Journal of Pediatric Psychology, Vol. 26, No. 8, 2001, pp. 485-490
© 2001 Society of Pediatric Psychology
A Peer Group Intervention for Adolescents With Type 1 Diabetes and Their Best Friends
1 Nemours Children's Clinic, 2 A. I. duPont Hospital for Children
All correspondence should be sent to Peggy Greco, Division of Psychology and Psychiatry, Nemours Children's Clinic, 807 Nira Street, Jacksonville, Florida 32247. E-mail: pgreco{at}nemours.org .
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Abstract |
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Objective: To devise and implement a structured intervention for integrating peers into diabetes care in a healthy and adaptive manner.
Methods: Adolescents with diabetes (n = 21) and their best friends (n = 21) participated in a group intervention aimed at increasing diabetes knowledge and social support of diabetes care. Measures of social support, knowledge about diabetes and support, diabetes functioning, and social functioning were obtained prior to and following intervention.
Results: Following the intervention, adolescents and their friends demonstrated higher levels of knowledge about diabetes and support, as well as a higher ratio of peer to family support, and friends demonstrated improved self-perception. Parents reported decreased diabetes-related conflict.
Conclusions: Peer group intervention approaches may result in increased positive peer involvement in adolescents' diabetes care.
Key words: type 1 diabetes; adolescents; intervention; social support; peer group.
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Introduction |
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Adolescents with diabetes experience physical, emotional, and social stress due to the demands of a complicated medical regimen (Johnson, 1988
) and are often
noncompliant with these demands (Kovacs,
Goldston, Obrosky, & Iyengar, 1992;
La Greca, 1988). In fact, most
serious cases of noncompliance commonly emerge in midadolescence
(Kovacs et al., 1992), at the
same time as rapid and continuous developmental changes. As adolescents
decrease their dependence on their parents, they often rely on peers for
support and behavioral norms (Berndt,
1992; Steinberg &
Silverberg, 1986). Although at times peers may be negative
influences (Thomas, Peterson, &
Goldstein, 1997), peers can also be important sources of
constructive support. Social support from peers has been rated as important by
adolescents with type 1 diabetes (Greco et
al., 1991); peers are more likely than family members to provide
companionship and emotional support in relation to diabetes care
(La Greca et al., 1995).
Although assessment of peer support has received some attention, no
controlled studies have examined the impact of peer support on adolescents'
diabetes care regimen. A structured approach to facilitating peer support may
serve a useful and necessary function as adolescents with diabetes may avoid
talking to peers about their illness. Jacobson and colleagues
(1986) noted that among newly
diagnosed children and adolescents with diabetes, over half did not talk about
diabetes with peers and over a third believed that their peers would like them
less if they knew about their diabetes.
Group-based problem-solving approaches have been found to be effective with
adolescents with diabetes (e.g., Anderson,
Wolf, Burkhart, Cornell, & Bacon, 1989); however, these groups
typically include other adolescents with diabetes. Minimal interaction may
occur among these adolescents outside of the group setting. It is the
influence of peers who are encountered on a daily basis, in school and social
settings, that can adversely affect adolescents' diabetes care
(Thomas et al., 1997).
Given the critical role that peers may play in adolescents' diabetes care, this pilot and feasibility study was undertaken to assess the effects of a peer group intervention on adolescents newly diagnosed with type 1 diabetes and their best friends. The specific aims of this study included (1) to devise a structured group program for integrating friends into adolescents' diabetes management in a healthy and adaptive manner; (2) to extend research that has suggested a positive benefit for social support for adolescents with type 1 diabetes by determining if this peer group intervention increases social support; and (3) to determine the generalization of the effects of this peer group intervention to diabetes functioning (i.e., adherence, adjustment to diabetes, and diabetes-related conflict) and social functioning (i.e., self-perception and peer relations).
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Method |
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Participants
Adolescents with type 1 diabetes, their parents, and chosen peers were recruited from two children's clinics in Florida and Delaware. Participants were identified through medical chart review and then contacted by research assistants. Twenty-three adolescents (62%) agreed to be included in the study and met the following eligibility criteria: age between 10 and 18, type 1 diabetes diagnosed not longer than 18 months, no other major chronic diseases or cognitive impairments, no foster care or residential psychiatric treatment, and absence of psychiatric diagnoses during the last 6 months. Travel distance was the primary reason provided for declining enrollment (both centers are tertiary care specialty clinics that draw from a 100-mile radius).
Adolescents chose a "best friend" to participate with them. The friend met the following inclusion criteria: age between 10 and 18 and regular consistent contact with the adolescent subject (adolescent-peer partners spent an average of 17.44 hours together per week). Two participants dropped out of the study following enrollment; thus, analyses are based upon the 21 adolescent-peer pairs (11 in Florida, 10 in Delaware) who completed the study.
Average ages of adolescents with diabetes and their peers were 13.1 and
13.6 years (SD = 1.98 and 2.25), respectively; mean duration of
diabetes was 8.43 months (SD = 4.62). There were 10 pairs of females
and 11 pairs of males. All adolescent/peer pairs were of the same gender and
all but one pair were of the same race (17 Caucasian pairs, 3 African American
pairs, and 1 Caucasian/African American pair). The mother was the
participating parent for all but two adolescents. Eighty-one percent of
adolescents and 71% of peers came from two-parent families. The average
socioeconomic status (SES) for the adolescents' families was 47.36
(SD = 13.34) using the Hollingshead Four-Factor Index
(Hollingshead, 1975),
indicating a primarily middle- to uppermiddle class sample. No demographic
variables differed by site. Institutionally approved informed consents were
signed before the study. Adolescents and their peers were each paid $45 for
their participation.
Measures
The Diabetes Social Support Inventory (DSSI;
La Greca et al., 1995) is an
interview consisting of 10 open-ended questions pertaining to diabetes support
provided by family and peers. This interview measure has established
acceptable interrater reliability and concurrent validity
(La Greca et al., 1995). The
adolescent is asked to list ways that family members and peers have provided
support for each of four specific regimen demands and then to rate the
frequency (on a 5-point scale) and intensity (on a 3-point scale) of the
support. Frequency is multiplied by intensity to obtain a composite score. A
separate "peer" version of the DSSI, (DSSI-P) was developed for
this study. Peers listed ways that they provide support to their adolescent
friends with diabetes for each of the four regimen tasks. The DSSI-P is
structured in the same manner as the DSSI.
All adolescents and their best friends completed the Diabetes Education and Support Assessment Tool (DESAT), a pre-and postintervention test designed to assess knowledge gained from the intervention sessions. This measure was specifically designed for this study and taps the four areas focused on during the intervention: physiology and basic knowledge of diabetes, problem-solving techniques, diabetes regimen demands, and stress management. This 30-item short-answer measure has a range of 0-36. Assessment of reliability and validity of the DESAT is ongoing.
The Teen Adjustment to Diabetes Scale (TADS;
Wysocki, 1993) is a 21-item
Likert-type scale with parallel parent and adolescent forms that measures
adolescent behavioral, affective, and attitudinal adjustment to type 1
diabetes. Internal consistency in a recent large-scale study was.81 for
adolescents,.87 for mothers, and.88 for fathers
(Wysocki et al., 2000). This
information was obtained separately from parents and adolescents with
diabetes.
The Diabetes Responsibility and Conflict Scale (DRC;
Rubin, Young-Hyman, & Peyrot,
1989) assesses parent-child division of diabetes responsibilities
and family conflict surrounding 15 diabetes tasks. Only the conflict scale of
this measure, which has a high internal consistency (.88) was used. This
information was obtained separately from parents and adolescents with
diabetes.
The Self-Care Inventory (SCI; La Greca,
Swales, Klemp, & Madigan, 1988, and validated by
Greco et al., 1990), a 15-item
Likert-type scale, measures adherence to various aspects of the diabetes
regimen including insulin shots, glucose testing, diet, and exercise. Internal
consistency in a recent large-scale study was.76 for adolescents,.81 for
mothers, and.82 for fathers (Wysocki et
al., 2000). The SCI was obtained separately from parents and
adolescents with diabetes.
Adolescents and their best friends also completed the Peer Interaction
Record (PIR; Thompson, 1994),
a measure of adolescents' social interactions with acceptable internal
consistency (.74). The PIR asks the respondent to estimate how often he or she
engaged in each of 12 typical activities during the past month. The extent of
the adolescent's activities and peer network is estimated from this
measure.
The Self-Perception Profile (SPP;
Harter, 1988) is a
multidimensional inventory that assesses social, academic, job, behavior, and
athletic competence. Only the global self-worth scale, which has acceptable
reliability and validity, was used in this study. This information was
obtained separately from adolescents with diabetes and their peer
partners.
The General Information Form (GIF) was administered to parents, adolescents, and peers to gather information on sociodemographic variables.
Procedure
Parent, adolescent, and peer came to the clinic for completion of baseline
questionnaires, following which they participated in a 4-week intervention.
Finally, subjects completed a second questionnaire session. Each questionnaire
session lasted approximately 2 hours.
Intervention
Each adolescent-peer pair attended four 2-hour education and support group
sessions led by licensed psychologists. Groups were composed of three to six
adolescent-peer pairs. Four separate intervention series (of four sessions
each) were held over the course of the study, two at each of the study
sites.
Each group leader followed a detailed treatment manual containing the didactic presentation, handouts, activities, and homework for each session. Treatment consistency was also maintained by phone consultation between the two group leaders prior to each group session. Each session followed the format of review of homework, didactic focus on particular topics, a game or exercise to practice applying these concepts, and assignment of homework for the following week. Incentives (e.g., sugarless gum, diet sodas) were given for the completion of homework. Attendance rates were exemplary; out of the 21 adolescent-peer pairs attending the four intervention sessions, only one peer missed one session.
Session one emphasized education topics such as the etiology, physiology, and treatment of type 1 diabetes. Session two focused on reflective listening skills and problem solving as applied to general, developmentally-relevant scenarios (e.g., conflict with parents or peers). Session three consisted of problem solving applied to diabetes-related situations, focusing on ways that peers could support and provide assistance in completing diabetes regimen demands. The last session focused on general stress management, the interaction of stress and diabetes, and techniques for reducing the impact of stress on diabetes.
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Results |
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Pre/post differences on the DESAT were examined as an indicator of knowledge gained during the intervention. Adolescents with diabetes evidenced a significant increase in knowledge about diabetes and support, as did their peer partners (see Table I).
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For peer support, global support on the DSSI did not improve significantly following intervention, contrary to expectation. However, given that global support from peers and family decreased following intervention, a ratio score was computed. This ratio score indicated that peers provided a greater proportion of support relative to family members following the intervention.
In regard to measures of diabetes-related functioning, parents reported significantly less diabetes-related conflict (DRC) and a trend toward improved adjustment (TADS) following intervention. No significant change in adherence (SCI) was noted; moderate levels of adherence were maintained throughout the study. Adolescent reports on these three diabetes-specific measures did not change significantly following intervention.
Peers reported significantly improved self-perception (SPP) following intervention, although adolescents reflected no significant change. There were no significant changes between baseline and postintervention scores on peer or adolescent reports of peer activities (PIR).
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Discussion |
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This pilot study represents a step toward the goal of improving quality of care for adolescents with type 1 diabetes. The first aim of this study was to develop a structured group program for integrating peers into the diabetes care of their adolescent friends in a healthy and adaptive manner. The intervention was effective at improving peers' knowledge about diabetes and ways to offer support; this finding may provide a preliminary indication of the validity of the intervention designed for this study. However, the unknown psychometric properties of the DESAT significantly limit the interpretation of this finding.
The second aim of this study was to note whether a structured group program
including both adolescents with diabetes and their peer partners would
increase social support offered for diabetes care. Interestingly, global
support did not increase as a result of the intervention. However, baseline
levels of support were significantly higher than noted in a previous study of
adolescent support (La Greca et al.,
1995). It is possible that this higher level of support was
influenced by demand characteristics; adolescents and peers were informed
about the intent of the study and also attended each baseline session
together, although the DSSI interviews were conducted separately. Given the
elevated levels of global support noted at baseline, the decrease in global
support offered following intervention may have represented regression to the
mean. The lack of time-specificity may have also blunted the DSSI's ability to
detect intervention effects. Changing instructions to reflect peer support
received over a specific period, such as 2 weeks, rather than inquiring about
peer support received in general, may improve the sensitivity of the DSSI.
Nevertheless, following intervention, peers provided a greater proportion of
support compared to family members following intervention, suggesting a
positive impact of the intervention on peer support.
The third aim of this study was to assess the effects of the peer group
intervention on diabetes and social functioning. Parents reported improvement
in their ratings of family conflict following intervention as well as better
adjustment. Given the significant associations between family conflict and
poor treatment adherence and metabolic control
(Anderson, Miller, Auslander, &
Santiago, 1981; Bobrow,
AvRuskin, & Siller, 1985;
Lorenz & Wysocki, 1991),
interventions that result in decreased family conflict deserve further
attention. Whether greater involvement of peers in diabetes care is a
mechanism through which the burden of diabetes care experienced by family
members is alleviated should be investigated.
Peers evidenced improvement in self-perception following the intervention.
It has been suggested that there may be positive consequences of a support
provider's contributions to supportive transactions
(Pierce, Sarason, Sarason, Joseph, &
Henderson, 1996). The preliminary indication of a positive impact
on peers' self-perception may suggest the importance of providing
support and points to the need to examine adolescents with diabetes from the
perspective of the dual roles of recipient and provider of social
support.
These findings should be considered in light of several limitations of the study. The small sample size and short follow-up period may have been two factors that hindered the detection of broader, statistically significant treatment effects. Although the use of two clinic subsamples from geographically diverse areas is an important feature of this study, sampling from two sites did not result in an ethnically or economically heterogeneous sample as intended, thus limiting the generalizability of the findings. A further limitation was the lack of a control group, which was not feasible for this pilot study.
The participation rate of 62% in this study is comparable to other child
clinical and pediatric psychology studies
(Betan, Roberts, & McCluskey-Fawcett,
1995). However, the completion rate of 91% and intervention
attendance rate of 99% are high and indicate the success of the incentives
used in this study as well as possibly capitalizing on the developmentally
normative trend for adolescents to prefer spending time with friends. This
high attendance and completion rate may be indicative of satisfaction, which
should be formally assessed in future studies.
Recent attention has been called to the need for pediatric psychologists to
promote effective, accessible, and affordable interventions, particularly
interventions that promote health or prevent psychological or physical harm
(Rae, 1998). Our findings
suggest promise for intervention approaches that focus on facilitating
positive peer involvement in adolescents' diabetes care as a tool for
promoting health in a developmentally appropriate manner.
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Acknowledgments |
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This research was supported by the Nemours Foundation Research Programs. We thank Sandra Duis, PhD, for her assistance with collecting and scoring data and all participating adolescents and their families for their time invested in this study.
Received March 7, 2000; revision received November 28, 2000; accepted January 16, 2001
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