Journal of Pediatric Psychology Advance Access originally published online on March 3, 2005
Journal of Pediatric Psychology 2005 30(8):683-688; doi:10.1093/jpepsy/jsi055
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Brief Report: In-Home Family Therapy for Adolescents with Poorly Controlled Diabetes: Failure to Maintain Benefits at 6-Month Follow-Up
Washington University School of Medicine
All correspondence concerning this article should be addressed to Michael A. Harris, Patient Oriented Research Unit, Campus Box 8208, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, Missouri 63110. E-mail: harris_ma{at}kids.wustl.edu.
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Abstract |
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Objective To examine 6-month follow-up data on the effectiveness of in-home Behavioral Family Systems Therapy (BFST) for adolescents with poorly controlled diabetes, using a pilot and feasibility study. Methods Eighteen adolescents with poorly controlled diabetes received ten 90-min sessions of in-home BFST. Diabetes-related functioning, general family functioning, and health status were assessed at baseline, immediately following treatment and 6-months after the treatment. Results Although the initial posttreatment follow-up evaluation indicated decreases in general family conflict, diabetes-related family conflict, and behavior problems, evaluation at a 6-month follow-up (N = 17) demonstrated that initial posttreatment improvements were no longer present for any of the variables assessed. Metabolic control remained unchanged from baseline to initial posttreatment as well as at 6-month follow-up. Conclusions A plausible explanation for this finding is that participating families were experiencing distress that required longer-term treatment for enduring results, beyond what was employed in this study. Further research is necessary before in-home BFST can be considered an effective psychosocial intervention for adolescents with poorly controlled diabetes.
Key words: family therapy; adolescents; diabetes.
Robin and Foster (1989)
introduced a model, Behavioral Family Systems Therapy (BFST), to address parent–adolescent conflict that integrates behavioral and family systems theoretical perspectives (Foster & Hoier, 1982). The BFST model postulates that the frequency, intensity, and duration of parent–adolescent conflict is modulated by problem-solving and conflict resolution skills, communication skills, degree, and extent of irrational beliefs about one another’s behavior, and the degree and extent of structural and systemic anomalies. Hence, BFST has four components that address these issues: (a) Training in problem-solving and conflict resolution; (b) family communication skills training; (c) cognitive restructuring to address cognitive distortions; and (d) systemic family therapy to modify structural anomalies. The overall goal of BFST is to reduce coercive family processes by establishing a family environment more conducive to the developmental demands of adolescence for increased independence and decision making.
The authors of this study, along with colleagues, have previously adapted, implemented, and evaluated an office-based version of BFST for adolescents with diabetes and their parents (Wysocki, Harris, Greco, Mertlich, & Buckloh, 2001; Wysocki, White, Bubb, Harris, & Greco, 1995). Findings revealed that adolescents with diabetes participating in office-based BFST evidenced better health behaviors and psychosocial outcomes than adolescents with diabetes participating in an educational/support group or adolescents in the control group (Harris, Greco, Wysocki, & White, 2001; Wysocki, Greco, Harris, Bubb, & White, 2001; Wysocki et al., 1997). Although BFST appears to be an efficacious and viable psychosocial treatment that involves multiple family members, there were a number of adolescents who participated in the intervention and did not improve, and in some cases got worse (Wysocki, Greco, et al., 2001).
The characteristics of the subgroup of youth in poor metabolic control who have not responded to medical and psychosocial intervention are somewhat unknown. What is known about the youth who are at risk for poor metabolic control is that there is a disproportionate number of African American youths, youths from single-parent homes, and youths from lower socioeconomic status families represented in this group (Delamater, Albrecht, Postellon, & Gutai, 1991; Harris, Greco, Wysocki, Elder-Danda, & White, 1999).
In trying to understand why this subgroup of adolescents with diabetes did not respond to BFST, it is reasonable to hypothesize that traditional psychosocial interventions do not appear to be appropriately tailored to the needs of these youths and their families (Gray, Marrero, Godfrey, Orr, & Golden, 1987). For example, traditional BFST, like most psychosocial interventions, is office based. There are multiple problems implementing office-based interventions in the context in which the behavior actually occurs (Evans & Boothroyd, 1997; Henggeler & Santos, 1997; McDaniel, Lusterman, & Philpot, 2001). Thus, office-based treatments might inadequately address the varied and most pressing needs of this subgroup of adolescents with diabetes who have not responded to traditional psychosocial and medical treatments. Stein (2001) suggests that in-home treatment for certain children with a chronic condition may be a feasible alternative to conventional, office-based care.
Because of the limitations of office-based BFST (Harris et al., 2001; Wysocki, Greco et al., 2001; Wysocki et al., 1997) coupled with the research suggesting that home-based family therapy can be effective with difficult-to-treat adolescents (Henggeler & Santos, 1997). The researchers examined BFST’s effectiveness when provided in the home to a subgroup of adolescents with poorly controlled diabetes. This study reports on the feasibility and effectiveness of in-home BFST at a 6-month follow-up for adolescents with poorly controlled diabetes. It was hypothesized that initial posttreatment improvements would be sustained at the 6-month follow-up. Given that, more time had elapsed enabling the families to use, refine, and maintain BFST skills, it was also hypothesized that improvements would be observed at the 6-month follow-up evaluation in variables that had not shown significant improvement at the initial posttreatment evaluation.
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A within-subjects single group design was used in this study because of limited resources coupled with anecdotal evidence supporting the fact that, without treatment, adolescents like the ones being recruited for this study either do not improve or get worse in the absence of treatment.
Participants
Participants included 18 adolescents with diabetes between the ages of 13 and 18 years and their primary caregiver(s). Only one of the original 18 adolescents participating in this study did not complete the 6-month follow-up. Inclusion criteria for adolescents selected for participation in the study included (a) chronically poor metabolic control as demonstrated by two or more consecutive hemoglobin A1c (HbA1c) values at or above 9.0%; or (b) a history of two or more missed clinic appointments within the past year with their most recent HbA1c value at or above 9.0%. The recruitment rate for the study was 45% enrolled (N = 18) with 55% declining to participate (N = 22). Participants enrolled in the study included a disproportionate number of African American adolescents (33%), adolescents from single-parent homes (33%), and adolescents from lower socioeconomic families (50%). The study sample was no different demographically from those families that declined to participate. There were various reasons families gave for declining to participate including too busy, not wanting anyone coming to their home, not interested in family therapy, or just not interested in participating in research. The study participants were different from the general clinic population, in that approximately 8.5% of the general clinic population is African American and fewer adolescents from the general clinic population reside in single-parent homes.
At baseline, the average HbA1c of the study sample was 11.3% with two previous HbA1c’s above 9% (mean 10.9%). The average HbA1c of those adolescents who declined to participate was 10.2% and was approximately 8.0% for the general clinic population. Fifty percent of the adolescents had missed two or more clinic visits within the past 12 months.
Procedures
The participants and parents identified for participation were contacted by phone or during their clinic visit for recruitment into this study. If the participants and their parents agreed to participate in this study, informed consent was obtained from the parents of the adolescent and assent was obtained for the adolescents. Adolescents and their parents were then asked to complete the baseline evaluation including many paper and pencil questionnaires assessing diabetes-related functioning and general family and psychosocial functioning. Metabolic control was assessed using a HbA1c assay (average blood sugar levels for the previous three months). The adolescents and their parents completed similar follow-up evaluations immediately after treatment (approximately 6–10 weeks from baseline) and 6 months later. Families received $50 for the completion of the baseline and follow-up evaluations.
Treatment
Adolescents and their parents received ten 1.5-hr sessions of in-home BFST (Robin & Foster, 1989) over a period of approximately 5–8 weeks. Sessions were conducted by a master’s level social worker and a doctoral level psychologist in training both of whom received extensive training from the principle investigator (PI) in diabetes management and in BFST. Each therapist was trained in BFST using the manual produced by the first author and colleagues for use with adolescents with chronic illnesses (Wysocki, Harris, et al., 2001). BFST consists of four therapy components that are used in accordance with each family’s treatment needs as identified by their responses to the questionnaires completed at baseline. The four therapy components of BFST are problem solving training, communication skills training, cognitive restructuring, and functional/structural family therapy (Wysocki, Harris, et al., 2001). All components of BFST address problems related to the adolescent’s diabetes as well as more general issues.
The home-based aspect of this study fits well with the theoretical underpinnings of BFST, in that BFST is heavily grounded in systems theory (Robin & Foster, 1989). Systems theory supports in-home interventions for many reasons including (a) the treatment being delivered in the context in which problems occur (e.g., the family’s home, neighborhood, and community), (b) the treatment involving those people who have the greatest impact on the adolescent, (c) the treatment accommodating the day-to-day demands of the family, and (d) a greater opportunity to identify and address extra-familial systems (school, peers, etc.) that have direct and indirect impact on the adolescent (Evans & Boothroyd, 1997; Henggeler & Santos, 1997; McDaniel et al., 2001).
Measures
Hemoglobin
During the baseline evaluation, at the initial follow-up and 6-month evaluations blood was collected for determination of HbA1c using the DCA2000 method. Hemoglobin A1c is a reliable and accepted measure of diabetic control over the previous 3 months and the DCA2000 method correlates well with the High Performance Liquid Chromatography (HPLC) method used by the Diabetes Control and Complications Trial (DCCT).
Self-Care Inventory
The Self-Care Inventory (SCI) is a 14-item, Likert-type measure assessing diabetes treatment adherence over the past 2 weeks (Greco et al, 1990). The SCI correlates significantly with metabolic control in adolescents with diabetes. In addition, the SCI correlates significantly with corresponding sections of the recall interview method advocated as a more rigorous and accurate assessment of diabetes treatment adherence (Greco et al, 1990).
Diabetes Mismanagement Questionnaire
The Diabetes Mismanagement Questionnaire (DMQ) is a 10-item multiple choice assessment completed by both the adolescent and his/her parent(s). The DMQ assesses three global areas of diabetes care including (a) existence and prevalence of inadequate self-care, (b) reasons for inadequate self-care, and (c) impact of inadequate care on metabolic control. The DMQ has been demonstrated to be psychometrically sound and clinically relevant for assessing mismanagement of diabetes in adolescents (Weissberg-Benchell et al., 1995).
Diabetes Responsibility and Conflict Scale
The Diabetes Responsibility and Conflict Scale (DRC) is 30-item instrument designed to assess parent–child divisions of diabetes-related responsibility and family conflict surrounding diabetes-related tasks in the past month (Rubin, Young-Hyman, & Peyrot, 1989). Internal consistency has been reported to be 0.88. The DRC has demonstrated positive correlations between parent and adolescent scores. Only the conflict items from the DRC were used for the purposes of this study.
Adjustment to Illness Scale
The Adjustment to Illness Scale (AIS) is an 8-item, Likert-type scale assessing the adolescent’s feelings of self-acceptance and acceptance by others despite having a chronic illness (Felton & Revenson, 1984). Internal consistency for the scale is 0.82 for adolescents with diabetes (Hanson, 1989).
Diabetes Family Behavior Checklist
The Diabetes Family Behavior Checklist (DFBC) is a 17-item Likert-type scale assessing supportive and nonsupportive family behaviors as they relate to the diabetes treatment regimen (Schafer, McCaul, & Glasgow, 1986). The DFBC was completed by parents and adolescents. The internal consistency for the supportive subscale items for parents is 0.73 and 0.63 for adolescents. The internal consistency for the nonsupportive subscale items for the parents is 0.43 and 0.60 for adolescents. Research has demonstrated that higher nonsupportive scores for adolescents have been significantly associated with poorer metabolic control in these adolescents (Schafer et al., 1986).
Child Behavior Checklist
The Child Behavior Checklist (CBCL) consists of 118 items that assess a child’s behavior and psychological status, and has excellent internal consistency and validity (Achenbach, 1991). The CBCL is completed by the adolescents’ parents. In addition, the adolescents complete a youth report form of the CBCL. Although the CBCL renders an array of subscale scores, only the total behavior problems score for each adolescent was used for the purposes of this report.
Conflict Behavior Questionnaire
The Conflict Behavior Questionnaire (CBQ) is a 20-item true/false scale that assesses general conflict between parents and their children. The CBQ was completed by parents and adolescents, alike. The CBQ has been used extensively in the literature and has adequate internal consistency (Robin & Foster, 1989). Robin and Foster (1989) have found that the CBQ discriminates between distressed and nondistressed families.
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The metabolic control of the adolescents was not significantly different based on results from paired t tests comparing mean baseline values with mean 6-month follow-up values (Table I). No statistically significant differences in self-reports of adherence, diabetes mismanagement, diabetes-related adjustment, diabetes-related conflict, diabetes family support, and diabetes family nonsupport were observed between baseline values and mean 6-month follow-up values for adolescents, mothers or fathers (Table I). In addition, no statistically significant differences were observed between mean baseline values and mean 6-month follow-up values for adolescent, mother, and father on self-reported measures of behavioral and psychological problems or parent–teen conflict (Table I).
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Discussion |
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This study piloted an in-home family therapy intervention for adolescents with diabetes in with poor metabolic control who had not responded to previous medical and psychosocial treatments. Overall, this study demonstrated that in-home BFST has the potential to be implemented with relative ease, with families actively participating in treatment. However, the results reported previously demonstrating initial posttreatment improvements (Harris & Mertlich, 2003
) were not sustained through the 6-month follow-up reported in this study.
In speculating why the initial posttreatment results were not sustained through the 6-month follow-up, one might hypothesize that for family therapy to be useful in treating diabetes adherence problems the intervention should be longer term (Gray et al., 1987). Research has also shown that adolescents and those of lower socioeconomic status are at higher risk for poorer metabolic control and difficulties with psychosocial well-being (Golden, 1998; Grey et al, 1998), which may not be amenable to short-term treatment. Given the similar characteristics of our population of adolescents with poorly controlled diabetes to the aforementioned adolescents, it seems likely that the duration of the in-home BFST (5–8 weeks) was not sufficient to sustain initial posttreatment results.
A notable success of this study was that all 18 families participating in the study completed all 10 sessions of BFST. This was something remarkable given that 50% of the adolescents had missed at least two clinic visits in the prior 12 months and most were identified by the health care team as coming from highly disorganized families. This finding may indicate that despite the chaotic nature of these families and the high demand on their time, when services are offered and delivered in a more convenient manner (i.e., in-home) nonparticipation is attenuated. In addition, this finding suggests that despite the health care team"s view of these families, the families are clearly interested in their adolescent’s diabetes and will make time to address problems with diabetes management.
Despite the failure to maintain initial posttreatment improvements at the 6-month follow-up, BFST is a standardized, empirically validated psychosocial treatment approach for adolescents with diabetes and should be considered a valued treatment approach in conjunction with any medical interventions for adolescents with diabetes. Another home-based treatment model is currently being tested with adolescents with poorly controlled diabetes and preliminary results are indicating a positive health and psychosocial impact of an ecologically grounded treatment for this population (Ellis, Naar-King, Frey, Rowland, & Greger, 2003). Further research is necessary to determine if and how an in-home version of BFST can be effective for adolescents with poorly controlled diabetes.
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This work was supported by a Pilot and Feasibility Study awarded to Michael A. Harris, PhD and funded by the Diabetes Research and Training Center of Washington University School of Medicine (NIH 5 P60 DK20579). Additional support was provided by the General Clinical Research Center of the Washington University School of Medicine, St. Louis, Missouri.
Received August 15, 2003; revision received November 17, 2004; accepted March 11, 2004
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References |
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TopAbstractMethodsResultsDiscussionReferences |
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Achenbach, T. M. (1991). Manual for the child behavior checklist/4–18 and 1991 profile. Burlington, VT: Department of Psychiatry, University of Vermont.
Delamater, A. M., Albrecht, D. R., Postellon, D. C., & Gutai, J. P. (1991). Racial differences in metabolic control of children and adolescents with type 1 diabetes mellitus. Diabetes Care, 14, 20–25.[Abstract]
Ellis, D. A., Naar-King, S., Frey, M., Rowland, M., & Greger, N. (2003). Case study: Feasibility of multisystemic therapy as a treatment for urban adolescents with poorly controlled type 1 diabetes. Journal of Pediatric Psychology, 28, 287–293.
Evans, M. E., & Boothroyd, R. A. (1997). Family preservation services for families with children who have mental health problems. In S. W. Henggeler & A. B. Santos (Eds.), Innovative approaches for difficult-to-treat populations. Washington, DC: APA Press.
Felton, B. J., & Revenson, R. A. (1984). Coping with chronic illness: A study of illness controllability and the influence of coping strategies on psychological adjustment. Journal of Consulting and Clinical Psychology, 52, 343–353.[CrossRef][Web of Science][Medline]
Foster, S., & Hoier, T. S. (1982). Behavioral and systems family therapies: A comparison of theoretical assumptions. American Journal of Family Therapy, 10, 13–23.
Golden, M. (1998). Incorporation of quality-of-life considerations into intensive diabetes management protocols in adolescents. Diabetes Care, 21, 885–886.[Web of Science][Medline]
Gray, D. L., Marrero, D. G., Godfrey, C., Orr, D. P., & Golden, M. P. (1987). Chronic poor metabolic control in the pediatric population: A stepwise intervention program. Diabetes Educator, 14, 516–520.
Greco, P., LaGreca, A. M., Auslander, W. F., Spetter, D., Skyler, J. S., Fisher, E., et al. (1990). ssessing adherence in IDDM: A comparison of two methods [Abstract]. Diabetes, 40, 108A.
Grey, M., Boland, E., & Maryanne, D., Yu, C., Sullivan-Bolyai, S., & Tamborlane, W. (1998). Short-term effects of coping skills training as adjunct to intensive therapy in adolescents. Diabetes Care, 21, 902–918.[Abstract]
Hanson, C. L. (1989). Cardiovascular and metabolic health in high risk youth. Unpublished manuscript. National Institutes of Health NIH/NIDDK grant #DK 41969-01.
Harris, M. A., Greco, P., Wysocki, T., Elder-Danda, C., & White, N. H. (1999). Adolescents with diabetes from single-parent, blended, and intact families: Health-related and family functioning. Families, Systems and Health, 17, 181–196.
Harris, M. A., Greco, P., Wysocki, T., & White, N. H. (2001). Family therapy with adolescents with diabetes: A litmus test for clinically meaningful change. Families, Systems and Medicine, 19, 159–168.
Harris, M. A., & Mertlich, D. (2003). Piloting home-based behavioral family systems therapy for adolescents with poorly controlled diabetes. Children’s Health Care, 32, 65–79.[CrossRef]
Henggeler, S. W., & Santos, A. B. (1997). Innovative approaches for difficult-to-treat populations. Washington, DC: American Psychiatric Press.
McDaniel, S. H., Lusterman, D. D., & Philpot, C. L. (2001). Casebook for integrating family therapy: An ecosystemic approach. Washington, DC: APA.
Robin, A., & Foster, S. L. (1989). Negotiating parent adolescent conflict. Guilford Press, New York.
Rubin, R. R., Young-Hyman, D., & Peyrot, M. (1989). Parent–child responsibility and conflict in diabetes care [Abstract]. Diabetes, 38, 7A.[CrossRef]
Schafer, L. C., McCaul, K., & Glasgow, R. E. (1986). Supportive and nonsupportive family behaviors: Relations to adherence and metabolic control in persons with type I diabetes. Diabetes Care, 9, 179–185.[Abstract]
Stein, R. (2001). Home-based comprehensive care services for children with chronic conditions. Children’s Services: Social Policy Research and Practice, 4, 189–201.
Weissberg-Benchell, J., Glasgow, A. M., Tynan, W. D., Wirtz, P., Turek, J., & Ward, J. (1995). Adolescent diabetes management and mismanagement. Diabetes Care, 18, 77–82.[Abstract]
Wysocki, T., Greco, P., Harris, M. A., Bubb, J., & White, N. H. (2001). Behavior therapy for families of adolescents with IDDM: Maintenance of treatment effects. Diabetes Care, 24, 441–446.
Wysocki, T., Harris, M. A., Greco, P., Harvey, L. M., McDonell, K., Elder, et al. (1997). Social validity of support group and behavior therapy interventions for families of adolescents with insulin-dependent diabetes mellitus. Journal of Pediatric Psychology, 22, 635–649.
Wysocki, T., Harris, M. A., Greco, P., Mertlich, D., & Buckloh, L. (2001). Behavioral family systems therapy for adolescents with a chronic illness: Treatment and implementation manual. Unpublished manuscript.
Wysocki, T., White, N. H., Bubb, J., Harris, M. A., & Greco, P. (1995). Family adaptation to diabetes: A model for intervention research. In J. L. Wallander & L. J. Siegel (Eds.), Adolescent health problems: Behavioral perspectives. New York: Guilford Press.
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