Maureen A. Frey

Multisystemic Therapy for Adolescents With Poorly Controlled Type 1 Diabetes: Reduced diabetic ketoacidosis admissions and related costs over 24 months

OBJECTIVE—The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated. RESEARCH DESIGN AND METHODS—A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care. RESULTS—Youth who received MST had significantly fewer hospital admissions than control subjects (χ2 = 11.77, 4 d.f., n = 127; P = 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P = 0.004), 12-month (P = 0.021), 18-month (P = 0.046), and 24-month follow-up (P = 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions. CONCLUSIONS—The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance.

Risky behavior and risk in adolescents with IDDM

PURPOSE To determine: (1) the frequency of risky behaviors (alcohol and other drug use, smoking cigarettes, smokeless tobacco use, and unprotected intercourse); (2) the perception of general risks and diabetes-related risks from risky behaviors; (3) if perception of risk is related to engaging in risky behaviors; and (4) if perception of general risks and diabetes-related risks are influenced by age, gender, or race in adolescents with insulin dependent diabetes mellitus (IDDM). Decreasing risky behaviors in youth with IDDM is important because of their increased vulnerability to specific disease related physiologic and pathologic changes. METHODS A descriptive, cross-sectional design was used. Data on risky behavior and perception of risk were obtained by self-report during a regularly scheduled clinic visit. One hundred and fifty-five adolescents between ages of 10-20 years participated. Correlational and students t-test analyses were used to test relationships and group differences (age, race, gender). RESULTS Thirty-nine percent of the sample reported alcohol use, 34% reported smoking cigarettes, 8% reported smokeless tobacco use, 10% reported drug use, and 29% reported unprotected intercourse. Perception of risk to peers from these behaviors was significantly higher (t = 8.1, df 153; p < .001) than risk to self. Females reported significantly lower (t = 3.08, df 52; p < .002) risk to self than males. There was no difference in perception of risk between youth who reported participating in risky behaviors (N = 38%) and those who did not (62%). Not surprisingly, the frequency of risky behavior increased with age (F = 15.46; p < .001). CONCLUSIONS Compared to community samples of middle school children, our sample had lower rates for most risky behaviors. As with community samples, the physical risks were known and perceived to be higher for peers than self. Perception of risk was not related to self-reports of risky behaviors. The lower rate of risky behaviors might reflect the success of educational efforts directed toward diabetes management or may be due to later initiation of behaviors, especially if personal social development is delayed. Additional research is indicated in order to understand the timing and trajectory of risky behavior and whether or not perception of risk deters youth with IDDM from engaging in risky behavior.

Multisystemic therapy for adolescents with poorly controlled type I diabetes : Stability of treatment effects in a randomized controlled trial

The primary purpose of the present study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, improved regimen adherence, metabolic control, and rates of hospitalization for diabetic ketoacidosis (DKA) among adolescents with chronically poorly controlled Type 1 diabetes 6 months after the completion of treatment. A randomized controlled trial was conducted with 127 adolescents and their families. Mean participant age was 13.2 years. Sixty-three percent of participants were African American, and 51% were female. Data were collected at baseline, treatment termination, and 6-month follow-up. Changes in glycated hemoglobin (HbA1c), frequency of blood glucose testing (BGT), and rate of DKA admissions were assessed. In intent-to-treat analyses, a main effect of MST on DKA admissions was found at both treatment termination and follow-up. Improvements in BGT were moderated by family composition; only 2-parent MST families maintained improvements at follow-up. Improvements in HbA1c for the MST group at treatment termination were lost at follow-up. Results show that intensive, home-based psychotherapy created stable reductions in serious lapses in adherence, as indexed by episodes of DKA, among youth with poorly controlled diabetes.

MST for Adolescents with Poorly Controlled Type I Diabetes: Reduced DKA Admissions and Related Costs over 24 Months

OBJECTIVE—The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated. RESEARCH DESIGN AND METHODS—A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care. RESULTS—Youth who received MST had significantly fewer hospital admissions than control subjects (χ2 = 11.77, 4 d.f., n = 127; P = 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P = 0.004), 12-month (P = 0.021), 18-month (P = 0.046), and 24-month follow-up (P = 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions. CONCLUSIONS—The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance.

Social ecological model of illness management in high-risk youths with type 1 diabetes.

In this study, the authors tested a social ecological model of illness management in high-risk, urban adolescents with Type 1 diabetes. It was hypothesized that management behaviors would be associated with individual adolescent characteristics as well as family, peer, and provider relationships. Questionnaires were collected from 96 adolescents in poor metabolic control and their primary caregivers. Variables in each system were correlated with illness management. Multiple regression demonstrated that higher externalizing symptoms, poorer family relationships, lower satisfaction with providers, and greater age contributed to the variance in illness management. Internalizing symptoms and peer relationships were no longer significant in the model. Results support a social ecological model of illness management in high-risk youths. Interventions grounded in social ecological theory are discussed.

The Effects of Multisystemic Therapy on Diabetes Stress Among Adolescents With Chronically Poorly Controlled Type 1 Diabetes: Findings From a Randomized, Controlled Trial

Objective. The goal of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Stress was also evaluated as a mediator of the effect of MST on adherence and metabolic control. Methods. A randomized, controlled trial was conducted with 127 adolescents with type 1 diabetes mellitus and chronically poor metabolic control (hemoglobin A1c levels of ≥8% at study enrollment and for the past 1 year) who received their diabetes care in a childrens hospital located in a major Midwestern city. Participants assigned randomly to MST received treatment for ∼6 months. Data were collected at baseline and at a 7-month posttest (ie, treatment termination). Changes in diabetes-related stress, as measured with a self-report questionnaire, were assessed. Structural equation models were used to test the degree to which changes in stress levels mediated the ability of the MST intervention to improve adherence and metabolic control. Results. In intent-to-treat analyses, participation in MST was associated with significant reductions in diabetes-related stress. Tests for moderation found no significant effects of age, gender, or ethnicity, which suggests that the intervention was equally effective in reducing diabetes stress for all participants. However, structural equation modeling did not provide support for diabetes stress as the mechanism through which MST improved health outcomes. Rather, the final model suggested that MST improved metabolic control through increased regimen adherence. Conclusions. Intensive, home-based psychotherapy reduces diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Such stress reductions are important for the psychological wellbeing of a subset of youths with diabetes who are at high risk for future health complications.

Use of Multisystemic Therapy to Improve Regimen Adherence Among Adolescents with Type 1 Diabetes in Poor Metabolic Control: A Pilot Investigation

The purpose of the current study was to conduct a pilot investigation to determine the effectiveness of Multisystemic Therapy (MST) for improving regimen adherence and metabolic control among adolescents with poorly controlled Type 1 diabetes. Thirty-one adolescents were randomly assigned to either MST or a control condition. MST treatment lasted approximately six months. Data were collected at study entry and at a six-month posttest. Twenty-five adolescents completed the study. Adolescents who received MST had significantly improved adherence to blood glucose testing and metabolic control from study entry to the six-month posttest, whereas controls did not. Adolescents receiving MST also had a decreased number of inpatient admissions at the six-month posttest. Improvements in metabolic control were related to improvements in parent report of adolescent adherence. Results suggest that MST holds promise as an intervention for improving adherence behavior and health outcomes among adolescents in poor metabolic control.

Functional Status Scale: New Pediatric Outcome Measure

OBJECTIVE: The goal was to create a functional status outcome measure for large outcome studies that is well defined, quantitative, rapid, reliable, minimally dependent on subjective assessments, and applicable to hospitalized pediatric patients across a wide range of ages and inpatient environments. METHODS: Functional Status Scale (FSS) domains of functioning included mental status, sensory functioning, communication, motor functioning, feeding, and respiratory status, categorized from normal (score = 1) to very severe dysfunction (score = 5). The Adaptive Behavior Assessment System II (ABAS II) established construct validity and calibration within domains. Seven institutions provided PICU patients within 24 hours before or after PICU discharge, high-risk non-PICU patients within 24 hours after admission, and technology-dependent children. Primary care nurses completed the ABAS II. Statistical analyses were performed. RESULTS: A total of 836 children, with a mean FSS score of 10.3 (SD: 4.4), were studied. Eighteen percent had the minimal possible FSS score of 6, 44% had FSS scores of ≥10, 14% had FSS scores of ≥15, and 6% had FSS scores of ≥20. Each FSS domain was associated with mean ABAS II scores (P < .0001). Cells in each domain were collapsed and reweighted, which improved correlations with ABAS II scores (P < .001 for improvements). Discrimination was very good for moderate and severe dysfunction (ABAS II categories) and improved with FSS weighting. Intraclass correlations of original and weighted total FSS scores were 0.95 and 0.94, respectively. CONCLUSIONS: The FSS met our objectives and is well suited for large outcome studies.

Transtheoretical model and condom use in HIV-positive youths

The purpose of the study is to test constructs of the Transtheoretical Model for predicting unprotected intercourse in HIV-positive youths (ages 16-25 years). Questionnaires and interviews about sexual behavior, stage of change, self-efficacy, substance use, emotional distress, and social support were obtained from 60 HIV-positive youths. Path analysis, with standard errors determined by methods appropriate to small samples, suggested that self-efficacy completely mediated the relationship between stage of change and unprotected intercourse acts. Social support specific to reducing risk was associated with increased self-efficacy. Emotional distress and low general social support were not associated with decreased condom use. The path between substance use and decreased condom use approached significance. Results highlight the potential of prevention interventions that simultaneously boost self-efficacy and social support specific to practicing safer sex as well as those that reduce substance use.

Improving health outcomes among youth with poorly controlled type I diabetes: the role of treatment fidelity in a randomized clinical trial of multisystemic therapy.

The purpose of the study was to assess whether therapist treatment fidelity was a predictor of treatment outcome in a randomized clinical trial of multisystemic therapy with 10- to 16-year-old youths with chronically poorly controlled Type I diabetes (N = 40). Treatment fidelity was assessed by objective ratings of therapy sessions and questionnaires completed by caregivers and by therapists. Relationships between fidelity measures were assessed. Structural equation modeling (SEM) was used to test whether high fidelity would lead to improved regimen adherence and to improved metabolic control outcomes via regimen adherence. Objective ratings of treatment fidelity were significantly related to therapist-reported but not to caregiver-reported treatment fidelity. SEM results supported a completely mediated pathway between treatment fidelity and metabolic control, with regimen adherence mediating the relationship. Results suggest that conducting complex behavioral interventions with a high degree of fidelity can improve treatment outcomes among youths with chronic illnesses.