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] Ն8% 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 ϳ6 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] ϭ 16.75, P ϭ 0.001) and 24-h recall interviews (F[1,125] ϭ 6.70, P ϭ 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] ϭ 6.25, P ϭ 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] ϭ 4.03, P ϭ 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 Care 28:1604 -1610, 2005T he deterioration in adherence behavior associated with the transition to adolescence is well documented among children with type 1 diabetes (1-3). However, a subset of high-risk adolescents demonstrate more serious adherence problems, as evidenced by chronically poor metabolic control (CPMC). In addition to the health risks associated with CPMC, such adolescents consume a disproportionate share of health care dollars due to inpatient hospitalizations for diabetic ketoacidosis (DKA) (4,5). The development of effective behavioral interventions for these adolescents is therefore of high priority. Given the known declines in adherence during adolescence, several interventions have been developed to improve adherence and metabolic control among youth with type 1 diabetes (6 -9). However, there have been few clinical trials that focus exclusively on those with CPMC. Existing intervention studies targeting adolescents with CPMC (10 -15) are generally characterized by either small sample size, low recruitment rates, short intervention periods, or limited success in improving behavioral and health outcomes.Furthermore, despite the substantial descriptive literature suggesting that adolescents with CPMC are embedded within multiple syste...

ABSTRACT. 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 >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 ϳ6 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. A dolescents with type 1 diabetes mellitus face a number of stressors and challenges as a result of their chronic illness. [1][2][3][4] These include the need to manage a complex medical condition that requires daily completion of multiple selfcare behaviors, the impact of diabetes on social interactions with family members, peers, and teachers, and the interference of symptoms such as hypoglycemia with daily activities.Previous studies investigated the impact of stress on health outcomes among persons with type 1 diabetes. The effects of stress on regimen adherence and metabolic control have been of particular interest. Stress has the potential to affect metabolic control directly through its impact on cortisol and other catabolic hormones that interfere with insulin metabolism. It may also affect metabolic control indirectly, by interfering with completion of self-care tasks. However, prior findings have been mixed, with some studies supporting a direct relationship between stress and metabolic control, some suggesting that adherence mediates the relationship between stress and me...

OBJECTIVE -The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated. RESEARCH DESIGN AND METHODS-A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care.RESULTS -Youth who received MST had significantly fewer hospital admissions than control subjects ( 2 ϭ 11.77, 4 d.f., n ϭ 127; P ϭ 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P ϭ 0.004), 12-month (P ϭ 0.021), 18-month (P ϭ 0.046), and 24-month follow-up (P ϭ 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions.CONCLUSIONS -The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance. Diabetes Care 31:1746-1747, 2008W e have previously reported on multisystemic therapy (MST), an intensive home-based family therapy, for youth with chronically poor metabolic control (CPMC). MST produced improvements in metabolic control and reducted indicators of serious nonadherence (DKA hospital admissions) at treatment termination (1,2). Reductions in admissions were maintained 6 months later (2). The present study investigated the effects of MST on DKA admissions at the conclusion of the trial and related cost savings. RESEARCH DESIGN ANDMETHODS -A total of 127 adolescents with CPMC and their families were recruited from endocrinology clinics at Children's Hospital of Michigan between 1999 and 2004. Eligible youth were diagnosed with type 1 diabetes for at least 1 year, had an average A1C of Ն8% during the year before study entry, and were aged 10 -17 years. Mean Ϯ SD A1C at study entry was 11.3 Ϯ 2.3%. A total of 92% of the subjects used injected insulin, and 8% used insulin pumps. Mean Ϯ SD age was 13.2 Ϯ 2.0 years, and 63% of participants were African American.A total of 64 participants were randomly assigned to MST and 63 to a control group. All families received quarterly visits with a multidisciplinary diabetes team. MST-treatment families also received 6 months of therapy (mean 5.7 months). Families were followed for 24 months total. MST targeted adherence-related problems within the family and broader community systems (1,3). These systems included family (e.g., poor parental supervision and oversight of the youth's diabetes care completion), school (e.g., inadequate communication between parents and school personnel regarding the youth's health needs), and health care system factors (e.g., barriers to keeping clinic appointments due to problems with transportation or family disorganization).The number of DKA admissions was obtained from the treating hospital's information system for the 6-month window before study entry (ba...

Results suggest that gender differences in adherence may be attributed, in part, to gender differences in externalizing symptoms in urban youth with poor metabolic control. Interventions targeting these symptoms may be necessary to improve adherence and HbA1C in both boys and girls.

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.