treatment after one baseline assessment because of time constraints.
During the intervention, youths were given the assessment instruments at the end of each session to complete and return the following session. Five youths were seen in a teaching room of the hospital, and one was seen in a university psychology clinic. Youths were seen individually for the intervention. We intended to schedule sessions on a weekly basis; however, illness, vacations, school events, and missed appointments resulted in frequent rescheduling. On average, sessions were held every 12.4 days.
Cognitive Behavioral Intervention
Each youth participated in an eight-session intervention used previously
with pediatric populations (Hains, Davies,
Parton, Totka, & Amoroso-Camarata, 2000;
Hains et al., 1997). The
intervention involved a conceptualization phase, a skill acquisition phase,
and an application phase (Meichenbaum,
1985). Four doctoral students in counseling psychology delivered
the intervention with the use of a treatment manual and the first author
supervised them weekly.
During the conceptualization phase (session 1), youths were taught how to identify negative cognitions and were given self-monitoring sheets for logging the occurrence of stressful situations and accompanying cognitions. In the skill acquisition phase (sessions 2-5), youths acquired cognitive restructuring and problem solving skills. During sessions 2 and 3, youths were taught how to challenge and restructure negative cognitions by examining evidence for and against these thoughts and by looking for alternative explanations for stressful events. In sessions 4-5, youths were taught a 4-step problem-solving strategy that involved (1) defining the problem, (2) considering solutions, (3) generating consequences for each solution, and (4) choosing and implementing a solution. Youths practiced cognitive restructuring and problem solving by applying the strategies to recent personal and diabetes-specific issues. Cognitive restructuring and problem-solving attempts between sessions were recorded on self-monitoring sheets. The application phase (sessions 6-8) involved practice of skills in anticipation of a future stressor. The youths disclosed likely stressful events that could occur before the next session. The therapist and the youth then rehearsed the acquired skills on the anticipated problem.
Three months after the completion of training, youths were contacted by phone to remind them of the follow-up assessment and were mailed the instruments to be completed and mailed back.
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Results |
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Anxiety, anger expression, and diabetes stress results are displayed in Figures 1, 2, and 3, respectively. For anxiety and anger expression, only youths with elevated scores during baseline (i.e., scores above the cutoff levels at least part of the time) are included in the figures. We should note that Amy was recruited for the study based on an elevated anxiety score. During baseline, her scores fell below the cutoff level, so we waited until she returned to an elevated level before initiating the intervention. For diabetes stress, the scores for all six youths are presented since the cutoff was not based on a standardized score and the baseline data for each youth were near or above our designated cutoff. The horizontal dotted line represents the designated cutoff levels.
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Alan and Thomas were the most consistent responders to treatment, displaying noticeable improvement on anxiety, anger expression, and diabetes stress in comparison to their baseline levels. Thomas's scores remained high early in treatment, but with the introduction of the three sessions for skill application, he demonstrated dramatic improvement. The gains for Alan and Thomas were maintained at follow-up. Kris showed a steady decrease in anxiety, which was maintained at follow-up. She did not show any change on diabetes stress until a decrease at the last assessment, but she was still well above the cutoff. Kris maintained this lower score at follow-up, but this was still above the cutoff level.
For Wendy, anxiety and diabetes stress levels increased after the initiation of treatment, possibly due to focusing on negative cognitions and situations. With the introduction of the three sessions for skill application, Wendy showed a slight decrease (although this change was promising, she did not improve much beyond baseline). Her follow-up scores indicated improved levels, especially for anxiety. David showed stable improvement on diabetes stress during treatment (the only measure on which he had elevated scores), but his follow-up increased to just above the cutoff. Amy did not show any consistent response to the intervention on either anxiety or diabetes stress.
Regarding diabetes stress, one additional procedural point needs to be addressed. A decision was made to use the DSQ as a stimulus for discussing diabetes stressors with Thomas, Amy, Wendy, and Kris since their stress remained elevated through five sessions. The therapists were instructed to ask these youths to discuss examples of diabetes stressors from the DSQ and to directly apply the acquired skills to these especially troubling situations. Thomas demonstrated improvement and Wendy reversed her increasing trend in stress after this procedural change.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Four of six distressed youths with Type I diabetes showed some evidence of improvement in response to the cognitive behavioral intervention. Treatment gains were maintained at follow-up as evidenced by scores at or below the designated cutoff. Consistent with other research (Boardway et al., 1993
;
Wysocki et al., 1999), this
study suggests that cognitive behavioral interventions show promise as a
viable treatment for the problems of adolescents with Type I diabetes. A variety of factors that affected the implementation of the study should be addressed. For instance, Thomas and Amy came from chaotic family situations. These issues were not easily dealt with, and, indeed, the intervention was not designed to address family functioning. Despite the fact that Thomas showed a dramatic improvement, these effects were rather short-lived. Within a few months after the follow-up, Thomas was hospitalized on two different occasions for psychiatric reasons. In addition, Thomas's sharp drop in diabetes stress came after the therapist used items from the DSQ as examples for application of acquired skills. Although we have no evidence, we cannot discount the possibility that Thomas could have supplied socially desirable responses on the DSQ for the remainder of the study.
One procedural deviation that may have influenced the results should be mentioned. Baseline assessments averaged every 16 days and treatment sessions averaged every 13 days (with variability between and within youths). Although these differences in assessment intervals are consistent with the provision of therapy in the "real world," they could have affected how the youths filled out the questionnaires and influenced the outcome in unknown ways.
Some variability was evident during baseline within youths. However, the repeated baseline assessments may have presented a more accurate picture of natural variability over time. This highlights an advantage of obtaining multiple baseline points in deciding when intervention is indicated for particular youths, and helping gauge treatment impact despite fluctuations in functioning.
The number of youths who did not complete the intervention is a concern. The percentage of minority youths dropping out raises important questions about how culturally appropriate the intervention was. Although all therapists were European-American, they came from a graduate program with a strong emphasis in multicultural counseling. More careful attention to cultural factors is needed in intervention studies in pediatric psychology. In addition, poorer metabolic control of those youths who dropped out may be indicative of greater overall problems of personal or family functioning and disease management, which could interfere with commitment to the intervention protocol.
A more flexible approach to the delivery of the intervention may benefit youths like Wendy, who may be showing signs of improvement, and is more in keeping with the likely provision of those services outside a clinical research context. Likewise, offering to conduct the intervention in settings more convenient or comfortable than the hospital (e.g., home, community center, church) might enhance participation rates, especially for minority youths. Regular booster sessions, arranged to coincide with clinic visits, may help youths maintain treatment gains at follow-up.
Considered within the context of other cognitive behavioral interventions
for youths with diabetes (e.g., Boardway et
al., 1993; Wysocki et al.,
1999,
2000), these results suggest
the need for a randomized clinical trial assessing the relative impact and
cost-effectiveness of individual cognitive behavioral therapy, behavioral
family systems therapy (Wysocki et al.,
2000), and a combination of these approaches in improving outcomes
for adolescents with diabetes in moderate versus poor glycemic control.
Developing a knowledge base for effectively matching patients and families
with treatments is a pressing need.
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Acknowledgments |
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This study was supported in part by a grant from the Children's Hospital of Wisconsin Foundation. A copy of the manual used in this study can be obtained by writing the first author.
Received September 14, 1999; revision received December 15, 1999; revision received March 2, 2000; accepted April 21, 2000
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