Journal of Pediatric Psychology, Vol. 25, No. 1, 2000, pp.

2333

Randomized, Controlled Trial of Behavior

Therapy for Families of Adolescents With InsulinDependent Diabetes Mellitus
Tim Wysocki,1,2 PhD, Michael A. Harris,3 PhD, Peggy Greco,1 PhD, Jeanne Bubb,4 MSW,
Caroline Elder Danda,3 AB, Linda M. Harvey,2 MS, Kelly McDonell,1 BA, Alexandra
Taylor,1 MA, and Neil H. White,3,4 MD, CDE
Nemours Childrens Clinic, 2University of Florida, 3Washington University School of Medicine, and
St. Louis Childrens Hospital

1
4

Objective: To describe the short-term results of a controlled trial of Behavioral Family Systems Therapy
(BFST) for families of adolescents with diabetes.
Methods: We randomized 119 families of adolescents with diabetes to 3 months treatment with either
BFST, an education and support Group (ES), or current therapy (CT). Family relationships, psychological adjustment to diabetes, treatment adherence and diabetic control were assessed at baseline, after 3 months
of treatment (reported here), and 6 and 12 months later.
Results: Compared with CT and ES, BFST yielded more improvement in parent-adolescent relations and
reduced diabetes-specific conflict. Effects on psychological adjustment to diabetes and diabetic control
were less robust and depended on the adolescents age and gender. There were no effects on treatment
adherence.
Conclusions: BFST yielded some improvement in parent-adolescent relationships; its effects on diabetes outcomes depended on the adolescents age and gender. Factors mediating the effectiveness of BFST must be
clarified.
Key words: behavior therapy; family therapy; adolescents; diabetes.

Treatment of insulin-dependent diabetes mellitus

(IDDM) is designed to maintain near-normal blood
glucose levels (DCCT Research Group, 1994). The
regimen includes several daily insulin injections,
self-monitoring of blood glucose, a prescribed meal
plan, regular exercise, and problem-solving tactics
All correspondence should be sent to Tim Wysocki, Nemours Childrens
Clinic, 807 Nira Street, Jacksonville, Florida 32207. E-mail: twysocki
@nemours.org.

q 2000 Society of Pediatric Psychology

to regulate blood glucose. Adaptation to IDDM is

often more difficult during adolescence when family communication and conflict resolution tend to
deteriorate. The treatment burden pervades daily
life, complicating other challenges of adolescence,
and the regimen often becomes the focus of parentadolescent conflict.
Family conflict has been associated with adolescents treatment adherence and diabetic control

24

in cross-sectional studies (Anderson, Miller, Auslander, & Santiago, 1981; Marteau, Bloch, & Baum,
1987). Because similar associations have been found
in longitudinal studies, we may infer that family
conflict may be related causally to poor diabetes
outcomes (Gustafsson, Cederblad, Ludvigsson, &
Lundin, 1987; Hauser et al., 1990). Other studies
point to parent-adolescent conflict specifically as a
correlate of poor diabetes outcomes (Bobrow,
AvRuskin, & Siller, 1985; Miller-Johnson et al.,
1994; Wysocki, 1993). The association between
parent-adolescent relationships and family conflict
may be bi-directional, but it is plausible that a treatment targeting family communication and conflict
resolution could improve adaptation to IDDM,
treatment adherence, and diabetic control. A few
studies support the effectiveness of family therapy
with this population, but none was a wellcontrolled trial of treatments that target parentadolescent communication (Ryden et al., 1994; Snyder, 1987).
Robin and Fosters (1989) behavioral family systems model suggests promising research directions,
portraying parent-adolescent conflict as a product
of the clash between the adolescents need for autonomy and parental needs to maintain stability.
They argue that parent-adolescent conflict is modulated by four factors: family problem-solving skills;
family communication; the degree to which family
members hold extreme beliefs about one another;
and the extent of family structural or systemic
anomalies. They have validated several assessment
tools based on the model (Prinz, 1977; Robin,
Koepke, & Moye, 1990) and behavioral family systems therapy (BFST), an intervention targeting their
central constructs. The model is supported by studies confirming the benefits of BFST and similar therapies (e.g. Barkley, Guevremont, Anastopoulos, &
Fletcher, 1992; Foster, Prinz, & OLeary, 1983; Guerney, Coufal, & Vogelsong, 1981). Since BFST reduces
parent-adolescent conflict, it could help families of
adolescents to cope with IDDM by improving their
communication and conflict resolution skills. Such
improvements could enhance parental social supports for diabetes self-care, reduce overall family
stress and clarify responsibility for diabetes tasks
(Wysocki et al., 1997). This paper compares the
short-term outcomes of three treatments: current
medical therapy alone or augmented by ten sessions
of participation in either BFST or an educational
support group.

Wysocki et al.

Method
Participants
The sampling plan was designed to recruit families
who were appropriate candidates for BFST. The
enrollment criteria were designed to ensure that
parent-adolescent conflict in each family might be
expected to impede management of diabetes. Because we considered severe psychopathology to be
a contraindication for BFST, families with recent
treatment for certain psychiatric diagnoses were excluded. Enrollment was limited to adolescents with
adequately stable family structure to enable completion of the various study requirements.
Adolescents with IDDM and their parents were
recruited in St. Louis, Missouri, or Jacksonville, Florida. Recruitment included an initial confirmation
of eligibility based on demographic factors followed by a screening process to ensure that enrolled
families had at least moderate levels of parentadolescent conflict. Initially, 380 families were contacted about the study and to verify that the adolescent met these criteria: age between 12 years (an age
at which parent-adolescent conflict often increases)
and 16.75 years (to ensure that adolescents lived at
home during the 15-month study); IDDM for at
least 1 year; no other major chronic diseases; no
mental retardation; no incarceration, foster care, or
residential psychiatric treatment; and absence of diagnoses of psychosis, major depression, or substance abuse disorder in parents or adolescents
during the prior 6 months. Families were not asked
to report on psychiatric diagnoses prior to that
point in time. Parents or step-parents living with
the patient were required to participate in the study
and other adult caregivers were allowed to participate. Of the 380 families contacted, 28 did not meet
all of the demographic enrollment criteria. The 174
families who denied interest in the study cited time
constraints (41%), travel distance (17%), minimal
parent-adolescent conflict (33%), and other factors
(9%) as reasons for not participating.
Eligible, interested families (n 5 178) then
signed an approved informed consent form and
completed two screening tools: the Conflict Behavior Questionnaire (CBQ; Prinz, Foster, Kent, &
OLeary, 1979) and the Diabetes Responsibility and
Conflict Scale (DRC; Rubin, Young-Hyman, &
Peyrot, 1989). This was done to limit study enrollment to families reporting parent-adolescent con-

Behavioral Family Therapy in IDDM

flict at levels that could impede family management

of IDDM. In consultation with the authors of these
tools, we identified cutoff scores that were expected
to exclude 60% of families (CBQ . 5; DRC . 24).
Only families in which at least one family member
obtained scores above these cutoffs on one or both
scales were eligible to enroll. Of 132 families exceeding this criterion, 119 (90%) enrolled in the
study. The CBQ was used only for pre-enrollment
screening purposes, while the DRC was also treated
as an outcome measure. Participants included 119
adolescents, 117 female caregivers, and 82 male
caregivers. The 46 families excluded by the screening procedure did not differ demographically from
those who enrolled. The apparent enrollment rate
of 31% (119 of 380 contacted) is artifically low as
the denominator includes families who were ineligible demographically (n 5 28), who failed the conflict screening criterion (n 5 46), or who reported
minimal parent-adolescent conflict as a reason for
refusing to participate (n 5 58). With these families
eliminated from consideration, the enrollment rate
is 52% (119 of 228 families enrolled). No patients
received mental health services from any of the researchers other than those received in this project.
Measures
Participants completed a baseline evaluation and
follow-up evaluations scheduled at posttreatment
(3 months), and at 6 and 12 months after the conclusion of treatment. This article reports only results of the baseline and 3-month (immediate
posttreatment) evaluations. Each evaluation included collection of interview, questionnaire, and
biochemical data; order of administration of instruments was counterbalanced among families. A research assistant administered questionnaires at
evaluation sessions; the research assistant completed telephone interviews during the 2 weeks preceding each of the four evaluations. A detailed
procedural manual promoted equivalence of methods across the two sites. Measures were chosen to
provide varied perspectives of the family processes
targeted by BFST and of the general and diabetesspecific outcomes expected to be affected by
changes in those factors. The following are the specific measures used.
Demographic Factors. Parents reported the patients age, gender, race, duration of IDDM, family
composition, family size, and the information

25

needed for measuring socioeconomic status (SES)

with the Hollingshead Four-Factor Index of Social
Status (Hollingshead, 1975). Tanner stage information was retrieved from each adolescents medical
record. Demographic data were updated at followup evaluations.
General Parent-Adolescent Relationships. The Parent-Adolescent Relationship Questionnaire (PARQ;
Robin et al.,1990) assesses the primary constructs in
the behavioral family systems model. It yields 16
subscales that load on three factors: Overt Conflict/
Skill Deficits; Extreme Beliefs; and Family Structure,
with higher scores indicative of worse family relations. There are separate forms for adolescents (314
items) and parents (280 items), and the normative
group included 314 adolescents and 427 parents.
Internal consistency based on the present sample
ranged from .73 to .89 for the three scales and did
not differ among adolescents, mothers, and fathers.
The Issues Checklist (IC) obtains ratings of the
frequency and intensity of recent conflicts around
44 issues (Prinz et al.,1979). It yields scores for the
number of conflict items endorsed and for conflict
frequency and intensity. Higher scores indicate
more parent-adolescent conflict. Internal consistency based on the present sample was .74 for adolescents, .72 for mothers, and .79 for fathers.
Montemayor and Hansons (1985) telephone recall interview was used to collect participants descriptions of conflict situations that occurred in the
prior day. The topic, participants, intensity, duration, and manner of conflict resolution (negotiation, withdrawal, and authoritarian parental action)
were recorded. Higher scores are less favorable. This
study yielded significant correlations between parents and youths for frequency (r 5 .68), intensity
(r 5 .57), and duration (r 5 .53) of conflict events.
IDDM-Specific Psychological Adjustment. The Teen
Adjustment to Diabetes Scale (TADS) is a 21-item
Likert-type scale with parallel parent and adolescent
forms that measures adolescents behavioral, affective, and attitudinal adjustment to IDDM (Wysocki, 1993). Higher scores indicate more favorable
adjustment to IDDM. Internal consistency, calculated from data obtained from the present sample,
was .81 for adolescents, .87 for mothers, and .88
for fathers.
The DRC (Rubin et al.,1989) assesses parentchild conflict over 15 IDDM tasks. Higher scores indicate more conflict about the diabetes regimen. Internal consistency based on the present sample was

26

.92 for adolescents, .86 for mothers, and .89 for fathers.
IDDM Treatment Adherence. Parents and teens
were interviewed separately during three 2030 min
telephone interviews over 2 weeks to elicit their recall of IDDM self-care during the prior day. The 24Hour Recall Interview (Johnson, 1995) yields reliable and valid scores for five adherence factors: Diet
Composition, Diet Amount, Insulin, Testing and
Eating Frequency, and Exercise. Higher scores indicate worse adherence. Each interview began with
assessment of IDDM treatment adherence and then
of teen-parent conflict using the Montemayor and
Hanson (1985) method.
The 14-item Self-Care Inventory (SCI) validated
by Greco et al. (1990) was used to sample adherence
over a longer interval than is captured by the recall
interviews. Higher scores indicate better treatment
adherence. Internal consistency based on the present sample was .76 for adolescents, .81 for mothers,
and .82 for fathers.
Health Status. At each evaluation, a 3 cc venous
blood sample was collected from each patient for
glycated hemoglobin (GHb) assays to index recent
diabetic control. A regression equation, based on
concurrent measurements on 56 split samples, was
used to enable treatment of all results as if they had
been obtained from one laboratory (i.e., GHbSt. Louis 5
1.007[GHbJacksonville] 2 .032). The normal range for
the assay is about 6%8% and higher values indicate poorer metabolic control.
Parents reported hospitalizations, emergency
room visits, and contacts with other mental health
professionals at the 3-month evaluation. These reports were verified by chart review or contact with
the pertinent health professionals when possible.
The study did not include collection of preenrollment measures of these variables.
Procedure
After the baseline evaluation, the research assistant
at the opposing center randomly assigned each family to one of the three conditions described below.
Randomization was stratified by the adolescents
gender and treatment center so that each center enrolled a similar number of boys and girls into the
three groups.
Current Therapy (CT). Patients in the CT group
(and in the other groups) continued in standard
therapy for IDDM directed by their physicians, including examination by a physician and GHb assay

Wysocki et al.

three or more times annually; two or more daily injections of mixed intermediate and short-acting
insulins; home blood glucose monitoring and recording of test results; IDDM self-management
training; a prescribed diet; physical exercise; and
annual evaluation for long-term diabetic complications.
Education and Support (ES). In the first 12 weeks
of the study, ES families attended 10 group meetings
emphasizing diabetes education and social support.
The meetings were designed to emulate a common
mental health service for families of chronically ill
adolescents and to serve as a best alternative therapy comparison. A masters level social worker
with extensive diabetes experience and a masters
level health educator served as group facilitators.
Panels of two to five families began and completed
a 10-session series together, attended by the parents
and adolescent with diabetes. Session content was
organized around the chapters of the American Diabetes Associations Diabetes Support Groups for Young
Adults: A Facilitators Manual (1990). The same materials and session outlines were used at both sites,
and the two facilitators conferred weekly by telephone to ensure consistency of the intervention.
Family communication and conflict resolution
skills were excluded from session content. Each session included a 45-min educational presentation by
a diabetes professional on one of the 10 topics, followed by 45 minutes of family interaction about
that topic led by the facilitator.
Behavioral Family Systems Therapy (BFST). Adolescents and parents in this group received 10 sessions
of Robin and Fosters (1989) BFST. Sessions were
conducted by one of two licensed psychologists
who each received about 150 hours of training and
supervised BFST experience and were certified as
proficient by Dr. Robin. Extensive efforts ensured
that each psychologists technical proficiency was
maintained throughout the study; every BFST session was audiotaped and rated by either Dr. Robin
or one of the project psychologists, and feedback
from these ratings was provided in weekly conference calls. These ratings verified excellent treatment
fidelity throughout the study. Neither psychologist
demonstrated any consistent or significant departure from prescribed therapy content or delivery. A
detailed therapy manual supplemented the guidelines offered by Robin and Foster (1989) and included session outlines, educational handouts, and
homework assignments used at both sites. BFST
consisted of four therapy components matched to

Behavioral Family Therapy in IDDM

families treatment needs as identified by the project psychologists based on study data and family
interaction in sessions: Problem-solving training provided families with a behavioral contracting approach to conflict resolution with training in
problem definition, generation of alternative solutions, group decision making, planning, implementation and monitoring of the selected solution, and
renegotiation or refinement of ineffective solutions.
Communication skills training included instructions,
feedback, modeling, and rehearsal targeting common parent-adolescent communication problems.
Cognitive restructuring was used to identify and
change family members exaggerated beliefs, attitudes, and attributions that may have impeded
effective parent-adolescent communication and
conflict resolution. Functional and structural family
therapy interventions targeted anomalous family
systemic characteristics (e.g., weak parental coalitions; cross-generational coalitions) that may have
impeded effective problem solving and communication.
Families received an individualized BFST treatment plan designed by the three project psychologists in accord with the results of baseline
assessments and observation of family interactions.
Sessions consisted of family problem-solving discussions and focused on IDDM-specific or general conflictual issues as appropriate for each family. The
psychologist used standard behavior therapy techniques of instructions, feedback, modeling, and rehearsal. Behavioral homework was assigned at each
session and reviewed at the next session. Families
were asked to practice the targeted skills at home
and to apply them to new problems.
Participation Incentives and Intervention
Adherence
To promote adherence to the study requirements,
we paid families $100 ($50 each for the parents and
adolescent) upon completing each evaluation. The
ES and BFST families could earn another $100 if
they completed all 10 treatment sessions. The 3month follow-ups were completed by 115 families
(96%). All 10 treatment sessions were completed by
87% of BFST families and 91% of ES families. Psychological services outside of the study were received by five CT families (22 sessions), three ES
families (21 sessions), and no BFST families. There
were no psychiatric admissions.

27

Data Reduction
To reduce the number of statistical comparisons,
clarify data presentation, and decrease measurement error, we calculated family composite scores
by summing and averaging the scores of individual
family members (e.g. Hanson, Henggeler, & Burghen, 1987). This was justified conceptually since
all family members reported on the same family behaviors and, in each case, there were significant
positive correlations (range .45 to .83) between family members scores. This reduced the number of
univariate tests from 45 to 21, reducing both the
risk of Type I error and variability in some measures.
Our conclusions did not differ when we analyzed
individual family members.

Results
Sampling and Randomization
The sampling plan was designed to enroll families
with parent-adolescent relationship difficulties that
were severe enough to impede family management
of diabetes. With the assay used for this study, a
GHb level of 10% was considered indicative of good
diabetic control. This criterion was exceeded by
73% of the enrolled adolescents, indicating that
most were in poor or fair diabetic control. Mean
scores for normative nondistressed families were exceeded by a substantial percentage of enrolled families on study measures for which these data were
available. The percentage of families in which at
least one family members baseline scores exceeded
the normative mean by one standard deviation or
more were CBQ: 74%; DRC: 64%; PARQ Overt Conflict/Skill Deficits: 27%; PARQ Extreme Beliefs: 21%;
PARQ Family Structure: 29%; and IC Number of
Items Endorsed: 28%. For those measures without
such a normative comparison group, 32% of the
sample had SCI scores below 42, indicative of average adherence below 50% for each of the 14 diabetes management tasks, whereas on the TADS, 29%
of the sample had scores below 63, indicative of
poor emotional or social adjustment to 21 diabetesrelated challenges. A total of 31 families (26%) did
not meet any of these criteria, and these families
were distributed equally among the three groups.
Taken as a whole, these data suggest that the distributions of scores for the study sample were shifted
in the direction of more frequent and severe parent-

28

Wysocki et al.

Table I. Characteristics of Study Participants at Baseline

Age (mean yrs 6 1 SD)

Duration of IDDM (mean yrs 6 1 SD)
Hollingshead index raw score (mean 6 1 SD)
Family size (mean # persons 6 1 SD)
Glycated hemoglobin (mean % 6 1 SD)

CT

BFST

ES

14.3 6 1.4

14.5 6 1.2

14.1 6 1.4

5.2 6 3.8

5.4 6 3.8

4.5 6 3.7

43.9 6 12.9

41.3 6 11.8

44.3 6 11.1

4.2 6 1.5

4.2 6 1.8

4.2 6 1.4

11.8 6 3.1

11.9 6 3.3

11.8 6 2.9

Gender
Male

20 (49%)

15 (39%)

15 (38%)

Female

21 (51%)

23 (61%)

25 (62%)
32 (80%)

Race
Caucasian

32 (78%)

29 (79%)

African American

9 (22%)

9 (21%)

7 (17%)

Hispanic

0 (0%)

0 (0%)

1 (3%)

Tanner stage
Prepubertal (stage I)

0 (0%)

1 (3%)

2 (5%)

Midpubertal (stages II-IV)

21 (51%)

17 (45%)

23 (58%)

Pubertal (stage V)

20 (46%)

20 (52%)

15 (37%)

Living with both biological parents

23 (56%)

15 (39%)

27 (68%)

Living with one biological parent

14 (34%)

17 (45%)

5 (12%)

Living with one biological and one step-parent

3 (7%)

5 (13%)

7 (17%)

Other

1 (3%)

1 (3%)

1 (3%)

Family composition

adolescent conflict and poorer adaptation to diabetes, confirming that a clinically appropriate sample
of families was enrolled.
Table I describes the three groups at baseline
with respect to the adolescents age, duration of
IDDM, gender, race, GHb level, Tanner stage, family
size and composition, and parental socioeconomic
status. Despite careful randomization, the three
treatment groups differed at baseline on several
demographic dimensions. The BFST group included
significantly fewer intact families (Kruskal-Wallis
H 5 7.05; p , .03) and more single-parent families
(Kruskal-Wallis H 5 7.27; p , .03) than did the
other two groups. The divorce rate for the CT group
was significantly lower than that for either the ES
or BFST groups (Kruskal-Wallis H 5 5.47; p , .05).
Table II shows that these demographic differences were accompanied by baseline differences in
several measures, indicating greater conflict and
poorer adaptation to IDDM among BFST families.
Analyses of variance (ANOVA) with treatment
group (degrees of freedom 5 2, 116) as the betweensubjects factor were conducted for family composite
baseline scores on the PARQ, DRC, IC, SCI, TADS,
and Recall Interviews and for GHb values. A significant main effect for groups, in each case indicative of less favorable status for the BFST group
compared with one or both of the other two groups,
was obtained on the following measures: PARQ Skill

Deficits/Overt Conflict scale (F 5 4.43; p , .02), IC

Intensity scale (F 5 3.19; p , .05), DRC (F 5 3.61;
p , .03), TADS (F 5 3.08; p , .05), SCI (F 5 3.29; p ,
.05), Recall Interview Testing/Eating Frequency (F 5
4.03; p , .03) and Diet Amount (F 5 3.71; p , .03)
factors, and Recall Interview scores for duration of
conflict events (F 5 3.15; p , .05). Subsequent analyses were designed to compensate for these pretreatment group differences as described below.
Statistical Analysis Strategy
Initial analyses consisted of repeated measures analyses of variance (MANOVA) and analyses of covariance (ANCOVA) using the baseline values of the
outcome measures as the covariates and with group,
adolescent age, and gender as between-subjects factors. The MANOVA revealed no significant group 3
time interactions for any measure. The ANCOVA
yielded no significant main effects at the 3-month
follow-up when baseline values of the outcome
measures served as covariates.
Pretreatment inequality of the groups may impede discrimination of true treatment effects from
those due to regression toward the mean. With such
baseline differences, interpretation of statistical
analyses may be impeded by strong correlations between the baseline value of a variable and the magnitude of change in that variable (Fleiss, 1986). This

Behavioral Family Therapy in IDDM

Table II.

29

Family Composite Scores and GHb Values (Mean 6 1 SD) for each Group at Baseline and 3-Month Follow-Up
Baseline

Posttreatment

Measures

CT

ES

BFST

CT

ES

BFST

41

40

38

41

39

35

Parent-Adolescent Relationship Questionnairea

Overt Conflict/Skill Deficitsb

51.2 6 3.9

52.8 6 5.4

53.3 6 5.7

51.0 6 5.4

51.4 6 5.6

50.2 6 6.7

Extreme Beliefs

49.6 6 3.4

51.2 6 5.1

51.1 6 4.4

49.4 6 3.9

50.1 6 6.3

46.9 6 5.3

Family Structure

51.7 6 6.6

52.3 6 6.4

51.7 6 5.6

50.8 6 6.4

51.3 6 7.0

49.8 6 6.4

Issues Checklista
No. of items endorsed

15.4 6 4.5

16.9 6 6.0

17.4 6 6.8

13.9 6 5.1

14.0 6 5.0

12.9 6 5.8

Total frequency of conflict

58.7 6 42.3

70.8 6 47.7

94.0 6 133.1

53.2 6 42.9

54.9 6 45.5

42.2 6 38.3

Total intensity of conflictb

31.0 6 13.1

36.5 6 13.9

40.8 6 20.2

29.0 6 16.9

31.9 6 16.3

26.7 6 16.2

Recall Interview conflict scoresa

Frequency

2.1 6 1.9

2.1 6 1.3

2.3 6 1.3

1.7 6 5.9

1.9 6 4.4

2.1 6 4.1

Intensity

1.7 6 1.3

1.7 6 0.7

1.9 6 1.2

1.8 6 3.2

1.3 6 3.1

1.2 6 2.3

8.5 6 9.1

11.0 6 19.3

10.7 6 15.5

Diabetes Responsibility and Conflict Scalea,b

28.6 6 8.3

29.5 6 8.1

32.5 6 9.4

25.5 6 6.5

26.2 6 7.0

24.8 6 7.6

Teen Adjustment to Diabetes Scaleb

72.8 6 10.5

77.0 6 10.2

78.2 6 9.7

77.3 6 9.6

77.0 6 10.7

73.6 6 11.3

Durationb

7.3 6 12.8

7.1 6 22.3

4.6 6 12.2

Recall interview adherence factorsa

Insulin

2.11 6 .39

.09 6 .51

.02 6 .49

2.07 6 .77

2.01 6 .89

.09 6 .79

Testing/eating frequencyb

2.17 6 .78

2.31 6 .58

.52 6 .75

2.01 6 .96

2.27 6 .83

.32 6 .93

Diet composition

2.14 6 .37

.10 6 .89

.04 6 .46

2.12 6 .76

2.11 6 .76

.26 6 .81

Diet amountb

2.22 6 .91

2.09 6 .97

.32 6 .87

.23 6 .94

2.03 6 .74

2.21 6 .58

.15 6 .83

.12 6 .78

2.29 6 .58

2.05 6 .45

.02 6 .51

.03 6 .82

Self-Care Inventoryb

51.1 6 6.6

49.4 6 7.7

46.7 6 9.3

49.7 6 6.8

49.5 6 7.6

47.5 6 8.7

Glycated hemoglobina (%)

11.8 6 3.1

11.8 6 2.9

11.9 6 3.3

11.7 6 3.2

11.6 6 2.5

12.3 6 2.9

Exercise

Higher scores are less favorable for these measures. For all others, lower scores are less favorable.
A significant ANOVA main effect for groups was obtained at baseline.

a
b

problem can be countered by treating baseline

scores as covariates (Llabre, Spitzer, Saab, Ironson, &
Schneiderman, 1991). Hence, ANCOVAs for posttreatment change in each primary outcome measure were completed, using the baseline value of the
outcome measure as a covariate. This approach controlled statistically for the baseline differences
between groups, reducing the influence of correlations between baseline status and change scores.
Because inspection of the data showed differences
as a function of the age and gender of the adolescent, all analyses treated the youths age group
(older [. 14.3 yrs] versus younger [, 14.3 yrs] based
on a median split in order to equate sample size)
and gender as additional between-subjects factors.
Table II shows the mean (6 1 SD) family composite
scores on each measure at baseline and 3-month
follow-up.
Measures of General Parent-Adolescent
Relationships
The ANCOVA revealed a significant main effect for
groups on mean change from baseline to posttreatment in family composite scores on the PARQ Overt

Conflict and Skill Deficits scale, F(2, 103) 5 2.98,

p 5 .050, and the Extreme Beliefs scale, F(2, 103) 5
5.45, p 5 .006, but no significant difference between
groups on the Family Structure scale. Post-hoc analyses using the Scheffe test showed that the BFST
group improved more on the Overt Conflict/Skill
Deficits scale than the CT, but not the ES, group.
On the Extreme Beliefs scale, the BFST group had
significantly greater improvement than either the
CT or ES groups. Neither the group 3 age, group 3
gender, nor group 3 age 3 gender interaction effects were significant for any of the three PARQ factor scores.
The ANCOVA revealed a significant main effect
for groups on change in the IC scores for number
of items endorsed, F(2, 103) 5 4.75, p 5.011, and
conflict intensity, F(2, 103 5 3.99, p 5 .022, but no
effect on conflict frequency, possibly due to excessive variability in that measure. Post-hoc analyses
confirmed greater reduction in number of items and
conflict intensity for BFST families than for either
CT or ES families. No age or gender interaction effects were significant for any IC score. No group or
interaction effects were significant for family conflict reported during recall interviews.

30

Wysocki et al.

Table III. Illustration of Significant Group by Age and Group by Age by Gender Interaction Effects on Baseline to PostTreatment Change
in Glycated Hemoglobin (GHb) Assays and Family Composite Scores on the Teen Adjustment to Diabetes Scale (TADS)
Group
CT

Age group
Younger
Older

ES

Younger

Gender

GHb changea

BFST

Younger
Older

TADS changeb

SD

1.23

.34

3.21

2.53

.56

21.36

.61

.06

.63

21.14

2.37

2.63

1.19

22.83

2.51

2.69

.65

.33

2.43

.86

.37

.11

1.82

2.05

.39

24.13

2.65

F
Older

SD

1.73

2.10

.57

4.79

2.08

2.60

.68

21.22

1.96

21.40

1.12

.73

2.13

2.54

1.16

6.03

1.91

2.19

.77

23.13

1.88

Lower scores are favorable.

Higher scores are favorable.

a
b

IDDM-Specific Psychological Adjustment

The ANCOVA revealed a significant main effect for
groups on change in DRC family composite scores
favoring the BFST group, F(2, 103) 5 3.08, p 5 .049,
indicative of decreased IDDM-specific conflict.
There were no significant age or gender interactions.
The ANCOVA analysis of change in family composite scores on the TADS revealed no significant
main effects for groups, but significant group 3
gender, F(2, 103) 5 3.35, p 5 .039, and group 3 age
3 gender, F(2, 103) 5 3.18, p 5 .046, interaction
effects were obtained, as shown in Table III. Older
boys showed improved adjustment to IDDM (e.g.,
higher TADS scores) after treatment with BFST and
worse adjustment following treatment with ES,
whereas older girls demonstrated the opposite treatment effects.

tained. Older adolescents in the BFST group demonstrated a mean increase in GHb of 1.51%, whereas
younger adolescents displayed a .89% decrease, indicative of improved metabolic control. The significant group 3 age 3 gender interaction effect is
presented in Table III, which shows that, among
BFST participants, older girls demonstrated a 2.19%
increase in GHb, while substantial decreases occurred for younger girls (21.40%) and moderate decreases were found for both younger (2.60%) and
older (2.54%) boys. A variety of analyses designed
to explore pretreatment differences between older
girls and other participants failed to reveal any
meaningful differences that might have mediated
these significant group 3 age 3 gender interactions.
There were no significant effects on the low frequencies of hospital admissions (2) or emergency
room visits (5) reported at the 3-month follow-up
evaluation.

IDDM Treatment Adherence

Discussion
No significant main or interaction effects were obtained for either the SCI family composite score or
the five factor scores obtained with the 24-Hour Recall Interview.
Health Status Measures
The ANCOVA revealed no significant main effects
for groups on baseline to 3-month change in GHb
levels. However, significant group 3 age, F(2, 103) 5
3.34, p 5 .041, and group 3 gender 3 age, F(2,
103) 5 3.72, p 5 .028, interaction effects were ob-

This article compares the short-term benefits of

BFST compared with continued current medical
therapy or participation in a diabetes support group
with a large, clinically relevant sample of families of
adolescents with diabetes. The average GHb level of
the study patients indicated very poor diabetic control, and the sample had generally unfavorable status on a variety of measures of parent-adolescent
relationships and adaptation to diabetes. This study
advances the methodology of previous trials of psychological treatments for families of youths with

Behavioral Family Therapy in IDDM

IDDM (Rubin & Peyrot, 1992) by using multiple

well-validated outcome measures and two appropriate comparison groups. In addition to these important features, the study goals went beyond those
of conventional treatment outcome studies by attempting to show that change in a clinically relevant
process (parent-adolescent relationships) yielded
changes in disease-related functioning and health
status.
Despite careful randomization, the three groups
differed at baseline along many clinically meaningful dimensions, impeding the confirmation of clear
treatment effects. Conventional MANOVA and
ANCOVA methods did not confirm treatment benefits for BFST; ANCOVA treating the baseline values
of the outcome measures as covariates enabled statistical control of these pretreatment differences.
These analyses revealed significant between-group
effects favoring BFST in terms of changes in several
family composite scores on the PARQ, IC, and DRC,
suggesting that BFST yielded some improvements
in parent-adolescent relationships. Change in
diabetes-specific outcomes such as GHb and TADS
scores was less robust and depended on the age and
gender of the adolescent. Older adolescent girls
tended to deteriorate along these dimensions after
BFST, whereas boys and younger girls derived benefits. There were no main or interaction effects obtained on measures of treatment adherence or
parent-adolescent conflict derived from recall interviews.
Given the analytic problems inherent in evaluation of change scores, particularly with substantial
group differences at baseline, the results of the
ANCOVA analyses should be interpreted very cautiously. Although treatment of the baseline outcome measures enabled some degree of statistical
control over these complications, the groups may
have differed qualitatively despite this statistical
manipulation. This report offers only suggestive evidence in support of the use of BFST with this population. The failure of the present randomization
illustrates the importance of stratification based on
key outcome variables in order to increase the probability of pretreatment equivalence of the groups.
This study expands the research literature on
psychological interventions for this population.
Previous studies supporting the efficacy of family
therapy for youths with IDDM (Ryden et al., 1994;
Snyder, 1987) lacked the large sample size, comparison groups, and multimodal assessment methods
used in this study. The Diabetes Control and Com-

31

plications Trial (DCCT Research Group, 1994)

showed that long-term maintenance of nearnormal blood glucose levels reduces the onset and
progression of diabetic complications by 50%-75%.
Those results were achieved with intensified use of
available medical tools, suggesting that translation
of the DCCT findings into clinical practice may depend on the validation of interventions for promoting adaptation to this more demanding treatment.
This study suggests some promise for BFST in
this regard, and the results suggest avenues for
further research to increase the impact of BFST on
diabetes outcomes. Targeting families of younger
adolescents with BFST to prevent, rather than remedy, family conflict around IDDM may be more effective. Others have also reported greater effectiveness of behavioral interventions among younger, or
more recently diagnosed, children with IDDM (Delamater et al., 1990; Kaplan, Chadwick, & Schimmel, 1985). Further, the realization of benefits in
important diabetes outcomes may require BFST sessions targeted specifically at each familys unique
barriers to adequate treatment adherence and diabetic control. Clearly, giving families general skills
that improve parent-adolescent relationships does
not guarantee that those skills will be applied to enhance family coping with diabetes. Other possibilities for improving the diabetes-specific impact of
BFST might include integrating it with other effective intervention strategies such as multifamily support groups (Satin, LaGreca, Zigo, & Skyler, 1989),
training in use of blood glucose data for diabetes
problem solving (Anderson, Wolf, Burkhart, Cornell, & Bacon, 1989; Delamater et al., 1990), employing a longer duration of intervention (Delamater et al., 1990), and implementing regularly
occurring booster sessions (Foster et al., 1983).
Our findings provide reason for optimism that further research on BFST can yield a disseminable and
broadly applicable intervention that can improve
family adaptation to IDDM.

Acknowledgments
This work was supported by grant 1-RO1-DK43802
Behavior Therapy for Families of Diabetic Adolescents awarded by the National Institutes of Health
(National Institute of Diabetes, Digestive and Kidney Diseases) to the first author and by the Pediatric
and General Clinical Research Centers of Washington University (RR06021 and RR00036). We thank

32

the following physicians and their respective clinic

staffs for their assistance in recruiting families for
this study: Thomas Aceto, George Bright, Dominique Darmaun, Myrto Frangos, John Galgani, Luigi Garibaldi, Santosh Gupta, Morey Haymond,
Nelly Mauras, Robert Miller, and Patricia Wolff. We
also thank Arthur L. Robin, PhD, and Diana
Guthrie, PhD, for their consultation in intervention
design and evaluation. A detailed BFST Treatment

Wysocki et al.

Implementation Manual can be obtained by sending a $20 check or money order payable to the
Nemours Childrens Clinic to Tim Wysocki, PhD,
Nemours Childrens Clinic, 807 Nira Street, Jacksonville, FL 32207.
Received September 2, 1997; revisions received February
24, 1998, July 23, 1998, and December 13, 1998; accepted December 29, 1998

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