Behavior therapy for families of adolescents with diabetes: maintenance of treatment effects.

OBJECTIVE: This study reports 6- and 12-month follow-up for the families of adolescents with diabetes who participated in a trial of Behavioral-Family Systems Therapy (BFST). RESEARCH DESIGN AND METHODS: A total of 119 families of adolescents with type 1 diabetes were randomized to 3 months of treatment with either BFST, an education and support (ES) group, or current therapy (CT). Family relationships, adjustment to diabetes, treatment adherence, and diabetic control were assessed at baseline, after 3 months of treatment, and 6 and 12 months later. This report focuses on the latter two evaluations. RESULTS: Compared with CT and ES, BFST yielded lasting improvements in parent-adolescent relationships and diabetes-specific conflict. Delayed effects on treatment adherence emerged at 6- and 12-month follow-ups. There were no immediate or delayed effects on adolescents' adjustment to diabetes or diabetic control. CONCLUSIONS: BFST yielded lasting improvement in parent-adolescent relationships and delayed improvement in treatment adherence, but it had no effect on adjustment to diabetes or diabetic control. A variety of adaptations to BFST could enhance its impact on diabetes outcomes.

Randomized, controlled trial of behavior therapy for families of adolescents with insulin-dependent diabetes mellitus.

OBJECTIVE: To describe the short-term results of a controlled trial of Behavioral Family Systems Therapy (BFST) for families of adolescents with diabetes. METHODS: We randomized 119 families of adolescents with diabetes to 3 months' treatment with either BFST, an education and support Group (ES), or current therapy (CT). Family relationships, psychological adjustment to diabetes, treatment adherence and diabetic control were assessed at baseline, after 3 months of treatment (reported here), and 6 and 12 months later. RESULTS: Compared with CT and ES, BFST yielded more improvement in parent-adolescent relations and reduced diabetes-specific conflict. Effects on psychological adjustment to diabetes and diabetic control were less robust and depended on the adolescent's age and gender. There were no effects on treatment adherence. CONCLUSIONS: BFST yielded some improvement in parent-adolescent relationships; its effects on diabetes outcomes depended on the adolescent's age and gender. Factors mediating the effectiveness of BFST must be clarified.

Social validity of support group and behavior therapy interventions for families of adolescents with insulin-dependent diabetes mellitus.

Compared the social validity of behavior therapy vs. support group interventions for reduction of parent-adolescent conflict among families of adolescents with diabetes. Families were randomized to 10 sessions of an Education and Support group (ES) or 10 sessions of Behavioral Family Systems Therapy (BFST). We compared participants' social validity ratings of BFST and ES using the Treatment Evaluation Questionnaire (TEQ). Mean TEQ scores were significantly more positive for BFST than ES and, for 13 of 20 items, BFST was rated significantly more positively by parents and/or adolescents. Adolescents rated ES less positively than did parents. Fathers' responses reflected fewer differences between ES and BFST. Results extend previous research on BFST and confirm its superiority over ES for targeting family conflict.

The success of elutriate tests in extended prediction of water quality after a dredging operation under freshwater and saline conditions.

Dredging simulation by elutriate tests accurately predicted concentrations of Hg, Cu, Mn and Fe released to the water column from contaminated sediment to within 1 order of magnitude. Hg and Cu concentrations increased by up to 7-fold after dredging, but declined to background concentrations within 48 h. Maximum loadings of Hg and Cu coincided with Fe and total organic carbon (TOC) water column concentrations, suggesting Hg and Cu are adsorbed onto particulates of Fe oxides and organic material. Seasonal changes in redox potential and temperature did not significantly affect metal release from sediments. Saline water did not cause significant increases in contaminant release from sediments to the water column over that observed for freshwater. Water quality standards of 1 µg l(-1) Hg and 28 µg l(-1) Cu as annual averages were not breached by dredging operations. Long-term effects of dredging on Hg and Cu availability, due to deposition of contaminated material as surficial sediments, is, however, of concern.

Family stress and resources: potential areas of intervention in children recently diagnosed with diabetes.

This article examines the relationships among family stress, family capabilities, and the health status of 53 children diagnosed with insulin-dependent diabetes mellitus. Assessments were done at an outpatient diabetes clinic of family coping, resources, and stress; disease-related knowledge; metabolic control (HbA1); and endogenous insulin (C peptide). Results indicated that higher levels of family stress and lower levels of family resources as reported by fathers were significantly associated with poor metabolic control. Multiple regression analyses revealed that levels of family stress and resources were more strongly related to metabolic control than were disease variables such as C peptide levels. Moreover, family stress was directly associated with metabolic control, and family resources showed indirect linkages. Findings suggest that family stress and resources are potential areas for social work intervention in children recently diagnosed with diabetes.

Depositional profiles and relationships between organotin compounds in freshwater and estuarine sediment cores.

A range of organotin compounds including tributyltin (TBT), dibutyltin (DBT) and monobutyltin (MBT) were measured in sediment cores collected from contaminated freshwater and estuarine sites in Essex and Suffolk, U.K. Butyltin compounds were found in significant quantities at depths of up to 60 cm within the sediments of marina and boatyard complexes with TBT concentrations ranging from <3 ng g(-1) (the detection limit) to >3000 ng g(-1). In general sediment TBT concentrations decreased with depth, but maximum enrichment tended to occur just below the surface. It was evident from these core profiles that the accumulation of organotins in surface deposits was on the decline and coincided approximately, with the implementation in 1987 of the UK retail ban on the sale of TBT based antifouling paints for application on vessels <25 m in length. The degradation rate for TBT in sediments was found to exhibit first order kinetics with half lives ranging from 0.9-5.2 years between different sites. Estimated degradation rates have also been determined for DBT and MBT. These ranged from 1.5-3.0 years for DBT and 1.8-3.7 years for MBT.

Spatial distribution of organotins in sediments of lowland river catchments.

A method is described for the measurement of nanogram quantities of a range of methyl and butyltin compounds. The method utilises a modified purge and trap/boiling point separation technique for the determination of organotin compounds in sediment samples. A spatial survey of sediment samples within 5 river systems in the East Anglia region of the United Kingdom was undertaken and identified a range of organotin compounds with concentrations of tributyltin (TBT) ranging from <3.9 ng g(-1) up to 1291 ng g(-1). The highest values were found in areas connected with boating activities. Wherever TBT was present, dibutyltin and monobutyltin were most commonly found along with small concentrations of certain methyltins.

The impact of heavy metals on lowland rivers and the implications for man and the environment.

Increased public awareness of river water quality problems has led to concern over the continued discharge of low-level contaminants in sewage treatment work (STW) final effluents. This paper discusses the source and nature of heavy metals during sewage treatment processes and examines their behaviour and fate in the aquatic environment. The influences of physico-chemical parameters and chemical speciation on metal mobility during sewage treatment and in receiving waters have been assessed. The importance of metal speciation with regard to aquatic toxicology is discussed and the effectiveness of current legislation in controlling the release of heavy metals to lowland river systems has been reviewed.

Weight loss from inappropriate insulin manipulation: an eating disorder variant in an adolescent with insulin-dependent diabetes mellitus.

This is the first in a series of papers being sponsored by the Psychosocial Committee of AADE that will highlight psychosocial issues encountered in the treatment of diabetes. The present case describes the assessment, diagnosis, and treatment of a young woman with IDDM who inappropriately manipulated her insulin to lose weight. The discussion focuses on the role of the diabetes treatment team in the early detection and prevention of maladaptive weight-loss behaviors. This is achieved through routine assessment, diabetes-specific dietary counseling, and the education of young patients and their parents on the serious health and financial consequences of inappropriate insulin a adjustment.

Risk factors to health in diabetic children: a prospective study from diagnosis.

This study explored associations between health status and psychosocial, family, and demographic factors among 42 children with recently diagnosed diabetes mellitus. Health status was assessed using glycosylated hemoglobin (HbA1), a measure of the children's level of metabolic control. Four groups of variables were investigated as possibly relating to metabolic control: demographics, family social climate, child's self-concept, and compliance with the treatment regimen. Metabolic control was associated with race, number of parents in the home, family cohesion, and socioeconomic status. Multiple regression analysis indicated that children from black and single-parent families were at higher risk for poorer disease control and that this pattern persisted 2 and 3 years after diagnosis. These findings can help identify families that may benefit from more effective interventions involving social work practice.

Randomized prospective study of self-management training with newly diagnosed diabetic children.

This study was designed to evaluate the effects of a self-management training (SMT) program on metabolic control of children with insulin-dependent diabetes mellitus (IDDM) in the first 2 yr after diagnosis. After standard in-hospital diabetes education, 36 children (mean age 9.3 yr, range 3-16 yr) were randomized to conventional follow-up, conventional and supportive counseling (SC), or conventional and SMT, which emphasized use of data obtained from self-monitoring of blood glucose. SC and SMT interventions consisted of seven outpatient sessions with a medical social worker during the first 4 mo after diagnosis and booster sessions at 6 and 12 mo postdiagnosis. Groups were similar with respect to age, sex, body mass index, socioeconomic status, C-peptide, and severity of illness at diagnosis. Metabolic control, measured quarterly by glycosylated hemoglobin (HbA1), improved substantially in all three treatment groups during the first 6 mo. SMT patients had significantly lower HbA1 levels than conventional patients at 1 yr (P less than 0.01) and 2 yr (P less than 0.05) postdiagnosis. SMT patients also had lower HbA1 levels than SC patients, but this did not reach statistical significance. The lower HbA1 levels of SMT patients were not explained by severity of illness at diagnosis, or insulin dose, body mass index, and C-peptide levels at 2 yr. These results suggest that an SMT program during the first few months after diagnosis helps avoid the deterioration in metabolic control often seen in children with IDDM between 6 and 24 mo after diagnosis.

Self-monitoring of blood glucose by adolescents with diabetes: technical skills and utilization of data.

Two studies of adolescent patients were conducted to determine their technical skills and utilization of data obtained by self-monitoring of blood glucose (SMBG). In Study 1, direct observations of 58 adolescents revealed an overall SMBG technical accuracy score of 82%. Most frequent errors were not cleaning fingers (45%), not placing blood on strips correctly (21%), and wiping strip at wrong time (14%). Technical performance was inversely correlated with blood glucose concentration, but was unrelated to other variables. In Study 2, a questionnaire was used to determine SMBG practices among 64 adolescents. Although the majority of patients reported doing daily SMBG, most did not record results in logbooks every time or utilize such data for self-management. No significant relationships were found between SMBG behaviors and other variables. We conclude that periodic evaluation and retraining are required for maintenance of SMBG skills and that methods to enhance utilization of SMBG data be developed for this patient population.

Stress and coping in relation to metabolic control of adolescents with type 1 diabetes.

The purpose of this study was to determine whether measures of anxiety, stress, and means of coping with stress differ in diabetic adolescents in good, fair, and poor metabolic control. Trait anxiety, perceived daily stress, and coping responses to a recent stressful event were assessed in 27 adolescents with Type 1 diabetes mellitus. Information also was obtained regarding the type of stressful events that subjects referred to in completing the coping measure, as well as their appraisals of the events. Hemoglobin A1 (HbA1) obtained at the time of the study was used as a measure of antecedent metabolic control. Based upon their HbA1, patients were divided into three metabolic control subgroups: good control (M = 8.4%; n = 8), fair control (M = 10.9%; n = 9), and poor control (M = 13.3%; n = 10). Patients in these subgroups were similar with regard to age, disease duration, and socioeconomic status. Results indicated that the subgroups did not differ on the anxiety and stress measures; however, analyses of the coping data indicated that patients in poor control employed significantly more wishful thinking and avoidance/help-seeking than did patients in good metabolic control. Furthermore, the metabolic control subgroups differed in the type of stressful events reported and their appraisals of the stressful events. These results support the hypothesis that the ways in which individuals with diabetes appraise and cope with stress is related to their metabolic control. The findings are discussed in relation to methodological issues and treatment implications.