Physician identification and management of psychosocial problems in primary care.

Often the burden of identifying children with behavioral or developmental problems is left up to the primary care physician (PCP). However, previous literature shows that PCPs consistently underidentify children with developmental/behavioral problems in pediatric primary care. For the current study, questionnaires containing three vignettes followed by questions addressing common psychosocial problems, general questions about their practice and training, and the Physician Belief Scale were distributed to physicians. Results indicated that physicians were better at identifying severe problems, had more difficulty identifying psychosocial problems with mild symptomatology, and tended to refer to a medical specialist or mental health professional more often for severe problems, depression or a developmental problem. Physicians tended to view treating psychosocial problems favorably.

Youth and parent education about diabetes complications: health professional survey.

OBJECTIVE: Avoiding complications is paramount in diabetes management, but little is known about how, when, and what diabetes professionals disclose to parents and youths about this topic. RESEARCH DESIGN AND METHOD: Pediatric diabetes experts (n = 534) were surveyed about their practices and attitudes regarding informing parents and youth about long-term diabetic complications. RESULTS: Professionals reported giving more information to parents, older children, and children with longer diabetes duration than younger or newly diagnosed children. Principal components analysis was completed to identify measurement factors of the attitudes about information sharing and variables affecting decision-making sections of the survey. These factor scores served as predictor variables in hierarchical multiple regression analyses. More information sharing was associated with more diabetes clinical activity, stronger sense of professional responsibility to disclose this information, less sensitivity about the emotional impact of this teaching, greater concern about exposure to inaccurate information, and less consideration of the family context (R(2) = 0.282, p < or = 0.0001). Greater propensity to share information about complications was found among health care providers who reported that they gave less consideration to such variables as the family's prior experience with diabetes in other family members or the child's duration of diabetes or the presence of psychiatric disorders in the child or family members. CONCLUSIONS: Patient characteristics and professionals' attitudes were associated with experts' willingness to inform families about long-term diabetic complications. Further research should explore how these practice variations affect coping with diabetes.

A multisite trial of a clinic-integrated intervention for promoting family management of pediatric type 1 diabetes: feasibility and design.

The feasibility of a family-based clinic-integrated behavioral intervention to improve family management of type 1 diabetes was evaluated. In each of four clinical sites, 30-32 families (a total of 122) were randomized to intervention or usual care comparison groups. The WE*CAN intervention, based on family problem-solving methods, was delivered during three routine clinic visits by trained 'Health Advisors'. Of eligible families across the four sites, 83% agreed to participate, of whom 96% completed the baseline, mid-term, and postintervention assessments. Families participated in an average of 2.85 intervention sessions over an 8-month period. The intervention was integrated into the clinic setting without impairing clinic flow and was implemented with fidelity and consistency across sites by trained non-professionals. The findings provide evidence of the feasibility of conducting a multisite trial to evaluate the effects of a clinic-integrated problem-solving intervention to improve family management. Many lessons were learned that provide guidance for recruitment, measurement, and intervention for the larger clinical trial.

Diabetes complications in youth: qualitative analysis of parents' perspectives of family learning and knowledge.

OBJECTIVE: Youth with type 1 diabetes face long-term risks of health complications of the disease. Little is known about patients' and parents' knowledge, acquisition of information, and family communication regarding these complications. This paper reports qualitative analyses of parental focus-group discussions of this topic. RESEARCH DESIGN AND METHODS: A total of 47 participants (30 mothers, 14 fathers, and 3 others) representing 33 children between the ages of 8 and 18 years with type 1 diabetes participated in 1 of 13 focus groups. Open-ended questions focused on the type and amount of information about long-term complications presented to parents by health care professionals at different time points, as well as the way that information was presented. Questions also elicited details about parent-child communication and exposure to misconceptions about diabetes complications. RESULTS: Qualitative analysis of the transcribed focus groups revealed that participants experienced significant anxiety about diabetes complications, with a shift from concern about daily management tasks to concern about long-term complications over time. Participants desired a flexible, collaborative educational approach, especially regarding the timing and type of information, relative to the child's age and duration of diabetes. Many parents wanted more sensitive communication and emotional support from health care providers. Motivating children appeared to be a particular challenge; family burnout with regard to diabetes care over time was reported. Knowledge was gained in many ways, yet misinformation was uncommon. CONCLUSIONS: Obtaining information about long-term complications is an important process that changes over the course of the disease and with the child's developmental level. More research is needed, especially regarding youth knowledge, learning, and beliefs about diabetes complications.

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.