Investigators:
- Tim Wysocki, PhD
Background
There are many published research studies showing that the management of diabetes mellitus depends greatly on how well families of adolescents with diabetes are able to work together and communicate about the disease and its treatment. This team of researchers has completed a previous large scale study showing that a family communication training program called Behavioral Family Systems Therapy was effective in helping families of adolescents with diabetes to develop more effective communication skills and better parent-adolescent relationships. However, it had weaker effects in terms of improving the adolescents adherence with medical treatment and their diabetic control. In this second study, we have adapted the treatment in several ways in an effort to improve its impact on these diabetes outcomes.
What We're Doing
A total of 104 families of adolescents with diabetes were recruited for participation in Jacksonville or St. Louis. Families were assigned randomly to be in one of three study conditions for a 6-month period. The three study conditions are Usual Care, Educational Support Group, and Behavioral Family Systems Therapy for Diabetes. After the 6-month treatment period, families continue to participate in the study for a 12-month follow-up period.
The Usual Care group continued to receive medical care for diabetes from their same endocrinologists, who followed the most recent treatment recommendations published by the American Diabetes Association.
The Educational Support group participated in 12 sessions of a diabetes support group conducted by a registered nurse who is a Certified Diabetes Educator. Sessions consisted of a 45-minute educational presentation on a diabetes topic, followed by a 45-minute group discussion of that topic. This is the most commonly used psychological intervention to enhance family coping with diabetes and it is widely accepted as providing psychological, as well as educational, benefits to participants.
The Behavioral Family Systems Therapy (BFST) group participated in 12 sessions with a psychologist, attended by members of the family only, during which they received family communication training that is specially designed to improve adolescents' adherence with diabetes treatment and diabetic control. Family members learned to recognize and change common communication errors and to resolve disagreements by negotiating behavioral contracts designed to improve diabetes outcomes. A registered nurse attended two sessions to provide training in using blood sugar test results for adjustment of insulin, diet, and exercise. Parents in the BFST group will be asked to simulate living with diabetes for one week, including four blood glucose tests per day, logbook recording of test results, three daily injections of a prescribed "dose" of sterile saline using an insulin syringe, doing one urine ketone test, following a meal plan based on carbohydrate counting, and managing one simulated episode of low blood sugar. This has been shown in another study to improve relationships between adolescents with diabetes and their parents.
Families took part in four comprehensive evaluations, each lasting about 3.5 to 4 hours, just before their assignment to one of these study conditions and again at the end of the 6-month treatment phase of the study and at follow-ups that will take place 6 months and 12 months after the end of the 6-month treatment phase. During these evaluations, participants will complete a variety of questionnaires, psychological tests, and interviews that will measure parent-adolescent relationships, family communication, adolescent psychological adjustment, adolescent learning ability and school achievement, family sharing of diabetes responsibilities, diabetes treatment adherence, and health care utilization. Glycosylated hemoglobin tests will be obtained at each of the four study evaluations and results of this test done by the adolescent's doctor during the study will be retrieved from the adolescent's medical chart. Each evaluation session will also include family participation in a problem solving discussion about diabetes that will be videotaped for later scoring.
Some of What We've Found
In the first funding cycle of this NIH grant (RO1-DK43802), we found that BFST yielded significant and lasting improvements in parent-adolescent relationships and reductions in diabetes-related family conflict, verified by both self-report questionnaire findings and directly observed family interactions. Delayed improvement in treatment adherence was evident 6 months after therapy had ended. Unfortunately, these clinically meaningful behavioral changes did not manifest in statistically significant improvements in diabetic control either at immediate post-treatment or at follow-ups 6 months and 12 months later.
From this second funding cycle, we have reported immediate post-treatment results in an oral abstract presentation at the 2004 Scientific Sessions of the American Diabetes Association and in a paper accepted for publication by the Journal of Pediatric Psychology. The results suggest that BFST selectively benefits those in the poorest diabetic control before intervention. Collection of one year follow-up data has just been completed with the full sample and further analyses will be reported.