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Family Functioning and Diabetic Ketoacidosis in Pediatric Patients with Type I Diabetes


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FAMILY FUNCTIONING AND DIABETI C KETOACIDOSIS IN PEDIATRIC PATIENTS WITH TYPE I DIABETES By KELLY N. WALKER A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2004

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Copyright 2004 by Kelly N. Walker

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This document is dedicated to my parents, Arnold and Cheryl Walker.

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iv ACKNOWLEDGMENTS I would like to thank Dr. Gary R. Geffke n for his mentorship and assistance during the previous two years. I truly appreciate all the time, effort, and perspective he has given me. I would also like to thank my parents for all their encouragement through the years. Their support has given me the courag e and confidence to reach for my dreams and never accept less than my personal best.

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v TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES............................................................................................................vii ABSTRACT.....................................................................................................................vi ii CHAPTER 1 INTRODUCTION........................................................................................................1 General Diabetes Overview..........................................................................................1 Diabetic Ketocidosis (DKA).........................................................................................2 Common Treatments for Type I Diabetes....................................................................3 Adherence in Type I Diabetes......................................................................................4 Family Functioning and the Pediatri c Patient with Type I Diabetes............................7 Family Functioning and DKA....................................................................................11 Purpose and Hypotheses of this Study........................................................................12 2 METHOD...................................................................................................................13 Participants.................................................................................................................13 Procedure....................................................................................................................14 Measures.....................................................................................................................14 Diabetes Family Behavior Scale (DFBS)............................................................14 Diabetes Family Behavior Checklist (DFBC).....................................................15 Diabetes Family Responsibi lity Questionnaire (DFRC).....................................15 3 RESULTS...................................................................................................................17 Preliminary Analyses..................................................................................................17 Logistic Regression....................................................................................................19 Moderating Logistic Regression.................................................................................22 4 DISCUSSION.............................................................................................................23 Limitations..................................................................................................................25 Conclusions and Clinical Implications.......................................................................26

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vi LIST OF REFERENCES...................................................................................................28 BIOGRAPHICAL SKETCH.............................................................................................33

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vii LIST OF TABLES Table page 1 Means and Standard Deviations for De mographic Information for Participants Experiencing and Not Experiencing DKA...............................................................14 2 Pearson r Correlations Between Demographic, Family Functioning Variables, and Incidence of DKA....................................................................................................18 3 Means and Standard Deviations for Fam ily Functioning Variables for Participants Experiencing and Not Experiencing DKA...............................................................18 4 Logistic Regression Analys is of DKA episodes by SPSS 11.0...............................21 5 The Observed and Predicted Frequencie s for DKA episodes by Logistic Regression With the Cutoff of 0.50............................................................................................21

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viii Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science FAMILY FUNCTIONING AND DIABETI C KETOACIDOSIS IN PEDIATRIC PATIENTS WITH TYPE I DIABETES By Kelly N. Walker May 2004 Chair: Gary R. Geffken Major Department: Clini cal and Health Psychology Type I diabetes is a chronic condition cau sed by an inability of the body’s cells to use sugar from foods for energy. Treatment involves daily insulin injections, a complicated regimen of blood glucose mon itoring, dietary guidelines, and specific exercise recommendations. In some indivi duals, diabetic keto acidosis (DKA), a life threatening complication of di abetes, can occur. The condition is typically caused by a shortage of insulin and chronic noncomplia nce to treatment. DKA may occur in any patient with diabetes, but patients with poor c ontrol are at a greater risk due to their noncompliant behaviors. Given the relationshi p between family functioning and adherence previously found in the litera ture, the purpose of this study is to determine if specific family functioning variables are related to episodes of DKA in pediatric patients with Type I diabetes. Specifically, it was predicte d that (1) higher parental warmth will be associated with lower occurrence of DKA, (2) higher parental negativity will be associated with higher occurrence of DKA, a nd (3) lack of responsibility for diabetes-

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ix related tasks will be associat ed with higher occurrence of DKA. Participants included 100 children with Type I diabetes and their care givers recruited from Shands Hospital and clinics at the University of Florida. Particip ants completed disease-specific measures of family functioning to assess variables incl uding parental warmth, parent and child perceptions of negativity, and family responsibility for the diabetes regimen. Glycosylated hemoglobin indexes and inciden ce of DKA were obtaine d by chart review. Family variables were analyzed to create a model to predict the presence or absence of DKA in children with Type I diabet es. This model was significant ( 2 (3, N = 100) = 26.137, p < .001) and diabetes specific family variables accounted for almost 44% of the variance. The data suggest that increased child perception of warmth and caring was associated with decreased odds of experi encing a DKA episode. The data also suggest increased parental negativity was associated with increased odds of experiencing a DKA episode. The hypothesis regarding family re sponsibility was not supported. The findings suggest that family factors play a significant role in the oc currence or absence of DKA in children’s long-term manage ment of their diabetes.

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1 CHAPTER 1 INTRODUCTION General Diabetes Overview Diabetes is a chronic condition caused by an inability of th e body’s cells to metabolize carbohydrates from foods for energy. Type I, or insulin-d ependent diabetes (IDD), results from a pancreatic failure to produce insulin, which is required for glucose to enter cells. Type II diabetes or non-insulin-dependent di abetes (NIDD), occurs when the body still produces insulin, but the glucose cannot be effectively utilized. The focus of this study will involve Type I patients, who are most commonly diagnosed in childhood. In contrast, Type II patients ar e most commonly diagnosed in adulthood, although the number of Type II patients is rising in childhood and adolescence. Type I patients require exogenous insulin, typically delivered through daily injections. Genetic factors may play a role in the etiology of Type I, but the exact cause is unknown. Even with modern medical advances, life expectan cy for the Type I patient is approximately 75% of normal, with disease related compli cations, such as retinopathy, nephropathy, and cardiovascular problems developing later in life (U.S. Health and Human Services, 1985). In 1985, it was estimated that approximate ly 1 in 600 children held a diagnosis of Type I diabetes (LaPorte et al., 1985), making it a serious and common chronic childhood illness. Currently, diabetes affects 6% of the U.S. population, or approximately 17 million individuals (Centers for Disease Control, 2002).

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2 Diabetic Ketocidosis (DKA) In children, the most severe problem of diabetes is diabetic ketoacidosis (DKA). DKA is a life threatening even t for Type I diabetes. In 1985, the mortality for DKA was between one and eight percent (Maz ze, Sinnock, Deeb, & Brimberry, 1985) Current mortality rates for DKA lie between 2.39.2% in the United Kingdom (Edge, FordAdams, & Dunger, 1999). The incidence rates of DKA in the United States is currently 38 per 1000 people with Type I diabetes per year (U.S. Health and Human Services, 1985). This condition is typica lly caused by a shortage of insulin or a dysfunction in insulin activity. The insu fficient amount of insulin in th e bloodstream forces the body to break down muscles and fats for energy, resulting in toxic levels of ketones in the bloodstream (Travis, 1985). DKA symptoms may include hyperglycemia, metabolic acidosis, vomiting, dehydration, and difficulty breathing. Treatment for DKA typically involves hospitalization to return the patient to normal functioning. Despite the severity of DKA, research examining the event is limited in the empirical literature. In a study of the rela tionship between adherence and DKA conducted by Morris et al. (1997), particip ants included 89 patients with diabetes under the age of 30, with a mean age of 16 years, and mean HbA1c approximately of 8.4%. Physician prescriptions and pharmacy records were comb ined to create an index score to assess adherence. Analyses with adherence i ndex scores, average HbA1c scores, and DKA episodes were significantly related. DKA episodes were sign ificantly related to lower adherence indexes. However, a dherence is not the onl y factor found to be associated with DKA (Liss et al., 1998; Travis, 1985). Although patients with poor control are at a greater risk due to their noncompliant behaviors (Travis, 1985), stress and family support have also found to be correlated with

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3 incidence of DKA in the empirical literatu re (Aikens, Wallander, Bell, & Cole, 1992). Stress may also play a role in a patien t experiencing a DKA episode, as stress may disrupt behavioral functioning with the diab etes regimen and several stress hormones have counter regulatory effects on insuli n. Other factors corre lated with DKA are psychiatric illness and family support, as indi cated by Liss et al. (1998) with a sample of 25 children with DKA hospitaliz ations and 25 matched outpatient controls with no history of DKA hospitalizations. Participan ts who had experienced DKA episodes had significantly higher psychiatric illness diagnos es, less diabetes-specific family support, lower self-esteem, and social competence. Common Treatments for Type I Diabetes Optimal treatment for Type I diabetes i nvolves a complicated re gimen of self-care tasks, a complex set of contingency based behaviors, and recommendations encompassing all aspects of the patient’s lif e. Further complicating treatment, these recommendations vary widely across indivi duals (McNabb, 1997). Additionally, as much as 98% of diabetes care is self-care by the patient (Anderson, 1995). Treatment of diabetes aims to lower blood glucose levels to values as close to normal metabolic functioning as possible. High bl ood glucose levels are associat ed with an increased risk of diabetic ketoacidosis, vision problems, polyuria, polydipsia, fatigue, decreased weight loss vaginitis, balanitis, reti nopathy, nephropathy, neuropath y, and poorer atherogenic lipid profile. Better metabolic control is acco mplished by an intensive treatment regimen involving frequent self-monitori ng of blood glucose, approp riate nutritional intake, regular exercise, individua lized insulin injections, pr evention and treatment of hypoglycemia and other acute chronic compli cations, and a periodic assessment of treatment goals. With regard to children, additional considerations must be taken

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4 including setting developmentally appropriate goals for self-management, proper diabetes education, “sick-day” management rules for di abetes-related and ot her illnesses, caution in overaggressive dietary ma nipulation, and assessment of lifestyle needs (American Diabetes Association, 2001). The Diabetes Control and Complications Trial (1986; 1993; 1994) demonstrated the benefits of an intensive regimen involving three or more insulin injections or insulin pump treatments as compared to the previ ous conventional therapy involving only 1-2 injections per day. This multi-site study i nvolving 1441 patients aged 13-39 years with Type I diabetes compared intensive therapy to conventional thera py. The results of the study found adherence to self-care was e ssential to prevent diabetes-related complications. Specifically, intensive thera py reduced the adjusted mean risk of retinopathy by 76% and slowed its progression in pre-existi ng cases by 54%. Intensive therapy also reduced the mean occurrence of microalbuminuria by 39%, reduced the risk of albuminuria by 54%, and the risk of c linical neuropathy by 60%. The only adverse event associated with intensive therapy wa s a two-to-threefold increase in severe hypoglycemia. Additionally, those in intensive therapy group reduced their glycosylated hemoglobin, a common measure of metabolic control in individuals with diabetes (Diabetes Control and Complications Trial, 1993). However, although the results of this study are generalizable to adolescents and chil dren, more research is needed with these populations. Adherence in Type I Diabetes Adherence has been previously defined as the “extent to which a person’s behavior (in terms of medications, following diets, or executing lifestyle changes) coincides with medical or health advice” (Haynes, 1 979, p. 2-3). These behavioral changes and

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5 modifications are necessary to follow medical and health advice but often present as a difficult task for many patients with chronic illn esses. In children with chronic illnesses, three main categories have been link ed to nonadherence including: regimen characteristics, disease characteristics, and patient/family variables (LaGreca & Schuman, 1995; Rapoff & Bernard, 1991). These f actors are of importance because each year nonadherence leads to higher health care costs and medical complications (Rapoff & Bernard, 1991). Specific to diabetes, thes e complications could include recurrent ketoacidosis and increased symptoms such as hyperglycemia and poorer metabolic control (Quittner, Espelage, Ievers-Landi s, & Drotar, 2000). Adolescents with poor metabolic control are at greater risk for more frequent hospitalizations (due to ketosis and hypoglycemia) and long-term complications such as retinopathy and renal failure (Cahill, Etzwiler, & Freinkel, 1976). However, even given these consequences, nonadherence remains a significant problem for pediatric pa tients with diabetes (Kovacs, Goldston, Obrosky, & Iyengar, 1992). A dherence rates in one study by Cerkoney and Hart (1980) found that only 2 individuals out of a sample of 30 individuals with diabetes were fully adherent with all aspects of the treatmen t regimen. Specifically in this study, the frequency of adherence to monitoring reco mmendations was at 57% and adherence to frequency and accuracy of in sulin injections reached a high of only 80% adherent (Cerkoney & Hart, 1980). Other studies have found diverse rates of adherence as well. Other studies cite dietary recommendation ad herence at an average of 65% (Glasgow, McCaul, & Shafer, 1987) and variation in adherence to an exercise program from 19% (Kratvitz et al., 1993) to 30% (Kamiya et al., 1995).

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6 A study by Morris and his colleagues (1997) noted the associations between treatment adherence and health outcome in 89 patients under 30-years-old. This study monitored the amount of insulin dispensed by the participating pa tient’s pharmacy, the patient’s gylcemic control through the HbA1 c index, and patient hospitalizations. The researchers found a failure to take insulin in at least 28% of the patients. Additionally, failure to take insulin was associated w ith poorer glycemic control, acute hospital admission for DKA, and other acute problems related to diabetes Interestingly, the lowest adherence rating was f ound in children 10-20 years ol d (Morris et al., 1997). This age-related finding is consiste nt with other studies, whic h have concluded children’s adherence deteriorates as disease duration increases into adolescence (Kovacs et al., 1992; LaGreca, Auslander, Greco, & Spetter, 1995). Specifically, older children have been found in the empirical l iterature to be less adherent and to demonstrate worse metabolic control than younger children (Johnson et al., 1992). This finding was replicated by Johnson (1995), and by Kovacs et al. (1992) who f ound that adolescents have poorer metabolic control and levels of self-care than children and adults. The researchers suggested this was due to the adolescents’ less-struc tured lifestyle and developmental phase characteri zed by a pattern of resistance to rules and authority, and peer pressure for conformity (Johnson, 1995; Kovacs et al., 1992). Further examination of the impact of nona dherence on a range of diabetes related problems in children and adolescents with di abetes was demonstrated in one study of residential treatment for diabetes where patie nts’ treatment regimens were monitored to ensure full adherence to their treatment regi men (Geffken et al., 1997). In this study, the individuals participating in re sidential treatment had a sign ificant reduction in diabetes-

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7 related hospitalizations improved school attendance, decr eased glycosylated hemoglobin levels, increased weight gai n, individualized insulin cha nges, improved knowledge about diabetes, and a normalization of familial att itudes toward the disease. However, when participants entered a follow-up phase of treatment where patients returned home, increases in glycosylated he moglobin levels occurred. Rese archers suggested that this increase may have been due to a decrease in treatment adherence, given the positive disease management found when the residential treatment center staff controlled patients’ treatment regimens. Researchers also suggest ed that the decreases in adherence might have been related to aspects of the family unit. Given the multitude of adherence complications consistently f ound in children, examination of the family context in which children with diabetes reside is imperative. Family Functioning and the Pediatric Patient with Type I Diabetes With regard to diabetes and treatment a dherence, family members and parents have been found to be the primary sources of support for adolescents with diabetes (LaGreca et al., 1995; Lewin et al., 2004). Greater family su pport has been found in the literature to be correlated with decreased age and shorte r disease duration of ch ildren’s diabetes and linked with better treatment adherence (LaGreca et al., 1995 ). Additional studies have strengthened the rela tionship found between family functioning and treatment adherence. Parents who provide more diabetes-specifi c support have adolescents with better treatment-regimen adherence than parents w ho were less supportive of diabetes care activities (Hanson, Henggeler, & Burghen, 1987) A study of parents of 34 adolescents with diabetes using the Camberwell Family Interview found that poor glycemic control was not associated with parent al apathy, criticism of the chil d, or marital discord, but that greater supportive emotional involvement by pa rents was associated with better glycemic

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8 control (Stevenson, Senskey, & Petty, 1991). A nother study explored family correlated variables using the Diabetes Family Beha vior Scale (DFBS), a diabetes-specific instrument, sampling 321 children and adolescen ts aged 7-18 years. The researchers found an association between the DFBS total score (indicating overall family support), guidance-control, and HbA1c (McKelvey et al ., 1993). With regard to health outcome, well-controlled patients have described their mothers as highly supportive at disease onset and less supportive over ti me, but a different pattern em erged for patients in poor control (Steinhausen, 1982). Parents who are less involved and supportiv e have children who are less adherent with their treatment regimen, make more mistak es in self-care, and have poorer metabolic control than children whose pa rents are involved in a deve lopmentally appropriate style (Weissberg-Benchell et al., 1995; Wysocki et al., 1996). A study assessing parental involvement using diabetes-specific measur es included 104 youth (8-17 years, 69 aged 812 years, 35 aged 13-17 years) who completed the Diabetes Conflict Scale and Diabetes Family Responsibility Questionnaire (DFRQ). Fifty-three percent of patients showed moderate parental involvement in blood gl ucose monitoring tasks, and 40% showed moderate parental involvemen t for insulin treatment. The study found that parental involvement was a significant predictor of adherence to blood glucose monitoring, and child conflict scores, parent conflict scores and self-report of blood glucose monitoring frequency predicted glycemic control. A dditionally, parents of older patients were significantly less involved than parents of younger patients. (Anderson et al., 2002). However, support and involvement are not the only family variables related to health outcome in pediatric patients with Type I diabetes. Negative pa tterns of interaction

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9 such as, parental hostility, nega tive parental interact ions, and lack of responsibility for the treatment regimen are also associated with adherence and health outcome (Schafer, Glasgow, McCaul, & Dreher, 1983; Worrall-D avies, Owens, Holland, & Haigh, 2002). In a study by Worrall-Davies et al. (2002), parent al hostility was correla ted with glycemic control, not over-involvement or criticism in a study of 45 children and their caregivers. Specifically, parental hostility, as assessed through an intervie w measure using an adapted form of the Camberwell Family In terview, was associated with elevated levels of glycosylated hemoglobin. Parental hostility acco unted for 22% to 29% of the variation in glycosylated hemoglobin 12 months before a nd 12 months after hostility was assessed. A study examining negative family interactio ns with diabetes specific instruments involved 34 adolescents 12-14 y ears old and assessed four as pects of regimen adherence (insulin injections, dietary pa tterns, glucose testing, and exer cise), psychosocial variables measured by the Barriers to Adherence a nd Problem Solving Scale and the Diabetes Family Behavior Checklist (DFBC), and metabolic control. Although psychosocial measures were not directly related to meta bolic control, they were associated with adherence. Negative family interactions, as measured on the DFBC, predicted the number of blood glucose tests conducted. The Barriers to Adherence scale predicted diet and measurement of insulin doses with higher barr ier ratings indicating that the children were less likely to follow their diabetic diet a nd to take care in measuring insulin doses. However, no significant relati onship was found between metabolic control and general family functioning (Schafer et al., 1983). St udies using diabetes-specific instruments have also contributed to th e association between family functioning and adherence to treatment. A study of 54 adults and 18 unrelat ed adolescents with Type I diabetes given

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10 Diabetes Family Behavior Checklist (DFBC) and adherence measures found differences in reporting between adolescents and adu lts. Adolescents reported more negative interactions with their families. In turn, a dolescents reporting negative interactions were in poorer control. In adults negative DFBC scores predicte d poorer adherence at a 6month follow-up interval and was marginally associated with HbA1c levels (Schafer, McCaul, & Glasgow, 1986). A study by Anderson, Auslander, Jung, Miller and Santiago (1990) examined lack of responsibility for the child ’s treatment regimen. The st udy included 121 children 6-21 years old and their mothers using the Diab etes Family Responsibility Questionnaire (DFRQ). The findings with the DFRQ found th at child age, disease duration, and the gender of the patient predicted mother and child patterns of sharing diabetes responsibilities. Additionally, disagreements between the mother and child in perception of who is assuming responsibility and adhe rence level predicted HbA1c levels. Higher levels of mother-child scores indicati ng, “no one takes responsibility” and lower adherence contributed to poorer metabolic cont rol. Age was also related to “no one takes responsibility” with higher disa greement between mothers and younger children. These findings with age were also significantly a ssociated with level of overall adherence, where lower adherence was found in older ch ildren, and age correlated with metabolic control with older ch ildren in poorer control than y ounger children (Anderson et al., 1990). Children assume increasing responsibil ity with increasing age and it has been suggested that the parental sh ift of responsibility for diabet es care to the child usually occurs around 12 years of age (La Greca et al., 1995).

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11 Family Functioning and DKA Few studies have explored the relations between family functioning, adherence, and health outcome assessed by incidence of DKA in children and adolescents with type I diabetes. Davis et al. (2001) examined the associations between psychosocial characteristics, adherence, and health outco me in 55 parents of children aged 4-10 years with type I diabetes and no other major dia gnoses. Four of the child ren had experienced a DKA episode within past year, excluding a diagnosis-related DKA. The study used the Parenting Dimensions Inventory to assess 8 parenting dimensions and the Self-Care Inventory (Hanson et al., 1996) to assess adhere nce. Parental warmth was associated with better adherence ratings and explained 27% of the variance in adherence ratings. Demographic variables, SES, parental c ontrol and restrictiven ess, and physical punishment did not predict adherence. Parental restrictiveness was, however, associated with worse glycemic control. Only Afri can American ethnicity and low SES were associated with more parental restrictivene ss and worse glycemic control (Davis et al., 2001). Other previously established factors co rrelated with DKA are psychiatric illness and family support. Liss and her colleague s (1998) studied 25 children with DKA hospitalizations and 25 matched outpatient controls without a history of DKA hospitalizations. Psychiatric il lness in participants was a ssessed using the Diagnostic Interview Schedule for Children (DISC) and diabetes-related family functioning was assessed using the Diabetes Family Behavi or Scale (DFBS). Pa rticipants who had experienced DKA episodes had significantly mo re psychiatric illness diagnoses, less diabetes-specific family support, lower sel f-esteem, and lower social competence. These participants’ families were lower on problem solving and diabetes-specific parental

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12 “warmth caring” (Liss et al., 1998). Currentl y, this is the only study to examine such family functioning variables with diabetes specific measures and DKA occurrence. Purpose and Hypotheses of this Study Empirical literature has established the importance of family functioning and its effect on adherence and health outcome in pediatric patients with Type I diabetes. However, the literature supporting family functioning variables and occurrence of DKA in this population is less examined and r ecognized. This study will strengthen those relationships by examining specific family f unctioning variables prev iously established as relevant in the literature to the health outcome event of diabetic ketoacidosis (DKA) in pediatric patients. Based on the previously presented literature, it is expected: 1. Higher parental warmth will be asso ciated with a lower occurrence of DKA episodes, 2. Higher parental negativity will be associ ated with an higher occurrence of DKA episodes, and 3. Lack of responsibility for diabetes-relate d tasks will be associated with an higher occurrence of DKA episodes.

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13 CHAPTER 2 METHOD Participants Participants were 100 children with Type I diabetes (45 male, 55 female) recruited from the inpatient program and outpatient diab etes clinic in Shands Hospital at the University of Florida. Eighty-nine particip ants were from the outpatient clinic seen during routine clinical physician appointments. Eleven participants were from the diabetes inpatient unit. These subjects were placed in the inpatient unit following physician recommendation due to poor metabolic control. Subjects were not recruited if they (a) were diagnosed with Type I diabetes for less than one year (b) were currently using an insulin pump, or (c) were diagnosed with a pervasive developmental disorder. Participants ranged in age from 7 to 18 years with a mean age of 13.2 years ( SD = 2.47). Thirty-four subjects (11 male, 23 female) ha d a history of presence of DKA according to a review of medical records. Of these subj ects, 65% were Caucasian, 23% were African American, 8% were Hispanic, and 3% were members of another ethnic group. Sixty-six subjects (34 male, 32 female) did not have a history of DKA accordi ng to a review of medical records. Of patients not having a hi story of DKA, 81% were Caucasian, 7% were African American, 5% were Hispanic, and 6% were members of another ethnic group. Between group analyses indica te the two groups differed si gnificantly on HbA1C indexes ( t = -4.93, p < .001). No other between group di fferences was found on demographic variables. Means and standard deviations for demographic variables are presented in Table 1.

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14 Table 1 Means and Standard Deviations for Demographic Information for Participants Experiencing and Not Experiencing DKA Variable DKA Sample n = 34 mean ( SD ) Non-DKA Sample n = 66 mean ( SD ) Age 13.79 (2.01) 12.95 (2.65) HbA1c 10.25 (2.02) 8.35 (1.37) Duration of Diabetes 6.52 (3.81) 5.05 (3.25) Procedure Outpatient participants were recruited while waiting for their routine clinical appointment. After consent was obtained, pediat ric patients and their caregiver completed demographic and diabetes-specific questionn aires. Inpatient participants and their caregivers were administered the questionnaires at the tim e of their admission to the inpatient program. Presence or absence of DKA was then obtained from a review of the participants’ medical records for both groups It was necessary to code DKA as a dichotomous variable as medical records we re non-specific and frequently described “multiple” episodes of DKA rather than a sp ecific number. DKA episodes experienced at the time of diagnosis of Type I diabetes were not considered as th ese episodes occurred before the patient and family were educated about the treatment regimen and disease. Measures Diabetes Family Behavior Scale (DFBS) The DFBS is a child-completed measure designed to assess diabetes-specific family support. Originally a 60-item scale, th e measure has been revised by to include 47 items. The measure includes a guidance-cont rol subscale (24 items) and warmth-caring subscale (23 items). Children rate how often certain supportive or non-supportive

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15 behaviors occur on a 5-point scale of (1) all th e time, (2) most of the time, (3) sometimes, (4) hardly ever, to (5) never. Scores range from 47 to 235, with lo wer scores indicating more diabetes-specific family support behavi ors. For the purposes of the current study, only the warmth-caring subscale was used. The warmth-caring subscale has an internal consistency of .79. Diabetes Family Behavi or Checklist (DFBC) The DFBC was designed to assess supportiv e and non-supportive family behaviors that have been shown to relate to diabetes self-care completed by children with diabetes and their caregivers. The scale consists of 16 questions divide d into 9 supportive behavior questions and 7 non-supportive be havior questions. Items are rated on a 5-point scale of (1) never, (2) twice a month, (3) once a week, (4) several ti mes a week, to (5) at least once a day. Scores are calculated to create a positive summary score range from 9 to 45, and a negative summary scores range from 7 to 35. For the purposes of this study, only the parental negativity scale was used. This scale has an intern al consistency of .60 (Schafer et al., 1986) and test-retest value of .77 for negative scores (LaGreca et al., 1995). Schafer and her colleagues (1986) found a correlation between negative DFBC scores and adherence to glucose tes ting, diet, and insulin injections. Diabetes Family Responsibility Questionnaire (DFRC) The Diabetes Family Responsibility Ques tionnaire (DFRC) is a scale designed to assess the perception of family members’ res ponsibility for diabetes-related behaviors. The scale includes 17 diabetes and general hea lth related circumstances divided into three subscales, General Health and Regimen tasks, General Health and Social Presentations, and Regimen Tasks and Social Presentations. Fo r each item, the rater indicates if the task is the responsibility of the parent, child, or shared by both. The same version of the form

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16 is given to parents and children with diabet es, and scores are then combined to get a mother-child didactic score. This score ra nges from 0 to 17, where 17 indicates that no one takes responsibility for any of the DFRC situations. For the purposes of this study, the ‘no responsibility’ score was used (Ande rson et al., 1990). Anderson et al. (1990) found the scale to have an internal cons istency between .69 to .85 for the various subscales and concurrent validity with the Family Environment Scale.

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17 CHAPTER 3 RESULTS Preliminary Analyses To explore relations between demographi c, family functioning variables, and incidence of DKA, Pearson product-moment correlation coefficients were obtained between the variables. Results are provided in Table 2. Age was si gnificantly correlated with HbA1c ( r = .21, p < .05) and duration of diabetes ( r = .25, p < .05). Warmth-Caring scores were negatively corre lated with HbA1c indexes ( r = -.35, p < .001), suggesting that children in poorer metabolic control ra te their caregivers as less warm and caring than children in better metabolic control. Pa rental negativity was significantly correlated with HbA1c ( r = .37, p < .001), suggesting that children in poorer metabolic control have caregivers who rate themselves as more nega tive regarding the child’s diabetes regimen. Finally, incidence of DKA was significan tly positively correlated with HbA1c ( r = .50, p < .001) and parental negativity ( r = .24, p < .001), and negatively correlated with warmth-caring scores ( r = -.38, p < .001). This suggests chil dren who had experienced a DKA episode presented with elevated HbA1cs, were more likely to rate parents as less warm and caring, and to have caregivers who rated themselves as more negative regarding the child’s diabetes regimen. T-te sts were run to expl ore group differences. Results indicated that th e DKA and non-DKA groups differed significantly on WarmthCaring ( t = 4.09, p < .001) and Parental Negativity scores ( t = -2.49, p < .05). Specifically, a rate of child-reported wa rmth caring was higher and parent-reported

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18 negativity was lower in families with ch ildren who did not experience DKA episodes. Means and standard deviations for measures are presented in Table 3. Table 2 Pearson r Correlations Between Demographic, Family Functioning Variables, and Incidence of DKA Age HbA1c Duration of Diabetes WarmthCaring No Responsibility Parental Negativity Age HbA1c .21* Duration of Diabetes .25* .12 WarmthCaring -.04 -.35** -.01 No Responsibility .09 .10 .19 -.02 Parental Negativity .13 .37** -.06 -.11 -.17 Incidence of DKA .16 .50** .20 -.38** .12 .24** p < .05, ** p < .01 Table 3 Means and Standard Deviations for Family Functioning Variables for Participants Experiencing and Not Experiencing DKA Variable DKA Sample n = 34 mean ( SD ) Non-DKA Sample n = 66 mean ( SD ) Warmth-Caring 48.50 (9.53) 55.77 (7.82)** No Responsibility 2.85 (2.71) 2.23 (2.40) Parental Negativity 20.00 (4.62) 17.09 (5.95)* ** indicates significant differences at p < .001 level indicates significant differences at p < .05 level

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19 Logistic Regression A logistic regression was performed to e xplore the effect of family functioning variables on DKA due to the dichotomous natu re of the dependent variable. Logistic regression has been suggested as an appr opriate choice for dichotomous dependent variables (Davis & Offord, 1997; Peng, Lee, & Ingersoll, 2002). The presence or absence of DKA was entered as the dependent variable Demographic predictors (age, gender, and ethnicity) were entered in the first step to control for possible influences. Family functioning variables (warmth/caring, no respons ibility for diabetes treatment regimen, and parental negativity) were en tered in the second step as the predictors. Analysis was performed using SPSS 11.0. A test of the full model with all predic tors against a constant-only model was statistically reliable, 2 (3, N = 100) = 26.137, p < .001, indicating that the predictors, as a set, reliably distinguished between ch ildren who had and had not experienced a DKA episode. The logistic regression resulted in a mo del that explained as much as 44% of the variance based on these variables (Nagelkerk e R Squared = .440). Using the Cox & Snell R Squared measure, the model accounted for 31.8% of the variance (R Squared = .318). Warmth-caring and parental negativity differentiated between the groups at p < .001 level. According to th e model, the log of the odds of a child experiencing a DKA episode was negatively related to warmth-caring scores ( p < .05) and positively related to parental negativity ( p < .05). In other words, children in fa milies with higher degrees of warmthcaring and less parental ne gativity were less likely to experience a DKA episode. Lack of responsibility for the treatment regimen was not a significant pr edictor in this model. This confirms the finding that family functioning variables of warmth/caring and parental

PAGE 29

20 negativity are related to a child’s health outcome. As there was no relationship between parent versus child responsibility for regimen and DKA, there was no support for the hypothesis that responsibility fo r the treatment regimen affects a child’s health outcome. To examine possible effects of multicollinearity, structure coefficients were calculated in accordance with Thompson and Borrello (1985). Analyses of structure coefficients indicate multicollinearity was not a problem with family variables. Odds ratios were calculated for significant predic tor variables. For each one unit increase in a participant’s warmth-caring subscale scor e, the odds of experiencing a DKA episode increases by 0.875. For every one unit increase in parent-report of ne gative behavior, the odds of experiencing a DKA increase by 1.150. Fu rther results are pr esented in Table 4. The full model classified correctly 90.9% of the children who did not experience a DKA episode, and 52.9% of the children who did experience a DKA episode, resulting in an overall prediction rate of 78.0% Overall classification predic tion rates are presented in Table 5.

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21 Table 4 Logistic Regression An alysis of DKA episodes by SPSS 11.0 Predictor SE Wald’s 2 df P e (odds ratio) rs Constant -3.85236.710.0111.916.021 Demographics Age .134.1131.3911.2381.143 Gender -.716.5851.4971.221.489 Ethnicity 6.5575.256 Family Functioning Warmth-caring -.134.03713.2191.001.875-.573 No responsibility .174.1152.2811.1311.190.181 Parental negativity .139.0556.3751.0121.150.361 Test 2 df P Overall model evaluation Model Chi-square 26.137 3 .001 Goodness-of-fit test Hosmer & Lemeshow 3.263 8 .917 Table 5 The Observed and Predicted Fr equencies for DKA episodes by Logistic Regression With the Cutoff of 0.50 Predicted Observed No Yes % Correct No 60 6 90.9 Yes 16 18 52.9 Overall % correct 78.0

PAGE 31

22 Moderating Logistic Regression Possible moderating effects of age on re lationships between family functioning variables and DKA were explored using gui delines as specified by Baron and Kenny (1986). More specifically, moderation is determ ined if the following guidelines are met. Moderating effects are indicated if the inte raction between family functioning variables (i.e. Warmth-Caring, Parental Negativity, a nd No Responsibility) demonstrate significant effects after controlling for family functio ning variables and age. Possible moderation was explored separately for each of the th ree family functioning variables. All three regression models indicated non-significant moderating eff ects between age and family functioning variables.

PAGE 32

23 CHAPTER 4 DISCUSSION The purpose of this study was to demonstr ate the association of family functioning variables and hospitalizations for DKA in pedi atric patients with Type I diabetes. Our results suggest a good fit for a model linking occurrence of DKA and family functioning characteristics. Specifically, our hypothesi s that families with increased amounts of warmth and caring would be associated w ith a lower occurrence of DKA was supported. The model also supports the hypothesis that increased amounts of parental-reported negativity would be a ssociated with higher occurrence of DKA. While warmth and caring, responsibility, and parent support as a group, have not been specifically examined in the literatu re with incidence of DKA, these findings are supported by the only study in the literat ure to examine one of these family characteristics, warmth-caring, and inciden ce of DKA (Liss et al., 1998). These findings are also supported by earlier studies reporting significant a ssociations between family support and metabolic control (Steinhausen, 1982; Stevenso n et al., 1991; WeissbergBenchell et al., 1995; Wysocki et al., 1996). However, the hypothesis regarding the asso ciation between lack of responsibility for the diabetes treatment regimen and in creased incidence of DKA episodes was not supported. This was surprising given the previ ously established asso ciation between lack of responsibility and poor meta bolic control (Anderson et al ., 1990). One possibility for this finding may be due to bias in self-repor t and social desirabili ty. Children and their caregivers may not have been willing to admit that no one takes responsibility for certain

PAGE 33

24 aspects of treatment in a clin ical setting. Another possibili ty is that this scale only indicates that someone in the family takes re sponsibility, but not wh ether that individual is the child or caregiver. Therefore, children may assume responsibility for aspects of the treatment regimen prematurely. This rati onale is supported in a study by LaGreca, Follansbee, and Skyler (1990) who found th at preadolescents who assume greater responsibility for diabetes car e are usually in poorer glycem ic control than their peers who have more parental support for diabetes responsibilities. Previous research in the empirical literature has found associations between age and family variables (Anderson et al., 1990; Anderson et al., 2002; LaGreca et al., 1995), and age and metabolic control (Johnson, 1995; Johnson et al., 1992; Kovacs et al., 1992). Given these previous findings, it was surpri sing that no association was found regarding the effects of age between family functioning variables and DKA. However, a major difference between this study and previous research examining the effects of age on health outcome has examined metabolic cont rol as the dependent variable, while the health outcome measure in this study was the presence or absence of DKA. This may be one possibility why a relationship between age, family functioning variables, and health outcome was not found. This study is the first to i nvestigate the associ ation between fam ily characteristics and DKA as a measure of health outcome in children with Type I diabetes. Previous literature examining family functioning has focused on health outcome as measured by metabolic control (McKelvey et al., 1993; Steinhausen, 1982). The association between family functioning and adherence has been we ll supported in the lite rature (LaGreca et al., 1995; Hanson et al., 1987), as has the a ssociation between family functioning and

PAGE 34

25 health outcome as measured by metabolic control, or glycosylated hemoglobin (Stevenson et al., 1991). However, the asso ciations between a dherence and health outcome are mixed, with some studies supporti ng the association and some studies not supporting the association. DKA commonly results from chronic poor metabolic control (Travis, 1985) and individuals experienci ng DKA often report more noncompliance with diabetes treatment than controls without DKA episodes (Morris et al., 1997; Liss et al., 1998). The current study demonstrates the more direct effect that family functioning has on the health outcome measure (i.e. DKA) that is related to adherence to the treatment regimen. Another strength of the study is the us e of diabetes-specific measures and questionnaires. Researchers have suggeste d that disease-specific measures of psychosocial variables are better predictors of adherence than global measures (Shafer et al., 1983). Similarly, disease-specific measures should serve as be tter indicators of characteristics in families including children w ith chronic illnesses than global measures. Global measures may not pick up on behaviors in the family unit related to aspects of the treatment regimen, health outcome, adherence, and the subtle differences in families including children with chronic illness as co mpared to families including only healthy children. Limitations This study has several limitations. First, the study design was cross-sectional, which prevents the researchers from making cau sal statements regard ing the direction of influence between family variables and health outcome. In fact, family measures were used to predict past episode s of DKA. However, since family variables have been previously associated with HbA1c levels, a nd HbA1c levels have been associated with

PAGE 35

26 DKA, it is probable that family functioni ng variables would predict DKA. Although the hypothesis that family functioning characteri stics influence a child’s adherence and therefore health outcome has clinical appeal it is possible that poor health outcome in children contributes to changes in the family environment. Future investigations with longitudinal designs assessing family variable s and subsequent incidence of DKA would be beneficial to explain th e relationship between family characteristics and health outcome. Second, the population used in this st udy is a sample of convenience taken from a tertiary care cente r serving a large geographic region. The percentage of individuals who have experienced a DKA episode in this sample is higher than the national average due to the tertiary care nature of the setting. Fina lly, the measures used in this study were self-report questionnaires. Social desirability may have played a role in participants’ responses and subsequently skewed the resu lts of the study if family members were overly positive in their report of family characteristics. Conclusions and Clinical Implications In conclusion, this study is the first of few studies to explicitly examine family functioning variables and DKA in children with Type I diabetes. Families with lower rates of parental warmth and higher rates of pa rental negativity are associated with higher occurrence of DKA episodes. Examination of these two variables alone correctly classifies a child’s likelihood of having e xperienced a DKA episode or not 78% of the time. Specifically, changes of only one unit in these variables (as measured by diabetesspecific measures) leads to a significant change in the odds that a child will fall into the group that has experienced a DKA episode. Th is is of clinical importance because families who present to a physician or psychol ogist with these characteristics could be targeted for early intervention or additional involvement direct ed at these specific aspects

PAGE 36

27 of warmth, caring, and negativity. This study also suggests the need to develop new interventions to more intensely address these aspects of the families. Targeting these family characteristics may improve complian ce and metabolic contro l, and decrease the probability that the child will experience futu re diabetes-related complications, such as DKA.

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28 LIST OF REFERENCES Aikens, J. E., Wallander, J. L., Bell, D. S., & Cole, J. A. (1992). Daily stress variability, learned resourcefulness, regimen adheren ce, and metabolic control in Type I diabetes mellitus: Evaluation of a path model. Journal of Consulting and Clinical Psychology, 60 113-118. American Diabetes Association. (2001). Sta ndards of medical care for patients with diabetes mellitus. Diabetes Care, 24 33-43. Anderson, B. J., Auslander, W. F., Jung, K. C., Miller, J. P., & Santiago, J. V. (1990). Assessing family sharing of diabetes responsibilities. Journal of Pediatric Psychology, 15 477-492. Anderson, B. J., Vangsness, L., Connell, A., Bu tler, D., Goebel-Fabbri, A., & Laffel, L. M. B. (2002). Family conflict, adherence, and glycemic control in youth with short duration Type 1 diabetes. Diabetic Medicine, 19 635-642. Anderson, R. M. (1995) Patient empowerment a nd the traditional medical model. A case of irreconcilable differences? Diabetes Care, 18 412-415. Baron, R. M. & Kenny, D. A. (1986). The mode rator-mediator variab le distinction in social psychological research: Conceptual, strategic, and statis tical considerations. Journal of Personality and Social Psychology, 52 1173-1182. Cahill, G. F., Etzwiler, L. D., & Freinkel, N. (1976). Editorial: “Control” and diabetes. New England Journal of Medicine, 29, 1004-1005. Centers for Disease Control. (2002). Diabet es: Disabling, deadly, and on the rise—2002. Department of Health and Human Services Retrieved March, 08, 2004, from http://www.cdc.gov/diabetes /pubs/pdf/diabetes2002.pdf. Cerkoney, K. A. & Hart, L. K. (1980). The re lationship between the health belief model and compliance of persons with diabetes mellitus. Diabetes Care, 3 594-598. Davis, L. J. & Offord, K.P. (1997). Logistic regression. Journal of Personality Assessment, 68 497-507. Davis, D. L., Delamater, A. M., Shaw, K. H., La Greca, A. M., Eidson, M. S., PerezRodriguez, J. E., & Nemery, R. (2001). Parenting styles, regimen adherence, and glycemic control in 4to 10-y ear-old children with diabetes. Journal of Pediatric Psychology, 26 123-129.

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29 Diabetes Control and Complications Trial Research Group. (1986). Di abetes control and complications trial: Design and methodologi c considerations for the feasibility phase. Diabetes, 35, 530-545. Diabetes Control and Complications Tria l Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The New England Journal of Medicine, 329 977-986. Diabetes Control and Complications Trial Research Group. (1994). Effect of intensive diabetes treatment on the development a nd progression of long-term complications in adolescents with insuli n-dependent diabetes mellitu s: Diabetes control and complications trial. The Journal of Pediatrics, 125 177-188. Edge, J. A., Ford-Adams, M. E., & Dunger, D. B. (1999). Causes of death in children with insulin dependent diabetes 1990-96. Archives of Disease in Childhood, 81, 318-323. Geffken, G. R., Lewis, C., Johnson, S. B., Siverstein, J. H., Rosenbloom, A. L., & Monaco, L. (1997). Residential treatment for youngsters with difficult to manage Insulin-Dependent Diabetes Mellitus. Journal of Pediatric Endocrinology and Metabolism, 10 517-527. Glasgow, R. E., McCaul, K. D., & Schafer, L. C. (1987). Self-care behaviors and glycemic control in type I diabetes. Journal of Chronic Diseases, 40 399-412. Hanson, C. L., Henggeler, S. W., & Burghe n, G. A. (1987). Social competence and parental support as mediators of the link between stress and metabolic control in adolescents with insulin-dependent diabetes mellitus. Journal of Consulting and Clinical Psychology, 55 529-533. Hanson, C. L., De Guire, M. J., Schinkel, A. M., Kolterman, O. G., Goodman, J. P., & Buckingham, B. A. (1996). Self-care beha viors in insulin-dependent diabetes: Evaluative tools and their associations with glycemic control. Journal of Pediatric Psychology, 21 467-482. Haynes, R. B. (1979). Introduction. In R.B. Ha ynes, D.W. Taylor, & D.L. Sackett (Eds.), Compliance in health care (pp. 1-10). Baltimore, Johns Hopkins University Press. Johnson, S. B. (1995). Insulin-dependent diabetes mellitus in childhood. In Roberts (Ed.), Handbook of pediatric psychology. (2nd Ed., pp. 263-285). New York: Guilford. Johnson, S. B., Kelly, M., Henretta, J. C., C unningham, W. R., Tomer, A., & Silverstein, J. H. (1992). A longitudinal analysis of adherence and health status in childhood diabetes. Journal of Pediatric Psychology, 17 537-553.

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30 Kamiya, A., Ohsawa, I., Fujii, T., Nagai, M., Yamanouchi, K., Oshida, Y., & Sato, Y. (1995). A clinical survey on the complian ce of exercise therapy for diabetic outpatients. Diabetes Research and Clinical Practice, 27 141-145. Kovacs, M., Goldston, D., Obrosky, D. S., & Iyengar, S. (1992). Prevalence and predictors of pervasive noncompliance w ith medical treatment among youths with insulin-dependent diabetes mellitus. Journal of the American Academy of Child and Adolescent Psychiatry, 31 1112-1119. Kratvitz, R. L., Hays, R. D., Sherbourne, C. D., Dimatteo, M. R., Rogers, W. H., Ordway, L., & Greenfield, S. (1993). Recall of recommendations and adherence to advice among patients with chronic medical conditions. Archives of Internal Medicine, 23 1869-1878. LaGreca, A. M., Auslander, W. F., Greco, P., Sp etter, D., Fisher, E. B., & Santiago, J. V. (1995). I get by with a little help from my family and fr iends: Adolescents’ support for diabetes care. Journal of Pediatric Psychology, 20 449-476. LaGreca, A. M., Follansbee, D., & Skyler, J. S. (1992). Developmental and behavioral aspects of diabetes management in youngsters. Children’s Health Care, 19 132139. LaGreca, A. M., & Schuman, W. (1995). Adhere nce to prescribed medical regimens. In Roberts (Ed.), Handbook of pediatric psychology. (2nd Ed., pp. 55-83). New York: Guilford. LaPorte, R. E., Tajima, N., Akerblom, H. K., Berlin, N., Brosseau, J ., Christy, M., et al. (1985). Geographic differences in the risk of insulin-dependent mellitus: The importance of registries. Diabetes Care, 8 (Suppl. 1), 101-107. Lewin, A. B., Geffken, G. R., Bimbo, L., M., Gelfand, K. M., Heidgerken, A.D., & Silverstein, J. H. (2004). The relationship between adherence and metabolic control revisited: The role of diabetes specific family factors. Manuscript submitted for publication. Liss, D. S., Waller, D. A., Kennard, B. D., Mc Intire, D., Capra, P., & Stephens, J. (1998). Psychiatric illness and family support in children and adolescents with diabetic ketoacidosis: A controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 37 536-544. Mazze, R. S., Sinnock, P., Deeb, L., & Brimberry, J. L. (1985). An epidemiological model for diabetes mellitus in the Un ited States: Five major complications. Diabetes Research and Clinical Practice, 1 185-191. McKelvey, J., Waller, D. A., North, A. J., Mark s, J. F., Schreiner, B., Travis, L. B., & Murphy, J. N. (1993). Reliability and validity of the diabetes family behavior scale. The Diabetes Educator, 19 125-132.

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31 McNabb, W. L. (1997). Adherence in diabetes: Can we define it and can we measure it? Diabetes Care, 20 215-218. Morris, A. K., Boyle, D. I., McMahon, A. D., Greene, S. A., MacDonald, T. M., & Newton, R. W. (1997). Adherence to insulin treatment, glycemic control, and ketoacidosis in insulin dependent diabetes mellitus. Lancet, 350 1505-1510. Peng, C. J., Lee, K. L., & Ingersoll, G. M. (2002). An introduction to logistic regression analysis and reporting. The Journal of Educational Research, 96 3-14. Quittner, A. L., Espelage, D. L., Ievers-L andis, C., & Drotar, D. (2000). Measuring adherence to medical treatments in chil dhood chronic illness: Considering multiple methods and sources of information. Journal of Clinical Psychology in Medical Settings, 7 41-54. Rapoff, M. A., & Bernard, M. U. (1991). Co mpliance with medical regimens. In J.A. Cramer and B. Spilker (Eds.), Patient compliance in medi cal practice and clinical trials (pp.73-98). New York: Raven Press. Schafer, L. C., Glasgow, R. E., McCaul, K. D., & Dreher, M. (1983). Adherence to IDDM regimens: Relationship to psychosoc ial variables and metabolic control. Diabetes Care, 6 493-498. Schafer, L. C., McCaul, K. D., & Glasgow R. E. (1986). Supportive and nonsupportive family behaviors: relationships to adhere nce and metabolic control in persons with type I diabetes. Diabetes Care, 9, 179-185. Steinhausen, H. C. (1982). Locus of control among psychosomatically and chronically ill children and adolescents. Journal of Abnormal Child Psychology, 10, 609-615. Stevenson, K., Senskey, T., & Petty, R. (1991) Glycaemic control in adolescents with Type I diabetes and parental expressed emotion. Psychotherapy & Psychosomatics, 55 170-175. Thompson, B., & Borrello, G. (1985). The impor tance of structured coefficients in regression research. Educational and Psychological Measurement, 45 203-209. Travis, L.B. (1985). Acute complications of Type 1 diabetes: Relationship to coping. In P.I. Ahmed & Ahmed (Eds.), Coping with juvenile diabetes (pp.149-164). Springfield, IL: Charles C. Thomas Publisher. U.S. Health and Human Services. (1985) Summary. In M.I. Harris & R.F. Hamman (Eds.), Diabetes in America (2nd ed., pp. 11-16). Bethesda, MD: U.S. Department of Health and Human Services. Weissberg-Benchell, J., Glasgow, A. M., Tyna n, W. D., Wirtz, P., Turek, J., & Ward, J. (1995). Adolescent diabetes management and mismanagement. Diabetes Care, 18 77-82.

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32 Worrall-Davies, A., Owens, D., Holland, P., & Haigh, D. (2002). The effect of parental expressed emotion on glycaemic control in ch ildren with Type I diabetes: Parental expressed emotion and glycaem ic control in children. Journal of Psychosomatic Research, 52 107-113. Wysocki, T., Taylor, A., Hough, B. S., Linschei d, T. R., Yeates, K. O., & Naglieri, J. A. (1996). Deviations from developmenta lly appropriate self-care autonomy. Associations with diabetes outcomes. Diabetes Care, 19 119-125.

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33 BIOGRAPHICAL SKETCH Kelly Walker is a native West Virginia n who completed a bachelor’s degree in psychology at West Virginia University in May 2002. Following her graduation, she began her post-graduate work at the Univer sity of Florida in August 2002, and plans to pursue a doctorate in clinical and health psychology follo wing the attainment of her master’s degree.


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Title: Family Functioning and Diabetic Ketoacidosis in Pediatric Patients with Type I Diabetes
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Copyright Date: 2008

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Holding Location: University of Florida
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Permanent Link: http://ufdc.ufl.edu/UFE0004901/00001

Material Information

Title: Family Functioning and Diabetic Ketoacidosis in Pediatric Patients with Type I Diabetes
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0004901:00001


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FAMILY FUNCTIONING AND DIABETIC KETOACIDOSIS IN PEDIATRIC
PATIENTS WITH TYPE I DIABETES















By

KELLY N. WALKER


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA


2004

































Copyright 2004

by

Kelly N. Walker

































This document is dedicated to my parents, Arnold and Cheryl Walker.















ACKNOWLEDGMENTS

I would like to thank Dr. Gary R. Geffken for his mentorship and assistance during

the previous two years. I truly appreciate all the time, effort, and perspective he has

given me. I would also like to thank my parents for all their encouragement through the

years. Their support has given me the courage and confidence to reach for my dreams

and never accept less than my personal best.

















TABLE OF CONTENTS

page

ACKNOW LEDGM ENTS ........................................ iv

LIST OF TABLES ...................... ....... ............ ............. vii

ABSTRACT ........... ................... ......................... viii

CHAPTER

1 INTRODUCTION ................... .................. .............. .... ......... .......

G general D iabetes Overview ....................................................
D iabetic K etocidosis (DK A)................................... ................. 2
Comm on Treatm ents for Type I Diabetes ............................................... .....3
A dherence in Type I D iabetes ......................... .................4
Family Functioning and the Pediatric Patient with Type I Diabetes............................7
Family Functioning and DKA .................................. .................. ........ ......... 11
Purpose and Hypotheses of this Study............................................. .. ......... 12

2 METHOD .......................... ..................... .........13

Participants ................................................13
Procedure ......................................................... ................. 14
M measures .................. ................... .......................................... 14
Diabetes Family Behavior Scale (DFBS).....................................................14
Diabetes Family Behavior Checklist (DFBC) .................................................15
Diabetes Family Responsibility Questionnaire (DFRC) ..............................15

3 RESULTS ...................................... ........................ ....................17

Prelim inary A analyses ............... .................................................................... ... ........ 17
Logistic Regression ................................................ ........ 19
M operating Logistic Regression.................................................. 22

4 DISCU SSION ................ ....................... .............................23

Limitations............................. .. .... ............ .............. ........25
Conclusions and Clinical Implications ............... ................................26



v









LIST OF REFERENCES ..................................... ............... ....................28

BIOGRAPHICAL SKETCH .................................................. ............... 33
















LIST OF TABLES


Table page

1 Means and Standard Deviations for Demographic Information for Participants
Experiencing and Not Experiencing DKA................................. .. ............. ....... 14

2 Pearson r Correlations Between Demographic, Family Functioning Variables, and
Incidence of DKA ....... ...._. ... ........... ..................18

3 Means and Standard Deviations for Family Functioning Variables for Participants
Experiencing and Not Experiencing DKA.................................... .................18

4 Logistic Regression Analysis of DKA episodes by SPSS 11.0 ...............................21

5 The Observed and Predicted Frequencies for DKA episodes by Logistic Regression
W ith the Cutoff of 0.50 ................................ ............................ 21
















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

FAMILY FUNCTIONING AND DIABETIC KETOACIDOSIS IN PEDIATRIC
PATIENTS WITH TYPE I DIABETES

By

Kelly N. Walker

May 2004

Chair: Gary R. Geffken
Major Department: Clinical and Health Psychology

Type I diabetes is a chronic condition caused by an inability of the body's cells to

use sugar from foods for energy. Treatment involves daily insulin injections, a

complicated regimen of blood glucose monitoring, dietary guidelines, and specific

exercise recommendations. In some individuals, diabetic ketoacidosis (DKA), a life

threatening complication of diabetes, can occur. The condition is typically caused by a

shortage of insulin and chronic noncompliance to treatment. DKA may occur in any

patient with diabetes, but patients with poor control are at a greater risk due to their non-

compliant behaviors. Given the relationship between family functioning and adherence

previously found in the literature, the purpose of this study is to determine if specific

family functioning variables are related to episodes of DKA in pediatric patients with

Type I diabetes. Specifically, it was predicted that (1) higher parental warmth will be

associated with lower occurrence of DKA, (2) higher parental negativity will be

associated with higher occurrence of DKA, and (3) lack of responsibility for diabetes-









related tasks will be associated with higher occurrence of DKA. Participants included 100

children with Type I diabetes and their caregivers recruited from Shands Hospital and

clinics at the University of Florida. Participants completed disease-specific measures of

family functioning to assess variables including parental warmth, parent and child

perceptions of negativity, and family responsibility for the diabetes regimen.

Glycosylated hemoglobin indexes and incidence of DKA were obtained by chart review.

Family variables were analyzed to create a model to predict the presence or absence of

DKA in children with Type I diabetes. This model was significant (X2 (3, N= 100) =

26.137, p < .001) and diabetes specific family variables accounted for almost 44% of the

variance. The data suggest that increased child perception of warmth and caring was

associated with decreased odds of experiencing a DKA episode. The data also suggest

increased parental negativity was associated with increased odds of experiencing a DKA

episode. The hypothesis regarding family responsibility was not supported. The findings

suggest that family factors play a significant role in the occurrence or absence of DKA in

children's long-term management of their diabetes.














CHAPTER 1
INTRODUCTION

General Diabetes Overview

Diabetes is a chronic condition caused by an inability of the body's cells to

metabolize carbohydrates from foods for energy. Type I, or insulin-dependent diabetes

(IDD), results from a pancreatic failure to produce insulin, which is required for glucose

to enter cells. Type II diabetes, or non-insulin-dependent diabetes (NIDD), occurs when

the body still produces insulin, but the glucose cannot be effectively utilized. The focus

of this study will involve Type I patients, who are most commonly diagnosed in

childhood. In contrast, Type II patients are most commonly diagnosed in adulthood,

although the number of Type II patients is rising in childhood and adolescence. Type I

patients require exogenous insulin, typically delivered through daily injections. Genetic

factors may play a role in the etiology of Type I, but the exact cause is unknown. Even

with modern medical advances, life expectancy for the Type I patient is approximately

75% of normal, with disease related complications, such as retinopathy, nephropathy, and

cardiovascular problems developing later in life (U.S. Health and Human Services,

1985). In 1985, it was estimated that approximately 1 in 600 children held a diagnosis of

Type I diabetes (LaPorte et al., 1985), making it a serious and common chronic childhood

illness. Currently, diabetes affects 6% of the U.S. population, or approximately 17

million individuals (Centers for Disease Control, 2002).









Diabetic Ketocidosis (DKA)

In children, the most severe problem of diabetes is diabetic ketoacidosis (DKA).

DKA is a life threatening event for Type I diabetes. In 1985, the mortality for DKA was

between one and eight percent (Mazze, Sinnock, Deeb, & Brimberry, 1985). Current

mortality rates for DKA lie between 2.3-9.2% in the United Kingdom (Edge, Ford-

Adams, & Dunger, 1999). The incidence rates of DKA in the United States is currently 3-

8 per 1000 people with Type I diabetes per year (U.S. Health and Human Services,

1985). This condition is typically caused by a shortage of insulin or a dysfunction in

insulin activity. The insufficient amount of insulin in the bloodstream forces the body to

break down muscles and fats for energy, resulting in toxic levels of ketones in the

bloodstream (Travis, 1985). DKA symptoms may include hyperglycemia, metabolic

acidosis, vomiting, dehydration, and difficulty breathing. Treatment for DKA typically

involves hospitalization to return the patient to normal functioning.

Despite the severity of DKA, research examining the event is limited in the

empirical literature. In a study of the relationship between adherence and DKA conducted

by Morris et al. (1997), participants included 89 patients with diabetes under the age of

30, with a mean age of 16 years, and mean HbAlc approximately of 8.4%. Physician

prescriptions and pharmacy records were combined to create an index score to assess

adherence. Analyses with adherence index scores, average HbAlc scores, and DKA

episodes were significantly related. DKA episodes were significantly related to lower

adherence indexes. However, adherence is not the only factor found to be associated with

DKA (Liss et al., 1998; Travis, 1985).

Although patients with poor control are at a greater risk due to their noncompliant

behaviors (Travis, 1985), stress and family support have also found to be correlated with









incidence of DKA in the empirical literature (Aikens, Wallander, Bell, & Cole, 1992).

Stress may also play a role in a patient experiencing a DKA episode, as stress may

disrupt behavioral functioning with the diabetes regimen and several stress hormones

have counter regulatory effects on insulin. Other factors correlated with DKA are

psychiatric illness and family support, as indicated by Liss et al. (1998) with a sample of

25 children with DKA hospitalizations and 25 matched outpatient controls with no

history of DKA hospitalizations. Participants who had experienced DKA episodes had

significantly higher psychiatric illness diagnoses, less diabetes-specific family support,

lower self-esteem, and social competence.

Common Treatments for Type I Diabetes

Optimal treatment for Type I diabetes involves a complicated regimen of self-care

tasks, a complex set of contingency based behaviors, and recommendations

encompassing all aspects of the patient's life. Further complicating treatment, these

recommendations vary widely across individuals (McNabb, 1997). Additionally, as much

as 98% of diabetes care is self-care by the patient (Anderson, 1995). Treatment of

diabetes aims to lower blood glucose levels to values as close to normal metabolic

functioning as possible. High blood glucose levels are associated with an increased risk

of diabetic ketoacidosis, vision problems, polyuria, polydipsia, fatigue, decreased weight

loss, vaginitis, balanitis, retinopathy, nephropathy, neuropathy, and poorer atherogenic

lipid profile. Better metabolic control is accomplished by an intensive treatment regimen

involving frequent self-monitoring of blood glucose, appropriate nutritional intake,

regular exercise, individualized insulin injections, prevention and treatment of

hypoglycemia and other acute chronic complications, and a periodic assessment of

treatment goals. With regard to children, additional considerations must be taken









including setting developmentally appropriate goals for self-management, proper diabetes

education, "sick-day" management rules for diabetes-related and other illnesses, caution

in overaggressive dietary manipulation, and assessment of lifestyle needs (American

Diabetes Association, 2001).

The Diabetes Control and Complications Trial (1986; 1993; 1994) demonstrated

the benefits of an intensive regimen involving three or more insulin injections or insulin

pump treatments as compared to the previous conventional therapy involving only 1-2

injections per day. This multi-site study involving 1441 patients aged 13-39 years with

Type I diabetes compared intensive therapy to conventional therapy. The results of the

study found adherence to self-care was essential to prevent diabetes-related

complications. Specifically, intensive therapy reduced the adjusted mean risk of

retinopathy by 76% and slowed its progression in pre-existing cases by 54%. Intensive

therapy also reduced the mean occurrence of microalbuminuria by 39%, reduced the risk

of albuminuria by 54%, and the risk of clinical neuropathy by 60%. The only adverse

event associated with intensive therapy was a two-to-threefold increase in severe

hypoglycemia. Additionally, those in intensive therapy group reduced their glycosylated

hemoglobin, a common measure of metabolic control in individuals with diabetes

(Diabetes Control and Complications Trial, 1993). However, although the results of this

study are generalizable to adolescents and children, more research is needed with these

populations.

Adherence in Type I Diabetes

Adherence has been previously defined as the "extent to which a person's behavior

(in terms of medications, following diets, or executing lifestyle changes) coincides with

medical or health advice" (Haynes, 1979, p. 2-3). These behavioral changes and









modifications are necessary to follow medical and health advice but often present as a

difficult task for many patients with chronic illnesses. In children with chronic illnesses,

three main categories have been linked to nonadherence including: regimen

characteristics, disease characteristics, and patient/family variables (LaGreca &

Schuman, 1995; Rapoff & Bernard, 1991). These factors are of importance because each

year nonadherence leads to higher health care costs and medical complications (Rapoff &

Bernard, 1991). Specific to diabetes, these complications could include recurrent

ketoacidosis and increased symptoms such as hyperglycemia and poorer metabolic

control (Quittner, Espelage, levers-Landis, & Drotar, 2000). Adolescents with poor

metabolic control are at greater risk for more frequent hospitalizations (due to ketosis and

hypoglycemia) and long-term complications such as retinopathy and renal failure (Cahill,

Etzwiler, & Freinkel, 1976). However, even given these consequences, nonadherence

remains a significant problem for pediatric patients with diabetes (Kovacs, Goldston,

Obrosky, & lyengar, 1992). Adherence rates in one study by Cerkoney and Hart (1980)

found that only 2 individuals out of a sample of 30 individuals with diabetes were fully

adherent with all aspects of the treatment regimen. Specifically in this study, the

frequency of adherence to monitoring recommendations was at 57% and adherence to

frequency and accuracy of insulin injections reached a high of only 80% adherent

(Cerkoney & Hart, 1980). Other studies have found diverse rates of adherence as well.

Other studies cite dietary recommendation adherence at an average of 65% (Glasgow,

McCaul, & Shafer, 1987), and variation in adherence to an exercise program from 19%

(Kratvitz et al., 1993) to 30% (Kamiya et al., 1995).









A study by Morris and his colleagues (1997) noted the associations between

treatment adherence and health outcome in 89 patients under 30-years-old. This study

monitored the amount of insulin dispensed by the participating patient's pharmacy, the

patient's gylcemic control through the HbAlc index, and patient hospitalizations. The

researchers found a failure to take insulin in at least 28% of the patients. Additionally,

failure to take insulin was associated with poorer glycemic control, acute hospital

admission for DKA, and other acute problems related to diabetes. Interestingly, the

lowest adherence rating was found in children 10-20 years old (Morris et al., 1997). This

age-related finding is consistent with other studies, which have concluded children's

adherence deteriorates as disease duration increases into adolescence (Kovacs et al.,

1992; LaGreca, Auslander, Greco, & Spetter, 1995). Specifically, older children have

been found in the empirical literature to be less adherent and to demonstrate worse

metabolic control than younger children (Johnson et al., 1992). This finding was

replicated by Johnson (1995), and by Kovacs et al. (1992) who found that adolescents

have poorer metabolic control and levels of self-care than children and adults. The

researchers suggested this was due to the adolescents' less-structured lifestyle and

developmental phase characterized by a pattern of resistance to rules and authority, and

peer pressure for conformity (Johnson, 1995; Kovacs et al., 1992).

Further examination of the impact of nonadherence on a range of diabetes related

problems in children and adolescents with diabetes was demonstrated in one study of

residential treatment for diabetes where patients' treatment regimens were monitored to

ensure full adherence to their treatment regimen (Geffken et al., 1997). In this study, the

individuals participating in residential treatment had a significant reduction in diabetes-









related hospitalizations, improved school attendance, decreased glycosylated hemoglobin

levels, increased weight gain, individualized insulin changes, improved knowledge about

diabetes, and a normalization of familial attitudes toward the disease. However, when

participants entered a follow-up phase of treatment where patients returned home,

increases in glycosylated hemoglobin levels occurred. Researchers suggested that this

increase may have been due to a decrease in treatment adherence, given the positive

disease management found when the residential treatment center staff controlled patients'

treatment regimens. Researchers also suggested that the decreases in adherence might

have been related to aspects of the family unit. Given the multitude of adherence

complications consistently found in children, examination of the family context in which

children with diabetes reside is imperative.

Family Functioning and the Pediatric Patient with Type I Diabetes

With regard to diabetes and treatment adherence, family members and parents have

been found to be the primary sources of support for adolescents with diabetes (LaGreca et

al., 1995; Lewin et al., 2004). Greater family support has been found in the literature to

be correlated with decreased age and shorter disease duration of children's diabetes and

linked with better treatment adherence (LaGreca et al., 1995). Additional studies have

strengthened the relationship found between family functioning and treatment adherence.

Parents who provide more diabetes-specific support have adolescents with better

treatment-regimen adherence than parents who were less supportive of diabetes care

activities (Hanson, Henggeler, & Burghen, 1987). A study of parents of 34 adolescents

with diabetes using the Camberwell Family Interview found that poor glycemic control

was not associated with parental apathy, criticism of the child, or marital discord, but that

greater supportive emotional involvement by parents was associated with better glycemic









control (Stevenson, Senskey, & Petty, 1991). Another study explored family correlated

variables using the Diabetes Family Behavior Scale (DFBS), a diabetes-specific

instrument, sampling 321 children and adolescents aged 7-18 years. The researchers

found an association between the DFBS total score (indicating overall family support),

guidance-control, and HbAlc (McKelvey et al., 1993). With regard to health outcome,

well-controlled patients have described their mothers as highly supportive at disease

onset and less supportive over time, but a different pattern emerged for patients in poor

control (Steinhausen, 1982).

Parents who are less involved and supportive have children who are less adherent

with their treatment regimen, make more mistakes in self-care, and have poorer metabolic

control than children whose parents are involved in a developmentally appropriate style

(Weissberg-Benchell et al., 1995; Wysocki et al., 1996). A study assessing parental

involvement using diabetes-specific measures included 104 youth (8-17 years, 69 aged 8-

12 years, 35 aged 13-17 years) who completed the Diabetes Conflict Scale and Diabetes

Family Responsibility Questionnaire (DFRQ). Fifty-three percent of patients showed

moderate parental involvement in blood glucose monitoring tasks, and 40% showed

moderate parental involvement for insulin treatment. The study found that parental

involvement was a significant predictor of adherence to blood glucose monitoring, and

child conflict scores, parent conflict scores, and self-report of blood glucose monitoring

frequency predicted glycemic control. Additionally, parents of older patients were

significantly less involved than parents of younger patients. (Anderson et al., 2002).

However, support and involvement are not the only family variables related to

health outcome in pediatric patients with Type I diabetes. Negative patterns of interaction









such as, parental hostility, negative parental interactions, and lack of responsibility for the

treatment regimen are also associated with adherence and health outcome (Schafer,

Glasgow, McCaul, & Dreher, 1983; Worrall-Davies, Owens, Holland, & Haigh, 2002). In

a study by Worrall-Davies et al. (2002), parental hostility was correlated with glycemic

control, not over-involvement or criticism in a study of 45 children and their caregivers.

Specifically, parental hostility, as assessed through an interview measure using an

adapted form of the Camberwell Family Interview, was associated with elevated levels of

glycosylated hemoglobin. Parental hostility accounted for 22% to 29% of the variation in

glycosylated hemoglobin 12 months before and 12 months after hostility was assessed.

A study examining negative family interactions with diabetes specific instruments

involved 34 adolescents 12-14 years old and assessed four aspects of regimen adherence

(insulin injections, dietary patterns, glucose testing, and exercise), psychosocial variables

measured by the Barriers to Adherence and Problem Solving Scale and the Diabetes

Family Behavior Checklist (DFBC), and metabolic control. Although psychosocial

measures were not directly related to metabolic control, they were associated with

adherence. Negative family interactions, as measured on the DFBC, predicted the number

of blood glucose tests conducted. The Barriers to Adherence scale predicted diet and

measurement of insulin doses with higher barrier ratings indicating that the children were

less likely to follow their diabetic diet and to take care in measuring insulin doses.

However, no significant relationship was found between metabolic control and general

family functioning (Schafer et al., 1983). Studies using diabetes-specific instruments

have also contributed to the association between family functioning and adherence to

treatment. A study of 54 adults and 18 unrelated adolescents with Type I diabetes given









Diabetes Family Behavior Checklist (DFBC) and adherence measures found differences

in reporting between adolescents and adults. Adolescents reported more negative

interactions with their families. In turn, adolescents reporting negative interactions were

in poorer control. In adults, negative DFBC scores predicted poorer adherence at a 6-

month follow-up interval and was marginally associated with HbAlc levels (Schafer,

McCaul, & Glasgow, 1986).

A study by Anderson, Auslander, Jung, Miller, and Santiago (1990) examined lack

of responsibility for the child's treatment regimen. The study included 121 children 6-21

years old and their mothers using the Diabetes Family Responsibility Questionnaire

(DFRQ). The findings with the DFRQ found that child age, disease duration, and the

gender of the patient predicted mother and child patterns of sharing diabetes

responsibilities. Additionally, disagreements between the mother and child in perception

of who is assuming responsibility and adherence level predicted HbAlc levels. Higher

levels of mother-child scores indicating, "no one takes responsibility" and lower

adherence contributed to poorer metabolic control. Age was also related to "no one takes

responsibility" with higher disagreement between mothers and younger children. These

findings with age were also significantly associated with level of overall adherence,

where lower adherence was found in older children, and age correlated with metabolic

control with older children in poorer control than younger children (Anderson et al.,

1990). Children assume increasing responsibility with increasing age and it has been

suggested that the parental shift of responsibility for diabetes care to the child usually

occurs around 12 years of age (La Greca et al., 1995).









Family Functioning and DKA

Few studies have explored the relations between family functioning, adherence, and

health outcome assessed by incidence of DKA in children and adolescents with type I

diabetes. Davis et al. (2001) examined the associations between psychosocial

characteristics, adherence, and health outcome in 55 parents of children aged 4-10 years

with type I diabetes and no other major diagnoses. Four of the children had experienced a

DKA episode within past year, excluding a diagnosis-related DKA. The study used the

Parenting Dimensions Inventory to assess 8 parenting dimensions and the Self-Care

Inventory (Hanson et al., 1996) to assess adherence. Parental warmth was associated with

better adherence ratings and explained 27% of the variance in adherence ratings.

Demographic variables, SES, parental control and restrictiveness, and physical

punishment did not predict adherence. Parental restrictiveness was, however, associated

with worse glycemic control. Only African American ethnicity and low SES were

associated with more parental restrictiveness and worse glycemic control (Davis et al.,

2001).

Other previously established factors correlated with DKA are psychiatric illness

and family support. Liss and her colleagues (1998) studied 25 children with DKA

hospitalizations and 25 matched outpatient controls without a history of DKA

hospitalizations. Psychiatric illness in participants was assessed using the Diagnostic

Interview Schedule for Children (DISC) and diabetes-related family functioning was

assessed using the Diabetes Family Behavior Scale (DFBS). Participants who had

experienced DKA episodes had significantly more psychiatric illness diagnoses, less

diabetes-specific family support, lower self-esteem, and lower social competence. These

participants' families were lower on problem solving and diabetes-specific parental









"warmth caring" (Liss et al., 1998). Currently, this is the only study to examine such

family functioning variables with diabetes specific measures and DKA occurrence.

Purpose and Hypotheses of this Study

Empirical literature has established the importance of family functioning and its

effect on adherence and health outcome in pediatric patients with Type I diabetes.

However, the literature supporting family functioning variables and occurrence of DKA

in this population is less examined and recognized. This study will strengthen those

relationships by examining specific family functioning variables previously established

as relevant in the literature to the health outcome event of diabetic ketoacidosis (DKA) in

pediatric patients. Based on the previously presented literature, it is expected:

1. Higher parental warmth will be associated with a lower occurrence of DKA
episodes,

2. Higher parental negativity will be associated with an higher occurrence of DKA
episodes, and

3. Lack of responsibility for diabetes-related tasks will be associated with an higher
occurrence of DKA episodes.














CHAPTER 2
METHOD

Participants

Participants were 100 children with Type I diabetes (45 male, 55 female) recruited

from the inpatient program and outpatient diabetes clinic in Shands Hospital at the

University of Florida. Eighty-nine participants were from the outpatient clinic seen

during routine clinical physician appointments. Eleven participants were from the

diabetes inpatient unit. These subjects were placed in the inpatient unit following

physician recommendation due to poor metabolic control. Subjects were not recruited if

they (a) were diagnosed with Type I diabetes for less than one year, (b) were currently

using an insulin pump, or (c) were diagnosed with a pervasive developmental disorder.

Participants ranged in age from 7 to 18 years with a mean age of 13.2 years (SD = 2.47).

Thirty-four subjects (11 male, 23 female) had a history of presence of DKA according to

a review of medical records. Of these subjects, 65% were Caucasian, 23% were African

American, 8% were Hispanic, and 3% were members of another ethnic group. Sixty-six

subjects (34 male, 32 female) did not have a history of DKA according to a review of

medical records. Of patients not having a history of DKA, 81% were Caucasian, 7% were

African American, 5% were Hispanic, and 6% were members of another ethnic group.

Between group analyses indicate the two groups differed significantly on HbA1C indexes

(t = -4.93, p < .001). No other between group differences was found on demographic

variables. Means and standard deviations for demographic variables are presented in

Table 1.









Table 1 Means and Standard Deviations for Demographic Information for Participants
Experiencing and Not Experiencing DKA
Variable DKA Sample Non-DKA Sample
n= 34 n= 66
mean (SD) mean (SD)

Age 13.79 (2.01) 12.95 (2.65)

HbAlc 10.25 (2.02) 8.35 (1.37)

Duration of Diabetes 6.52 (3.81) 5.05 (3.25)


Procedure

Outpatient participants were recruited while waiting for their routine clinical

appointment. After consent was obtained, pediatric patients and their caregiver completed

demographic and diabetes-specific questionnaires. Inpatient participants and their

caregivers were administered the questionnaires at the time of their admission to the

inpatient program. Presence or absence of DKA was then obtained from a review of the

participants' medical records for both groups. It was necessary to code DKA as a

dichotomous variable as medical records were non-specific and frequently described

"multiple" episodes of DKA rather than a specific number. DKA episodes experienced at

the time of diagnosis of Type I diabetes were not considered as these episodes occurred

before the patient and family were educated about the treatment regimen and disease.

Measures

Diabetes Family Behavior Scale (DFBS)

The DFBS is a child-completed measure designed to assess diabetes-specific

family support. Originally a 60-item scale, the measure has been revised by to include 47

items. The measure includes a guidance-control subscale (24 items) and warmth-caring

subscale (23 items). Children rate how often certain supportive or non-supportive









behaviors occur on a 5-point scale of (1) all the time, (2) most of the time, (3) sometimes,

(4) hardly ever, to (5) never. Scores range from 47 to 235, with lower scores indicating

more diabetes-specific family support behaviors. For the purposes of the current study,

only the warmth-caring subscale was used. The warmth-caring subscale has an internal

consistency of .79.

Diabetes Family Behavior Checklist (DFBC)

The DFBC was designed to assess supportive and non-supportive family behaviors

that have been shown to relate to diabetes self-care completed by children with diabetes

and their caregivers. The scale consists of 16 questions divided into 9 supportive behavior

questions and 7 non-supportive behavior questions. Items are rated on a 5-point scale of

(1) never, (2) twice a month, (3) once a week, (4) several times a week, to (5) at least

once a day. Scores are calculated to create a positive summary score range from 9 to 45,

and a negative summary scores range from 7 to 35. For the purposes of this study, only

the parental negativity scale was used. This scale has an internal consistency of .60

(Schafer et al., 1986) and test-retest value of .77 for negative scores (LaGreca et al.,

1995). Schafer and her colleagues (1986) found a correlation between negative DFBC

scores and adherence to glucose testing, diet, and insulin injections.

Diabetes Family Responsibility Questionnaire (DFRC)

The Diabetes Family Responsibility Questionnaire (DFRC) is a scale designed to

assess the perception of family members' responsibility for diabetes-related behaviors.

The scale includes 17 diabetes and general health related circumstances divided into three

sub scales, General Health and Regimen tasks, General Health and Social Presentations,

and Regimen Tasks and Social Presentations. For each item, the rater indicates if the task

is the responsibility of the parent, child, or shared by both. The same version of the form






16


is given to parents and children with diabetes, and scores are then combined to get a

mother-child didactic score. This score ranges from 0 to 17, where 17 indicates that no

one takes responsibility for any of the DFRC situations. For the purposes of this study,

the 'no responsibility' score was used (Anderson et al., 1990). Anderson et al. (1990)

found the scale to have an internal consistency between .69 to .85 for the various

subscales and concurrent validity with the Family Environment Scale.














CHAPTER 3
RESULTS

Preliminary Analyses

To explore relations between demographic, family functioning variables, and

incidence of DKA, Pearson product-moment correlation coefficients were obtained

between the variables. Results are provided in Table 2. Age was significantly correlated

with HbAlc (r = .21, p < .05) and duration of diabetes (r = .25, p < .05). Warmth-Caring

scores were negatively correlated with HbAlc indexes (r = -.35, p < .001), suggesting

that children in poorer metabolic control rate their caregivers as less warm and caring

than children in better metabolic control. Parental negativity was significantly correlated

with HbAlc (r = .37, p < .001), suggesting that children in poorer metabolic control have

caregivers who rate themselves as more negative regarding the child's diabetes regimen.

Finally, incidence of DKA was significantly positively correlated with HbAlc (r = .50, p

< .001) and parental negativity (r = .24, p < .001), and negatively correlated with

warmth-caring scores (r = -.38, p < .001). This suggests children who had experienced a

DKA episode presented with elevated HbAlcs, were more likely to rate parents as less

warm and caring, and to have caregivers who rated themselves as more negative

regarding the child's diabetes regimen. T-tests were run to explore group differences.

Results indicated that the DKA and non-DKA groups differed significantly on Warmth-

Caring (t = 4.09, p < .001) and Parental Negativity scores (t = -2.49, p < .05).

Specifically, a rate of child-reported warmth caring was higher and parent-reported










negativity was lower in families with children who did not experience DKA episodes.

Means and standard deviations for measures are presented in Table 3.

Table 2 Pearson r Correlations Between Demographic, Family Functioning Variables,
and Incidence of DKA
Age HbAlc Duration Warmth- No Parental
of Diabetes Caring Respon- Negativity
sibility
Age

HbAlc .21*

Duration .25* .12
of Diabetes

Warmth- -.04 -.35** -.01
Caring

No .09 .10 .19 -.02
Responsibility

Parental .13 .37** -.06 -.11 -.17
Negativity

Incidence of .16 .50** .20 -.38** .12 .24**
DKA
*p <.05, **p< .01

Table 3 Means and Standard Deviations for Family Functioning Variables for
Participants Experiencing and Not Experiencing DKA
DKA Sample Non-DKA Sample
Variable n = 34 n = 66
mean (SD) mean (SD)
Warmth-Caring 48.50 (9.53) 55.77 (7.82)**

No Responsibility 2.85 (2.71) 2.23 (2.40)

Parental Negativity 20.00 (4.62) 17.09 (5.95)*

** indicates significant differences atp < .001 level
* indicates significant differences atp < .05 level









Logistic Regression

A logistic regression was performed to explore the effect of family functioning

variables on DKA due to the dichotomous nature of the dependent variable. Logistic

regression has been suggested as an appropriate choice for dichotomous dependent

variables (Davis & Offord, 1997; Peng, Lee, & Ingersoll, 2002). The presence or absence

of DKA was entered as the dependent variable. Demographic predictors (age, gender, and

ethnicity) were entered in the first step to control for possible influences. Family

functioning variables (warmth/caring, no responsibility for diabetes treatment regimen,

and parental negativity) were entered in the second step as the predictors. Analysis was

performed using SPSS 11.0.

A test of the full model with all predictors against a constant-only model was

statistically reliable, X2 (3, N= 100) = 26.137, p < .001, indicating that the predictors, as

a set, reliably distinguished between children who had and had not experienced a DKA

episode. The logistic regression resulted in a model that explained as much as 44% of the

variance based on these variables (Nagelkerke R Squared = .440). Using the Cox & Snell

R Squared measure, the model accounted for 31.8% of the variance (R Squared = .318).

Warmth-caring and parental negativity differentiated between the groups atp < .001

level. According to the model, the log of the odds of a child experiencing a DKA episode

was negatively related to warmth-caring scores (p < .05) and positively related to parental

negativity (p < .05). In other words, children in families with higher degrees of warmth-

caring and less parental negativity were less likely to experience a DKA episode. Lack of

responsibility for the treatment regimen was not a significant predictor in this model. This

confirms the finding that family functioning variables of warmth/caring and parental









negativity are related to a child's health outcome. As there was no relationship between

parent versus child responsibility for regimen and DKA, there was no support for the

hypothesis that responsibility for the treatment regimen affects a child's health outcome.

To examine possible effects of multicollinearity, structure coefficients were

calculated in accordance with Thompson and Borrello (1985). Analyses of structure

coefficients indicate multicollinearity was not a problem with family variables. Odds

ratios were calculated for significant predictor variables. For each one unit increase in a

participant's warmth-caring subscale score, the odds of experiencing a DKA episode

increases by 0.875. For every one unit increase in parent-report of negative behavior, the

odds of experiencing a DKA increase by 1.150. Further results are presented in Table 4.

The full model classified correctly 90.9% of the children who did not experience a DKA

episode, and 52.9% of the children who did experience a DKA episode, resulting in an

overall prediction rate of 78.0%. Overall classification prediction rates are presented in

Table 5.









Table 4 Logistic Regression Analysis of DKA episodes by SPSS 11.0

Predictor 8 SEJf Wald's df P e r,
x2 (odds ratio)

Constant -3.852 36.710 .011 1 .916 .021


Demographics

Age

Gender

Ethnicity

Family Functioning

Warmth-caring

No responsibility

Parental negativity


.134

-.716


-.134

.174

.139


.113

.585


.037

.115

.055


Test

Overall model evaluation
Model Chi-square

Goodness-of-fit test
Hosmer & Lemeshow


1.391

1.497

6.557


13.219

2.281

6.375

X2


.238

.221

.256


.001

.131

.012

P


1.143

.489


.875 -.573

1.190 .181

1.150 .361


26.137 3 .001


3.263 8 .917


Table 5 The Observed and Predicted Frequencies for DKA episodes by Logistic
Regression With the Cutoff of 0.50
Predicted


Observed


Yes

6

18


Yes

Overall % correct


% Correct

90.9

52.9

78.0











Moderating Logistic Regression

Possible moderating effects of age on relationships between family functioning

variables and DKA were explored using guidelines as specified by Baron and Kenny

(1986). More specifically, moderation is determined if the following guidelines are met.

Moderating effects are indicated if the interaction between family functioning variables

(i.e. Warmth-Caring, Parental Negativity, and No Responsibility) demonstrate significant

effects after controlling for family functioning variables and age. Possible moderation

was explored separately for each of the three family functioning variables. All three

regression models indicated non-significant moderating effects between age and family

functioning variables.














CHAPTER 4
DISCUSSION

The purpose of this study was to demonstrate the association of family functioning

variables and hospitalizations for DKA in pediatric patients with Type I diabetes. Our

results suggest a good fit for a model linking occurrence of DKA and family functioning

characteristics. Specifically, our hypothesis that families with increased amounts of

warmth and caring would be associated with a lower occurrence of DKA was supported.

The model also supports the hypothesis that increased amounts of parental-reported

negativity would be associated with higher occurrence of DKA.

While warmth and caring, responsibility, and parent support as a group, have not

been specifically examined in the literature with incidence of DKA, these findings are

supported by the only study in the literature to examine one of these family

characteristics, warmth-caring, and incidence of DKA (Liss et al., 1998). These findings

are also supported by earlier studies reporting significant associations between family

support and metabolic control (Steinhausen, 1982; Stevenson et al., 1991; Weissberg-

Benchell et al., 1995; Wysocki et al., 1996).

However, the hypothesis regarding the association between lack of responsibility

for the diabetes treatment regimen and increased incidence of DKA episodes was not

supported. This was surprising given the previously established association between lack

of responsibility and poor metabolic control (Anderson et al., 1990). One possibility for

this finding may be due to bias in self-report and social desirability. Children and their

caregivers may not have been willing to admit that no one takes responsibility for certain









aspects of treatment in a clinical setting. Another possibility is that this scale only

indicates that someone in the family takes responsibility, but not whether that individual

is the child or caregiver. Therefore, children may assume responsibility for aspects of the

treatment regimen prematurely. This rationale is supported in a study by LaGreca,

Follansbee, and Skyler (1990) who found that preadolescents who assume greater

responsibility for diabetes care are usually in poorer glycemic control than their peers

who have more parental support for diabetes responsibilities.

Previous research in the empirical literature has found associations between age

and family variables (Anderson et al., 1990; Anderson et al., 2002; LaGreca et al., 1995),

and age and metabolic control (Johnson, 1995; Johnson et al., 1992; Kovacs et al., 1992).

Given these previous findings, it was surprising that no association was found regarding

the effects of age between family functioning variables and DKA. However, a major

difference between this study and previous research examining the effects of age on

health outcome has examined metabolic control as the dependent variable, while the

health outcome measure in this study was the presence or absence of DKA. This may be

one possibility why a relationship between age, family functioning variables, and health

outcome was not found.

This study is the first to investigate the association between family characteristics

and DKA as a measure of health outcome in children with Type I diabetes. Previous

literature examining family functioning has focused on health outcome as measured by

metabolic control (McKelvey et al., 1993; Steinhausen, 1982). The association between

family functioning and adherence has been well supported in the literature (LaGreca et

al., 1995; Hanson et al., 1987), as has the association between family functioning and









health outcome as measured by metabolic control, or glycosylated hemoglobin

(Stevenson et al., 1991). However, the associations between adherence and health

outcome are mixed, with some studies supporting the association and some studies not

supporting the association. DKA commonly results from chronic poor metabolic control

(Travis, 1985) and individuals experiencing DKA often report more noncompliance with

diabetes treatment than controls without DKA episodes (Morris et al., 1997; Liss et al.,

1998). The current study demonstrates the more direct effect that family functioning has

on the health outcome measure (i.e. DKA) that is related to adherence to the treatment

regimen.

Another strength of the study is the use of diabetes-specific measures and

questionnaires. Researchers have suggested that disease-specific measures of

psychosocial variables are better predictors of adherence than global measures (Shafer et

al., 1983). Similarly, disease-specific measures should serve as better indicators of

characteristics in families including children with chronic illnesses than global measures.

Global measures may not pick up on behaviors in the family unit related to aspects of the

treatment regimen, health outcome, adherence, and the subtle differences in families

including children with chronic illness as compared to families including only healthy

children.

Limitations

This study has several limitations. First, the study design was cross-sectional,

which prevents the researchers from making causal statements regarding the direction of

influence between family variables and health outcome. In fact, family measures were

used to predict past episodes of DKA. However, since family variables have been

previously associated with HbAlc levels, and HbAlc levels have been associated with









DKA, it is probable that family functioning variables would predict DKA. Although the

hypothesis that family functioning characteristics influence a child's adherence and

therefore health outcome has clinical appeal, it is possible that poor health outcome in

children contributes to changes in the family environment. Future investigations with

longitudinal designs assessing family variables and subsequent incidence of DKA would

be beneficial to explain the relationship between family characteristics and health

outcome. Second, the population used in this study is a sample of convenience taken from

a tertiary care center serving a large geographic region. The percentage of individuals

who have experienced a DKA episode in this sample is higher than the national average

due to the tertiary care nature of the setting. Finally, the measures used in this study were

self-report questionnaires. Social desirability may have played a role in participants'

responses and subsequently skewed the results of the study if family members were

overly positive in their report of family characteristics.

Conclusions and Clinical Implications

In conclusion, this study is the first of few studies to explicitly examine family

functioning variables and DKA in children with Type I diabetes. Families with lower

rates of parental warmth and higher rates of parental negativity are associated with higher

occurrence of DKA episodes. Examination of these two variables alone correctly

classifies a child's likelihood of having experienced a DKA episode or not 78% of the

time. Specifically, changes of only one unit in these variables (as measured by diabetes-

specific measures) leads to a significant change in the odds that a child will fall into the

group that has experienced a DKA episode. This is of clinical importance because

families who present to a physician or psychologist with these characteristics could be

targeted for early intervention or additional involvement directed at these specific aspects






27


of warmth, caring, and negativity. This study also suggests the need to develop new

interventions to more intensely address these aspects of the families. Targeting these

family characteristics may improve compliance and metabolic control, and decrease the

probability that the child will experience future diabetes-related complications, such as

DKA.
















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BIOGRAPHICAL SKETCH

Kelly Walker is a native West Virginian who completed a bachelor's degree in

psychology at West Virginia University in May 2002. Following her graduation, she

began her post-graduate work at the University of Florida in August 2002, and plans to

pursue a doctorate in clinical and health psychology following the attainment of her

master's degree.