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FAMILY FUNCTIONING AND DIABETIC KETOACIDOSIS IN PEDIATRIC
PATIENTS WITH TYPE I DIABETES
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
Kelly N. Walker
This document is dedicated to my parents, Arnold and Cheryl Walker.
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
ACKNOW LEDGM ENTS ........................................ iv
LIST OF TABLES ...................... ....... ............ ............. vii
ABSTRACT ........... ................... ......................... viii
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
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
LIST OF REFERENCES ..................................... ............... ....................28
BIOGRAPHICAL SKETCH .................................................. ............... 33
LIST OF TABLES
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
Kelly N. Walker
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.
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
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.,
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
2. Higher parental negativity will be associated with an higher occurrence of DKA
3. Lack of responsibility for diabetes-related tasks will be associated with an higher
occurrence of DKA episodes.
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 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)
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.
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
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.
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
Duration .25* .12
Warmth- -.04 -.35** -.01
No .09 .10 .19 -.02
Parental .13 .37** -.06 -.11 -.17
Incidence of .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
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
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 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
Overall model evaluation
Hosmer & Lemeshow
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
Overall % correct
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
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
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
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
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
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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