Use of Multisystemic Therapy to Improve Regimen Adherence Among Adolescents With Type 1 Diabetes in Chronic Poor Metabolic Control

Abstract

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...

Behavioral and Psychosocial Interventions in Diabetes

“…The principles of CBT are straightforward, and clinicians can incorporate strategies based on these principles into their work with patients (66). Interventions involving CBT-based approaches have produced positive outcomes (67)(68)(69).…”

The Effects of Multisystemic Therapy on Diabetes Stress Among Adolescents With Chronically Poorly Controlled Type 1 Diabetes: Findings From a Randomized, Controlled Trial

“…24 They were recruited in the period between 1999 and 2004, from an endocrinology clinic within a tertiary care children's hospital located in a major Midwestern metropolitan area. Inclusion criteria were as follows: (1) diagnosed as having type 1 diabetes for Ն1 year, (2) CPMC, as defined by an average glycohemoglobin (hemoglobin A1c [HbA1c]) level of Ն8% during the year before study entry, as well as a most recent HbA1c level of Ն8%, (3) between 10 and 17 years of age, and (4) sufficient mastery of English to communicate with therapists and to complete study measures.…”

“…Results of our prior studies showed MST to be effective in improving regimen adherence and metabolic control and decreasing hospital admissions in this population. [22][23][24] The purposes of the present study were to determine the effectiveness of the MST intervention in reducing adolescent stress related to diabetes and to investigate whether participant characteristics such as age, gender, and ethnicity were related to the success of MST in reducing stress. The primary targets of the intervention were family and extrafamily barriers to good adherence (eg, low levels of parental monitoring of diabetes self-care tasks and support for completion of self-care tasks or negative family interactions regarding diabetes care).…”

A systematic review of parent/peer-based group interventions for adolescents with type 1 diabetes: interventions based on theoretical/therapeutic frameworks

“…Following broad and narrow screening, 17 papers were considered suitable for inclusion in the review. [56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72] A study flow diagram of included and excluded studies is provided in Figure 1.…”

“…57 The MST group also had a decreased number of inpatient admissions whereas the number of inpatient admissions increased among control group participants. Furthermore, the findings of their study in 2007 demonstrated that MST increased support for diabetes care from both primary and secondary caregivers in two-parent but not in single-parent families.…”