Contracting and Monitoring Relationships for Adolescents with Type 1 Diabetes: A Pilot Study

Abstract

Background: Adolescents are developmentally in a period of transition-from children cared for by their parents to young adults capable of self-care, independent judgment, and self-directed problem solving. We wished to develop a behavioral contract for adolescent diabetes management that addresses some negotiable points of conflict within the parent-child relationship regarding self-monitoring and then assess its effectiveness in a pilot study as part of a novel cell phone-based glucose monitoring system. Methods: In the first phase of this study we used semistructured interview techniques to determine the major sources of diabetes-related conflict in the adolescent-parent relationship, to identify factors that could facilitate or inhibit control, and to determine reasonable goals and expectations. These data were then used to inform development of a behavioral contract that addressed the negotiable sources of conflict between parents and their adolescent. The second phase of this research was a 3-month pilot study to measure how a novel cell phone glucose monitoring system would support the contract and have an effect on glucose management, family conflict, and quality of life. Results: Interviews were conducted with 10 adolescent-caregiver pairs. The major theme of contention was nagging about diabetes management. Two additional themes emerged as points of negotiation for the behavioral contract: glucose testing and contact with the diabetes clinical team. Ten adolescent-parent pairs participated in the pilot test of the system and contract. There was a significant improvement in the Diabetes Self-Management Profile from 55.2 to 61.1 (P < 0.01). A significant reduction in hemoglobin A1c also occurred, from 8.1% at the start of the trial to 7.6% at 3 months (P < 0.04). Conclusions: This study confirms previous findings that mobile technologies do offer significant potential in improving the care of adolescents with type 1 diabetes. Moreover, behavioral contracts may be an important adjunct to reduce nagging and improve outcomes with behavioral changes.

Codesigned Shared Decision-Making Diabetes Management Plan Tool for Adolescents With Type 1 Diabetes Mellitus and Their Parents: Prototype Development and Pilot Test (Preprint)

“…[5,21] Research supports ongoing intervention designed to reduce family conflict in order to improve diabetes-related outcomes. [5,8,[22][23][24] However, resources to address family conflict, including access to social work services, family counseling, and psychological services are sparse in clinical diabetes care. The desires of patients to have these services and the evidence that they are related to superior diabetes outcomes should encourage the field to push for routinely integrating them in the diabetes clinic setting.…”

“…[7] Diabetes self-care goals outlined with the diabetes care team in the form of "behavioral contracts" have been used to address: (1) goals for frequency of SMBG; (2) goals for frequency of contact with the diabetes clinic team: and (3) parent and youth responsibilities. [3,[8][9][10] However, these "contracts" can be perceived as punitive if they are not constructed using patientcentered communication as adolescents can be sensitive to authoritarian treatment. [11] Our objective was to co-design with a patient and parent advisory board (PAB), an intervention for improving adolescent diabetes self-care that utilized shared decision making.…”

Novel Health Mobile Technology as an Emerging Strategy in Diabetes Management

“…A cellphone-connected glucometer along with telephone and SMS communication was used to monitor the behavioral pattern of adolescent type 1 diabetic patients, resulted in a significant improvement in the self-management profile and a reduction in HbA1c [27]. A telehealthcare program was used to monitor self-management behavior in adult type 2 diabetic patients [28].…”

Protocol Development, Treatment Fidelity, Adherence to Treatment, and Quality Control

“…During the course of our trials, we reviewed the contract at selected appointments to remind the participant of the study's requirements. In several areas of behavioral research, a behavioral contract has been reported to increase protocol compliance and participant retention (Carroll, DiMeglio, Stein, & Marrero, 2011;Hartz, Brennan, Aulakh, & Estrin, 2010;Liberman & Rotarius, 1999;Solanto, Jacobson, Heller, Golden, & Hertz, 1994). This approach also meshes well with occupational therapy's emphasis on client-centered care, because the client takes on an important role in identifying targets for therapeutic intervention for inclusion in the contract.…”