Toward conceptual clarity in a critical parenting construct: parental monitoring in youth with chronic illness.

Parental monitoring has been defined as "a set of correlated parenting behaviors involving attention to and tracking of the child's whereabouts, activities, and adaptations." This construct is of significant interest due to its relatedness to a broad range of youth risk behaviors, including risky sexual behavior, substance abuse, and poor adherence. However, to date, measures of parental monitoring are largely absent from the chronic illness literature. The present article focuses upon two key problems in the operationalization of the monitoring construct to date: (a) poor conceptual specificity in parenting constructs such as monitoring, overprotection, and over-involvement when used to date among youth with chronic conditions and (b) the confounding of existing measures of parental monitoring with items evaluating parental knowledge of youth activities, which has resulted in a lack of data regarding the mechanisms by which parents obtain their information. Recommendations for the future development of monitoring measures are discussed.

The parental monitoring of diabetes care scale: development, reliability and validity of a scale to evaluate parental supervision of adolescent illness management.

PURPOSE: Monitoring of adolescents' behavior and whereabouts has been repeatedly identified as an important predictor of adolescent behavioral outcomes. However, to date, measures of parental supervision and monitoring are lacking in the chronic illness literature. The present study describes development and initial evaluation of a measure of parental monitoring of the illness management of adolescents with diabetes: the Parental Monitoring of Diabetes Care scale (PMDC). METHODS: Ninety-nine parents of 12-18-year-old children with type 1 diabetes completed the PMDC. Measures of illness management and metabolic control were also obtained. RESULTS: The PMDC demonstrated good internal consistency (alpha coefficient = .81) and test-rest reliability (ICC = .80). Supporting the instrument's construct validity, confirmatory factor analysis indicated that a five subdomain structure had an acceptable fit to the data, [chi(2) (181.65)/df (126) = 1.44, Bollen-Stine chi(2) = 165.03, p = .32, comparative fit index (CFI) = .91, and root-mean-square error of approximation = .07]. In structural equation models, parental monitoring as assessed by the PMDC had a significant direct effect on adolescent diabetes management, accounting for 38% of the variance. Parental monitoring also had a significant indirect effect on metabolic control. CONCLUSIONS: The PMDC represents an important first step in the development of measures of parental monitoring for use with adolescents with chronic medical conditions.

Brief report: maintenance of effects of motivational enhancement therapy to improve risk behaviors and HIV-related Health in a randomized controlled trial of youth living with HIV.

OBJECTIVE: To examine the maintenance of effects of Motivational Enhancement Therapy (MET) shown to improve risk behaviors and viral load in youth living with HIV (YLH) immediately posttreatment. METHODS: Sixty-five youth (ages 16-25 years) were randomized to Healthy Choices or a waitlist control. Frequency of substance use, frequency of unprotected intercourse, and viral load were obtained at baseline, 3, and 6 months after study entry. The waitlist control then received intervention. An additional data collection was obtained at 9 months for follow-up of the original treatment group. RESULTS: One-tailed ANOVA showed that the treatment group had greater reductions in viral load and alcohol use from baseline to 6 months. These reductions appeared to be maintained at 9-month follow-up. Improvements in sexual risk were not evident. CONCLUSIONS: MET showed significant promise in reducing substance use and in improving HIV-related health in YLH immediately posttreatment. These effects were maintained after treatment termination.

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.

Predicting metabolic control in the first 5 yr after diagnosis for youths with type 1 diabetes: the role of ethnicity and family structure.

The primary purpose of this study was to determine if there were differences in trajectories of metabolic control between African American and White youth with type 1 diabetes in the first 5 yr after diagnosis. A secondary purpose was to investigate other sociodemographic variables that often covary with race/ethnicity such as number of parents in the home and family income to determine if they predicted trajectories of metabolic control in youth with diabetes over and above the effects of ethnicity. A convenience sample of 71 youth was recruited. Multilevel modeling was used to estimate the population trajectory and to investigate the contribution of other variables. Differences in metabolic control between African American and White youth began shortly after diagnosis and continued to accelerate well beyond the point of diagnosis. However, subsequent analysis showed that deterioration in metabolic control could equally well be explained by living in a single-parent household. At 24 months postdiagnosis, the metabolic control in youth from single-parent families worsened almost three times as fast as that in youth from two-parent families (0.11 vs. 0.04%/month). The difference in hemoglobin A1c level at 24 months was 1.34% (p = .007). Neither family income nor clinical variables such as child's age, Tanner stage, or body mass index was significant predictor of metabolic control. Diabetes care providers should consider developing targeted interventions such as parent social support resources or school-based youth monitoring programs for youth in single-parent families.

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.

Family mediators and moderators of treatment outcomes among youths with poorly controlled type 1 diabetes: results from a randomized controlled trial.

OBJECTIVE: To determine whether multisystemic therapy (MST) improved family relationships among youths with poorly controlled type 1 diabetes and whether these changes mediated MST effects on health outcomes. The moderating effect of family demographics on study outcomes was also assessed. METHODS: A randomized controlled trial was conducted with 127 youths. Changes in general family relationships and caregiver support for diabetes care from baseline to treatment completion were assessed. Structural equation modeling (SEM) was used to test whether changes in family relations mediated improvements in frequency of blood glucose testing (BGT) and metabolic control. RESULTS: MST increased support for diabetes care from both primary and secondary caregivers in two-parent but not in single-parent families. However, MST had the strongest effects on BGT and metabolic control in single-parent families. SEM did not support family relations as the mediator of improved BGT or metabolic control. Rather, MST had a direct effect on BGT for all participants. BGT mediated improvements in metabolic control among single-parent families. CONCLUSIONS: MST improved family relationships for youths with diabetes in two-parent but not in single-parent families. Objective outcomes related to diabetes were strongest for single-parent families. Other processes such as increased parental monitoring may have been responsible for improved health outcomes among these families.

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 > or =8% at study enrollment and for the past 1 year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants assigned randomly to MST received treatment for approximately 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 chronic poor metabolic control: a randomized controlled trial.

OBJECTIVE: The aim of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could improve adherence and metabolic control and decrease rates of hospital utilization among adolescents with chronically poorly controlled type 1 diabetes. RESEARCH DESIGN AND METHODS: A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and chronically poor metabolic control (HbA(1c) [A1C] > or =8% for the past year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants randomly assigned to MST received treatment for approximately 6 months. Data were collected at baseline and at 7 months posttest (i.e., treatment termination). Changes in A1C adherence, as measured by semistructured interviews and blood glucose meters and hospital admissions and emergency department visits, were assessed. RESULTS: In intent-to-treat analyses, participation in MST was associated with significant improvements in the frequency of blood glucose testing as assessed by blood glucose meter readings (F[1,125] = 16.75, P = 0.001) and 24-h recall interviews (F[1,125] = 6.70, P = 0.011). Participants in MST also had a decreasing number of inpatient admissions, whereas the number of inpatient admissions increased for control subjects (F[1,125] = 6.25, P = 0.014). Per protocol analyses replicated intent-to-treat analyses but also showed a significant improvement in metabolic control for adolescents receiving MST compared with control subjects (F[1,114] = 4.03, P = 0.047). CONCLUSIONS: Intensive, home-based psychotherapy improves the frequency of blood glucose testing and metabolic control and decreases inpatient admissions among adolescents with chronically poorly controlled type 1 diabetes.

Diabetes management in adolescents in poor metabolic control.

PURPOSE: This study was conducted to describe and compare adolescent and parent report of diabetes management and to identify racial/ethnic differences in diabetes management and metabolic control in adolescents in poor metabolic control. METHODS: The convenience sample consisted of 31 mother-adolescent dyads. Diabetes management was measured by the Diabetes Management Scale. Descriptive statistics, bivariate correlations, and t-tests were used to analyze the data. RESULTS: The overall mean of individual management activities was 66% for adolescents and 68% for mothers. Mismanagement of insulin was reported by 25% of the adolescents yet this behavior was supervised only 65% of the time. Better metabolic control was related to eating 3 meals a day, getting insulin every day, and more assistance with meals. African American adolescents were in poorer metabolic control than European Americans. CONCLUSIONS: Diabetes management behaviors are performed much less frequently than recommended by adolescents and their mothers. Additional research is necessary to identify modifiable factors that contribute to inadequate diabetes management to identify intervention strategies to improve diabetes management in adolescents with poor metabolic control.

King's conceptual system and theory of goal attainment: past, present, and future.

Imogene King is universally recognized as a pioneer of nursing theory development. Her interacting conceptual system for nursing and her theory of goal attainment have been included in every major nursing theory text, are taught to thousands of nursing students, form the basis of nursing education programs, and are implemented in a variety of service settings.