Psychosocial Interventions for Children With Type 1 Diabetes and Their Parents

Over the past three decades, a variety of psychosocial and behavioral interventions have been utilized in the context of type 1 diabetes (for comprehensive reviews of such interventions, see Delamater 2007;

Hampson et al. 2000; Winkley et al. 2006). These interventions have tended to fall into one of four overlapping categories: 1) patient/family education and teaching of self-management skills; 2) improvement of adherence to medical regimens; 3) psychosocial interventions for children; and 4) family-based interventions.

Clearly, knowledge about diabetes and its treatment is an essential basis for diabetes management. Thus, systematic efforts have been made to impart such information through clinic-based interventions that occur immediately after diagnosis, as well as through other avenues such as summer camps (e.g., Harkavy et al. 1983; Karaguzel et al. 2005; San-tiprabhob et al. 2008). What is also clear, however, is that diabetes knowledge is insufficient for successful diabetes management. Indeed, knowledge is inconsistently associated with HbA1c levels (e.g., Johnson 1995). To further enhance diabetes management, researchers have used a variety of approaches that build on a knowledge base, such as group coping skills training (Grey et al. 2000) or behavioral contracting (e.g., Wysocki et al. 1989). Wysocki et al. (2003) aptly pointed out that families may also benefit from specific training in the use of self-monitoring of blood glucose, because a number of studies have documented that such efforts result in better diabetic control, better adherence, and less diabetes-related conflict (Anderson et al. 1989; Delamater et al. 1990; Wysocki et al. 1992). Although methodological problems still plague much of this research, many of these interventions appear to be at least moderately effective in improving disease management, particularly when the interventions are theoretically driven (Hampson et al. 2000).

More recently, the critical role of the family and family system has also been highlighted in diabetes management (Delamater 2007). Indeed, comprehensive psychosocial and family-based interventions have been developed in the hopes of better addressing issues of adherence, interpersonal adjustment, peer relations, and family relationships. In a series of studies, Wysocki and colleagues have evaluated the effect of behavioral family systems therapy on a wide range of behavioral, emotional, and medical outcomes in youth with type 1 diabetes (Wysocki et al. 1999, 2000, 2001, 2006, 2007). Behavioral family systems therapy, adapted from the work of Robin and Foster (1989), focuses on the teaching of problem-solving and communication skills in the context of the family system. Wysocki and colleagues have demonstrated that behavioral family systems therapy results in improved conflict resolution and communication skills, enhanced parent-child relationships, and improved adherence and glycemic control.

Similarly, Ellis and colleagues have adapted multisystemic therapy, a comprehensive family systems-based program originally developed for youth with significant mental health problems and delinquency (Henggeler and Borduin 1990), for the treatment of adolescents with type 1 diabetes who were in poor control (Ellis et al. 2005a, 2005b). Multisystemic therapy targets not only the individual and family system but also the larger community system, which in the case of youth with diabetes also includes the school and health care system. Targeting adolescents with chronic poor metabolic control, Ellis et al. (2005a, 2005b) demonstrated that 6 months of multisystemic therapy resulted in improvements in blood glucose testing, decreased inpatient hospital admissions, reduced direct care costs, and improved metabolic control. With a focus primarily on parental adjustment, Hoff et al. (2005) piloted a randomized clinical trial involving an intervention for parents of children newly diagnosed with type 1 diabetes. This intervention, based on uncertainty in illness theory, was designed to decrease parental uncertainty and distress and to indirectly improve child emotional functioning. Significant reductions in distress were observed for both mothers and fathers in the intervention group, as well as maternal ratings of child behavior problems. These reductions were still apparent for both mothers and fathers at a 6-month follow-up.

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