Psychosocial predictors of acute complications of diabetes in youth.

In this paper we determine whether individual and family psychosocial functioning predicts the risk for recurrent acute diabetic complications. An onset-cohort of 61 children and adolescents with Type 1 diabetes received conventional diabetes care. Episodes of ketoacidosis and of severe hypoglycemia were recorded for 8 years, and glycaemic control was measured by glycohaemoglobin. Measures of psychosocial functioning of the patient and parents were obtained during the first year. Over 8 years, 28% of subjects had at least one episode of ketoacidosis, and 21% had at least one episode of hypoglycaemia. The odds of observing recurrent hypoglycaemia versus recurrent ketoacidosis was 14 times greater in boys than in girls (Fisher's exact test p < 0.05). Girls with recurrent ketoacidosis had more behaviour problems and lower social competence, they reported higher levels of family conflict, and their parents reported lower levels of family cohesion, expressiveness and organization in year one. These relationships were independent of any association with poor glycaemic control. Recurrent hypoglycaemia in boys was generally unrelated to individual and family functioning or glycohaemoglobin. Despite our small sample size, our findings are suggestive of relationships that may lead to early identification of patients who are prone to recurrent ketoacidosis, and to the development of early intervention strategies.

Family environment and glycemic control: a four-year prospective study of children and adolescents with insulin-dependent diabetes mellitus.

An onset cohort of children and adolescents with insulin-dependent diabetes mellitus (IDDM) and their parents were studied. Aspects of family environment were evaluated at study inception, and their influence on the initial level of, and change in, glycemic control over 4 years was examined. Family measures of expressiveness, cohesiveness, and conflict were linked to differences in the longitudinal pattern of glycemic control. In particular, the encouragement to act openly and express feelings directly (expressiveness) seemed to ameliorate deterioration of glycemic control over time in both boys and girls. Boys were especially sensitive to variations in family cohesiveness and conflict; those from more cohesive and less conflicted families showed less deterioration in glycemic control. This study demonstrated the important influence of family psychosocial factors present at diabetes onset on glycemic control in children and adolescents over the first 4 years of IDDM.

Self-perception and adolescent psychopathology: a clinical-developmental perspective.

The relationship between self-perception and adolescent psychopathology was examined on nine domains of self-perception in a group of adolescent psychiatric inpatients and a comparison group of nonpatients. Inpatients rated themselves significantly lower in four domains, and correlations between symptom reports and domains of self-perception supported a relationship between negative self-perception and psychopathology. Further analysis suggested less differentiated self-perceptions among inpatients than among nonpatients. Implications for developmental assessments and clinical interventions are discussed.

Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: I. The influence of patient coping and adjustment.

An onset cohort of adolescents and children with insulin-dependent diabetes mellitus was studied over a 4-year period. Individual patient psychosocial and demographic factors were assessed at study inception and used to examine aspects of adherence over the follow-up. We found that initial assessment of patient coping (defense level, adaptive strength, and locus of control) and adjustment at study inception were predictive of the level of patient adherence to diabetic regimen over the 4 years of study. Psychosocial variables predicted adherence outcomes independent of patient age. This was found for three domains of adherence, i.e., diet, insulin adjustment, and metabolic monitoring, and for the composite index derived from the separate adherence scales. Preadolescents (ages 9-12) at study entry were more adherent than patients who were already adolescent (ages 13-16) when diagnosed. Using multiple regression, three factors (age, adjustment, ego defense level) accounted for 47% of the variance in adherence. No factors were predictive of change in adherence during the follow-up. Thus, psychosocial characteristics of diabetic children assessed shortly after diagnosis predicted typical or average adherence over a 4-year period. Identification of such characteristics may be useful in developing strategies for intervention early in the course of illness.

Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: II. Immediate and long-term linkages with the family milieu.

Cross-sectional and longitudinal findings drawn from a 4-year longitudinal study of an onset cohort of preadolescents and early adolescents with insulin-dependent diabetes and their families are presented. Patient and parent perceptions of the family environment near the time of diagnosis are used to examine patterns of adherence in the first year of illness as well as over the four follow-up years. We found that family conflict, cohesion, and organization were strongly associated with independently rated first-year adherence levels. The strongest predictor of longer term adherence was family conflict, as experienced by the patients. In addition, parents' and youngsters' perceptions of family cohesion predicted improved adherence as well as overall higher levels of patient adherence. The findings are discussed with respect to the clinical implications of discovering those family characteristics that can, shortly after diagnosis, predict short- and long-term adherence. In addition, we present planned investigations intended to further clarify paths from family perceptions to individual diabetes behaviors.

Perceptions of control, competence, and contingency as influences on the stress-behavior symptom relation in school-age children.

Analyzed data from 154 school-age children and their mothers to examine the relations between stress, perceived competence and contingency, and behavior symptoms. Analyses focused on the relative merits of unidimensional vs multidimensional measures of control in predicting symptoms. The stress of undesirable life events and behavior symptoms were related in the expected direction. Multiple regression models with R2 ranging from .11 to .14 (all ps less than .0002) included significant main effects for stress, competence, and control. Analyses supported the relative superiority of the multidimensional measure of control. Models containing main effects and interaction terms were of equivalent magnitudes in accounting for variance in symptom scores. Findings support the idea of perceived control as a moderator of the stress-illness relation and are consistent with earlier suggestions that simple main effects models may be the most useful in examining these relations.

How families cope with diabetes in adolescence. An approach and case analyses.

In this paper we describe our newly constructed Family Coping Coding System. This scheme was constructed to identify family coping strategies that involve appraisal, problem solving, and emotion management dimensions. We discuss the theoretical rationale, meanings and reliability of the coping codes, and illustrate them through excerpts drawn from family discussions of a recent stressful situation (the onset of a chronic or acute illness in an adolescent member). Finally, we consider the clinical research relevance of this new assessment technique, exemplifying this potential with respect to medical compliance. We present analyses of two families with diabetic adolescents who strikingly differ with respect to compliance, and explore which family coping strategies may be predictive of an adolescent's favorable or problematic compliance to diabetes management.

Psychologic predictors of compliance in children with recent onset of diabetes mellitus.

A group of 57 children with recent onset of insulin-dependent diabetes mellitus was studied over 18 months. Compliance with the prescribed diabetic treatment deteriorated over this period. Adolescents (aged 13 to 15 years) were less compliant than preadolescents (aged 9 to 12 years). Initial patient reports of self-esteem, perceived competence, social functioning, behavioral symptoms, and their adjustment to diabetes predicted subsequent compliance behaviors. The findings highlight the linkage of child personality and adjustment with self-care of diabetes, and suggest that psychosocial assessment soon after diabetes is diagnosed may help identify patients at risk for later compliance problems.

Psychological adjustment of children with recently diagnosed diabetes mellitus.

Children with recent onset of insulin-dependent diabetes mellitus (IDDM) were compared with a sample of children with a recent acute medical problem. No differences were found in terms of self-esteem, locus of control, behavioral symptoms, or social functioning. A separate assessment of adjustment to diabetes was strongly correlated with each of these general personality, behavioral symptom, and social functioning measures. Sociodemographic factors such as age, gender, and social class did not predict the level of adjustment to diabetes. This study suggests that onset of diabetes does not necessarily lead to major disruptions of psychological adaptation. It also affirms the view that early adjustment to diabetes is embedded in a context of overall personality development and adaptation.

Children with recently diagnosed diabetes: interactions within their families.

Cross-sectional findings drawn from the first year of a 4-year longitudinal study of preadolescent and early adolescent insulin-dependent diabetics and their families are presented. Using direct observation techniques and a specially designed coding system, the family interactions of 56 families with a recently diagnosed diabetic child are compared with those of 49 families with a child of similar age and sex, who has had a recent, serious acute illness. The two samples are contrasted in terms of each family member's (mother, father, and child) enabling and constraining interactions, controlling for social class differences. The findings reveal that the diabetic children and their parents expressed significantly more enabling (e.g., focusing, problem solving, active understanding) speeches than comparable members of the acute illness group. In addition, there are indications of particular constraining interactions (devaluing) occurring between fathers and diabetic children. Several alternative interpretations are offered to account for these results, together with plans for future research directions to investigate these hypothesized explanations.

Marital separation and health: stress and intervention.

Marital separation is a stressful life event implicated in much current thinking and practice in mental health, health psychology and psychosomatic medicine. This study examines marital separation in a controlled, prospective design. The participants were 314 Health Maintenance Organization (HMO) subscribers followed over a two year period. Marital separation was experienced by 127 of these participants early in the two-year study period. A stratified random half of these separated individuals participated in a short-term psychoeducational group intervention, "Seminars for the Separated." Measures of psychosocial adjustment and medical utilization were analyzed to describe correlates of marital separation and to evaluate the intervention. Statistically significant increases in medical utilization by people experiencing marital separation were observed in comparisons with married control subjects. Much of this increased utilization occurred in the year surrounding the actual separation and may be accounted for by mental health visits as well as nonmental health contacts with the health plan. The effects of the intervention were not evident until controls for baseline levels of medical utilization were introduced into the multivariate analysis. Even then, intervention effects were slight. Methodological problems and implications for further study are presented.

The stress of marital separation: intervention in a Health Maintenance Organization.

Relationships between life stress and illness form the basis of much current thinking and practice in psychosomatic medicine. This study examines a particular life stress, marital separation, in a controlled, prospective design. Participants are 237 Health Maintenance Organization [HMO] subscribers followed over a two-year period. Marital separation was experienced by 117 of these participants early in the two-year study period. A stratified random half of these separated individuals participated in a short-term psychoeducational group intervention, "Seminars for the Separated." Measures of psychosocial adjustment and medical utilization were analyzed to describe correlates of experiencing marital separation and to evaluate the intervention. Statistically significant increases in medical utilization by people experiencing marital separation were observed in comparisons with married control subjects. Much of this increased utilization is in the year surrounding the actual separation and is accounted for by mental health visits. Effects of the intervention were not evident until controls for baseline levels of medical utilization were introduced. Even then, intervention effects were slight. Methodological problems and implications for further study are presented.