Michael A. Harris

Randomized Trial of Behavioral Family Systems Therapy for Diabetes Maintenance of effects on diabetes outcomes in adolescents

OBJECTIVE—Studies showing that family communication and conflict resolution are critical to effective management of type 1 diabetes in adolescents have stimulated interest in evaluating psychological treatments targeting these processes. Previous trials have shown that Behavioral Family Systems Therapy (BFST) improved parent-adolescent relationships but not treatment adherence or glycemic control. This study evaluates a revised intervention, BFST for Diabetes (BFST-D), modified to achieve greater impact on diabetes-related family conflict, treatment adherence, and metabolic control. RESEARCH DESIGN AND METHODS—A sample of 104 families of adolescents with inadequate control of type 1 diabetes was randomized to either remain in standard care (SC) or to augmentation of that regimen by 12 sessions of either a multifamily educational support (ES) group or 12 sessions of BFST-D over 6 months. Pertinent measures were collected at baseline and at follow-up evaluations at 6, 12, and 18 months. RESULTS—BFST-D was significantly superior to both SC and ES in effects on A1C, while effects on treatment adherence and family conflict were equivocal. Improvement in A1C appeared to be mediated by improvement in treatment adherence. A significantly higher percentage of BFST-D youth achieved moderate or greater improvement (>0.5 SD) in treatment adherence compared with the SC group at each follow-up and the ES group at 6 and 18 months. Change in treatment adherence correlated significantly with change in A1C at each follow-up. CONCLUSIONS—These results support the efficacy of BFST-D in improving A1C, but further research is needed to identify the mechanisms of this effect and to achieve cost-effective dissemination of the intervention.

Randomized, Controlled Trial of Behavioral Family Systems Therapy for Diabetes: Maintenance and Generalization of Effects on Parent-Adolescent Communication

We report a randomized trial of a revised Behavioral Family Systems Therapy for Diabetes (BFST-D) intervention. Families of 104 adolescents with diabetes were randomized to standard care (SC) or to 6 months of an educational support group (ES) or BFST-D. Family communication and problem-solving skills were assessed at 0, 6, 12, and 18 months by independent rating of videotaped family problem-solving discussions. BFST-D improved individual communication of adolescents and mothers, but not fathers. BFST-D significantly improved quality of family interaction compared to SC (10 of 12 comparisons) and ES (6 of 12 comparisons). Changes in family communication were differentially associated with changes in glycemic control, adherence, and family conflict. BFST-D improved family communication and problem solving relative to SC and modestly relative to ES.

Research on social support in adolescents with IDDM: a critical review.

This article provides a review of the findings of 32 scientific studies that examined the relationship between social support and adherence/metabolic control in adolescents with insulin-dependent diabetes mellitus. Social support included qualitative family support characteristics, communication patterns, sibling and peer relationships, and regimen- specific support behaviors. The literature was examined in the context of adolescent development. Although the results of these studies were somewhat inconsistent, some general patterns emerged that are described and discussed in detail. Methodological limitations and suggestions for future research are provided.

Diabetes Resilience: A Model of Risk and Protection in Type 1 Diabetes

Declining diabetes management and control are common as children progress through adolescence, yet many youths with diabetes do remarkably well. Risk factors for poor diabetes outcomes are well-researched, but fewer data describe processes that lead to positive outcomes such as engaging in effective diabetes self-management, experiencing high quality of life, and achieving in-range glycemic control. Resilience theory posits that protective processes buffer the impact of risk factors on an individual’s development and functioning. We review recent conceptualizations of resilience theory in the context of type 1 diabetes management and control and present a theoretical model of pediatric diabetes resilience. Applications to clinical care and research include the development of preventive interventions to build or strengthen protective skills and processes related to diabetes and its management. The ultimate goal is to equip youths with diabetes and their families with the tools to promote both behavioral and health-related resilience in diabetes.

Executive Function, Adherence, and Glycemic Control in Adolescents with Type 1 Diabetes: a Literature Review

The aim of the present review was to examine and report findings from published research to date that has examined associations between executive function (EF), adherence, and glycemic control in youth with type 1 diabetes. A review of the published research is presented with the objectives of reporting the following: (1) the associations between EF and adherence, (2) the associations between EF and glycemic control, (3) proposed methodological considerations needed to advance related research, (4) recommendations for future research, and (5) clinical recommendations. The major conclusions of this review support the presence of an association between EF, adherence, and glycemic control. Additional prospective and controlled studies are necessary to fully understand the impact of EF on the ability of youth to independently manage type 1 diabetes.

Family Therapy for Adolescents with Poorly Controlled Diabetes: Initial Test of Clinical Significance

OBJECTIVE We examined a structured family therapy approach in promoting clinically meaningful improvements in parent-adolescent conflict in adolescents with poorly controlled diabetes. METHOD Eighteen adolescents with poorly controlled diabetes and their parent(s) participated in 10 sessions of home-based Behavioral Family Systems Therapy (BFST). Outcome comparisons were made using a sample of adolescents with poorly controlled diabetes (n = 40) from a previous study. Clinically significant improvements were determined by calculating SD differences between treatment and comparison groups on measures of diabetes-related and general parent-adolescent conflict. RESULTS Home-based BFST produced change in diabetes-related family conflict ranging from 1/3 to 1/2 SD and general family conflict ranging from 1/3 to 3/4 SD. CONCLUSIONS BFST produced change in family conflict, a variable shown through previous research to relate to treatment adherence in adolescents with diabetes. The test of clinical significance represents an example of a method useful for pediatric research.

Piloting Home-Based Behavioral Family Systems Therapy for Adolescents With Poorly Controlled Diabetes

This study employed a within-subjects design in which 18 adolescents with poorly controlled diabetes received 10 11/2-hr sessions of home-based Behavioral Family Systems Therapy (BFST). Adolescents and their parents completed a variety of psychosocial questionnaires at baseline and immediately following their last session of BFST. Metabolic control was assessed at each evaluation using a hemoglobin A1c assay. The initial posttreatment follow-up evaluation indicated that participants participating in 10 sessions of home-based BFST evidenced pre- to posttreatment decreases in general family conflict, diabetes-related family conflict, and behavior problems. In addition, pre- to posttreatment improvements were observed for treatment adherence of adolescents with poorly controlled diabetes. No significant differences were observed between pre- and posttreatment HbA1c values.

Seeing Is Believing: Using Skype to Improve Diabetes Outcomes in Youth

OBJECTIVE The objective of this study was to compare the relative effectiveness of two modes of delivering Behavioral Family Systems Therapy for Diabetes (BFST-D) to improve adherence and glycemic control among adolescents with type 1 diabetes with suboptimal glycemic control (HbA1c ≥9.0% [≥74.9 mmol/mol]): face to face in clinic (Clinic) and Internet videoconferencing (Skype) conditions. RESEARCH DESIGN AND METHODS Adolescents aged 12 to 18 years and at least one adult caregiver were randomized to receive BFST-D via the Clinic or Skype condition. Participants completed up to 10 therapy sessions within a 12-week period. Changes in youth- and parent-reported adherence and glycemic control were compared before and after the intervention and at follow-up assessment. RESULTS Using an intent-to-treat analytic approach, no significant between-group differences were identified between the before, after, and follow-up assessments. Groups were collapsed to examine the overall effects of BFST-D on adherence and glycemic control. Results identified that statistically significant improvements in adherence and glycemic control occurred from before to after the intervention; improvements were maintained at 3-month follow-up. CONCLUSIONS Delivery of BFST-D via Internet-based videoconferencing is viable for addressing nonadherence and suboptimal glycemic control in adolescents with type 1 diabetes, potentially reducing important barriers to care for youth and families.

Pumpers, skypers, surfers and texters: technology to improve the management of diabetes in teenagers

A variety of innovative technologies are available to assist with the management of diabetes in teenagers. Technologies include devices that assist with the direct day‐to‐day management of diabetes including insulin pumps and continuous glucose monitors. These devices are being used more and more with teenagers as a means of improving treatment adherence and glycaemic control. In addition, telehealth is being used to deliver care and support around diabetes management issues for teens with diabetes. Telehealth used in diabetes care for teens includes cell phones and video‐conferencing. The goal of this telehealth technology is to support health behaviours and implement behavioural change strategies in a way that is more integrated into the everyday lives of patients and even in the context in which the behaviours occur in ‘real time’. Finally, information and support via the Internet are gaining acceptance and use among teens with diabetes as an effective means of strategies for improved diabetes self‐care. All three of these broad uses of technology in diabetes in teens represent flexible, innovative, and accessible approaches to improving both diabetes management and glycaemic control in this ‘at risk’ population.

Behavioral Health Care for Adolescents with Poorly Controlled Diabetes via Skype: Does Working Alliance Remain Intact?

Background: Increasingly various technologies are being tested to deliver behavioral health care. Delivering services via videoconferencing shows promise. Given that the patient-provider relationship is a strong predictor of patient adherence to medical regimens, addressing relationship quality when services are not delivered face-to-face is critical. To that end, we compared the therapeutic alliance when behavioral health care was delivered to youth with poorly controlled type 1 diabetes mellitus (T1DM) and their caregivers in-clinic with the same services delivered via Internet-based videoconferencing (i.e., Skype™). Methods: Seventy-one adolescents with poorly controlled T1DM (hemoglobin A1c ≤9%) and one of their caregivers received up to 10 sessions of a family-based behavioral health intervention previously shown to improve adherence to diabetes regimens and family functioning; 32 were randomized to the Skype condition. Youth and caregivers completed the working alliance inventory (WAI), a 36-item measure of therapeutic alliance, at the end of treatment. Additionally, the number of behavioral health sessions completed was tracked. Results: No significant differences in WAI scores were found for those receiving behavioral health care via Skype versus in-clinic. Youth WAI goal and total scores were significantly associated with the number of sessions completed for those in the clinic group. Conclusion: Behavioral health can be delivered to youth with T1DM via Internet-based videoconferencing without significantly impacting the therapeutic relationship. Thus, for those adolescents with T1DM who require specialized behavioral health care that targets T1DM management, Internet-based teleconferencing represents a viable alternative to clinic-based care.