Psychosocial correlates of glycemic control as a function of age in youth with insulin-dependent diabetes

J O U R N A L OF A D O L E S C E N T H E A L T H CARE 1986;7:311-319

Psychosocial Correlates of Glycemic Control as a Function of Age in Youth with Insulin-dependent Diabetes KENTON L. BURNS~ PH.D.I PHYLLIS GREENI B.A., AND H. PETER CHASEr M.D.

Research into the psychosocial correlates of glycemic control in youth with insulin-dependent diabetes has been variable in outcome. The present study tested the hypothesis that psychosocial correlates will vary with the individual's developmental stage. Psychosocial measures completed by or about youth, parents, and family were regressed against glycosylated hemoglobin (Ghb), an index of glycemic control. Correlation sets based on age (810,11-13, and 14-16 years) were tested for overall significance. One of the three sets originating from youth and one of six from parents attained setwise significance, allowing interpretation of individually significant coefficients. Relationships within these sets provided limited confirmation of the initial proposition. Health locus of control beliefs in 8-10 year olds, and parental continuity and consistency of expectations and affirmations of structure and organization within the 11-13-year-old group, were salient correlates of Ghb, suggesting a potential focus for preventive/supportive family assistance. KEY WORDS:

Psychosocial correlates Age of youth Glycemic control Insulin-dependent diabetes There is increasing interest in the interrelationships between psychosocial factors and health behavior among children and adolescents. For young persons coping with a chronic disease particular behavioral and psychosocial factors may make a critical difference between adequate and dysfunctional health maintenance. A good example is insulin-dependent diabetes, where adequate daily metabolic and longterm health maintenance requires vigilance, selfFrom the Barbara Davis Centerfor Childhood Diabetes, University of Colorado Health Sciences Center, Denver, Colorado. Address reprint requests to: Dr. Kenton L. Burns, Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, B-140, Denver, CO 80262. Manuscript accepted September 12, 1985.

monitoring, and daily health-care behavior. The adequacy of this behavior may to a significant degree depend on prior and concurrent psychosocial factors such as patterns of parental guidance and coping, cooperation, and interactive patterns within the family (1-5). Patterns of psychosocial relationships with glycemic control within diabetic persons has been a recent area of inquiry. For adults results have been fairly consistent: better and improved glycemic control are associated with better and improved indexes of quality of life and personal adjustment (6-9). Among children and youth who have diabetes, however, findings have been inconsistent. Although some studies have reported a relationship between psychosocial variables and the level of glycemic control (2, 10), others studies have reported few or no relationships (3, 11-13). The thesis of our study is that psychosocial relationships to health-care outcomes among youth, i.e., glycemic control in youth with insulin-dependent diabetes, will to a significant degree depend on the individual's age and developmental stage. That is, the multiple developmental changes occurring across age (physical, behavioral, psychosocial) should be reflected in changing patterns of the patient's psychosocial relationships with glycemic control. Discrepancies in previous research may in part be the result of lumping together or confounding age-related differences.

Methods Subjects and Procedures

The present analysis tests the central proposition given above by assessing relationships within three critical age periods: late childhood (age 8-10 years), early adolescence (age 11-13 years) and middle adolescence (age 14-16 years). Fast-paced internal (psy-

© Society for Adolescent Medicine, 1986 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017

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chologic and physiologic) and external (social, transactional) developmental change (14) occurs during these periods and age-based differences in relation to glycemic control may be distinct. Specifically, baseline (pretreatment) data from within a larger study of the effects of a series of workshops for children with insulin-dependent diabetes and their families (results in preparation) were aggregated according to age. These data were a number of psychosocial measures provided by youth and their parents, the content reflecting a range of personal, family, and behavioral variables (Tables 2 and 3). The hypothesis of age-based differences in psychosocial relations to glycemic control was tested by separately analyzing relationships within the three age brackets and contrasting the patterns. Age-based relations that attained significance as a whole and differed from patterns identified in other age groups would support the hypothesis. In contrast to previous studies that have mostly used cut scores defining "good" and "poor" glycemic control, the present study used correlation and linear regression analysis, which used information from the entire distribution of the glycemic control index. Data were obtained from families who accepted an invitation to participate in either a workshop or the control condition of the larger study. Invitation to either was by random selection from a large diabetes clinic. Both groups shared the common attribute of having volunteered for an extensive set of activities (workshops and/or series of measures over time) and, because the invitation acceptance rate was 30%, it was a self-select sample. In light of the low acceptance rate it was important to determine whether the study sample differed from the clinic population along important dimensions. Table I compares characteristics of the study sample with the metropolitan Denver patient population of the university clinic from which the sample was drawn. The study sample compares remarkably well with general population characteristics, with a slight bias toward twoparent Anglo families. Only within the age group 11-13 years does glycosylated hemoglobin (Ghb) % differ appreciably, the mean (study sample 11.1 versus population 12.3) and range for the study sample reflecting modestly better glycemic control. Present study results may thus generalize to primarily Anglo, two-parent, urban clinic family samples, although caution should be used because of unknown volunteer selective influences. At an initial appointment participant families t

Table 1. Characteristics of Study Participants Compared with Metropolitan Clinic Population Age (yr)

Study Sample

Clinic Population

age (yr) SD Female Male )f Ghb (%) SD, range )( durationa SD, range Anglo Black Hispanic Unknown/other Single parent Two parents

9.25 0.68 7 (47%) 8 (53%) 11.9 1.60, 9.5-14.6 44.5 19.77, 12-77 14 (93%) 0 1 (7%) 0 3 (20%) 12 (80%)

9.39 0.81 21 (43%) 28 (57%) 11.5 1.91, 7.4-14.7 44.52 33.33, 2-129 35 (71%) 4 (8%) 3 (6%) 7/0 17 (35%) 32 (65%)

11-13 age (yr) SD Female Male Ghb (%) SD, range Durationa SD, range Anglo Black Hispanic Unknown/other Single parent Two parents

11.81 0.93 12 (57%) 9 (43%) 11.1 2.03, 7.5-14.9 64.3 38.9, 21-159 21 (100%) 0 0 , 0 5 (24%) 16 (76%)

12.15 0.81 53 (51%) 50 (49%) 12.29 2.11, 8.6-17.8 55.31 39.91, 2-162 82 (80%) 2 (2%) 8 (8%) 10/0 29 (28%) 74 (72%)

14-16 9( age (yr) SD Female Male )( Ghb (%) SD, range Durationa SD, range Anglo Black Hispanic Unknown/other Single parent Two parents

14.94 0.80 14.(39%) 22 (61%) 12.58 2.42, 5.7-16.9 67.2 47.3, 13-170 31 (86%) 1 (3%) 3 (8%) 0 9 (25%) 27 (75%)

15.21 0.86 39 (55%) 74 (45%) 12.92 2.64, 7.3-22.8 79.39 47.01, 6-205 128 (79%) 7 (4%) 13 (8%) 13/2 60 (37%) 103 (63%)

8-10

Home location b

Urban = 70; rural = 2

Urban = 315; rural = 0

Abbreviations: Ghb = glycosylated hemoglobin; SD = standard

deviation. aDuration of diabetes in months. bUrban criterion: Residence within Denver metropolitan area or front range city.

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T a b l e 2. Y o u t h P s y c h o s o c i a l M e a s u r e s : C o r r e l a t i o n s w i t h G l y c o s y l a t e d H e m o g l o b i n ( P a r t i a l l i n g A g e of C h i l d ) Age-Based Correlation with Glycosylated Hemoglobin Measure Multidimensional Health Locus of Control Scale (15) Chance Powerful Others Internal Total Diabetes Knowledge Test~ Adjustment Scale (16) Peer Family School Attitude Toward Diabetes and Body Dependence-independence Total adjustment score Self-Esteem Inventory (17) General Self Social Self-Peers Home-Parents School-Academic Total Achenbach Child Behavior Checklist (18) Mo-rated Social Summary Mo-rated Behaviorial Summary Mo-rated N u m b e r Behavior Problems Fa-rated Social Summary Fa-rated Behavioral Summary Fa-rated N u m b e r Behavior Problems Perceived Competence Scale (19) Cognifive Social Physical General Interview Well-being School Future Diabetic m a n a g e m e n t Competence-Adherence Health Medical caregiver Relations Total

8-10 yr ~ (n = 15)

11-13 yr b (n = 21)

14-16 yr (n = 36)

8-16 yr (n = 72)

-0.36 0.01 0.71 a -0.26 0.26

0.35 -0.32 0.42 -0.24 -0.04

-0.15 -0.12 0.20 -0.19 0.06

-0.07 -0.23 0.33`/ -0.26 c 0.06

0.52 0.54 0.48 0.74a 0.31 0.66 c

-0.17 0.35 0.10 - 0.15 0.05 0.01

-0.17 0.15 0.19 0.10 - 0.02 0.09

-0.06 0.23 0.22 0.15 0.06 0.16

0.07 0.02 -0.40 c - 0.13 -0.11

0.14 0.21 -0.29 c -0.01 0.01

----~

0.51¢ 0.61 d 0.21 0.55 c 0.54c

0.13 0.18

-0.19 -0.03

-0.13 0.31

0.09 0.20

0.19 0.21 0.24

0.03 0.31 -0.25

0.32 -0.36 -0.01

0.23 -0.15 -0.06

0.25

-0.17

-0.01

-0.03

-0.48 -0.41 0.24 -0.32

0.11 -0.21 0.05 O. 19

-----

0.01 -0.26 0.24 0.19

0.25 0.28 0.16

0.16 0.20 -0.03

0.22 0.19 -0.06

0.43 0.27

0.18 0.03

0.42 c 0.01

0.34 d 0.06

-0.38 0.36

0.34 0.21

0.32 0.28

0.24 c 0.28 c

0.18 0.26 c -0.02

aSet significant at p < 0.05. bSet significant at p < 0.10. cTwo-tailed p < 0.05. `/Two-tailed p < 0.01. ¢Available from Suzanne B. Johnson Ph.D., Department of Clinical Psychology and Pediatrics, University of Florida.

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Table 3. P a r e n t Psychosocial M e a s u r e s : A g e - B a s e d Correlations W i t h G l y c o s y l a t e d H e m o g l o b i n (Partialling A g e of Child) Age-Based Correlation With Glycosylated Hemoglobin 8-10 yr Measure Diabetes Knowledge Testc Multidimensional Health Locus of Control Scale(15) Chance Powerful Others Internal Total Depression Scale(20) Anxiety Scale(21) Apprehension Tension Low Self-Control Emotional Instability Suspicion Total Family Environment Scale(22) Cohesion Expressiveness Conflict Independence Achievement Orientation Intellectual-Cultural Orientation Active-Recreational Orientation Moral-Religious Emphasis Organization Control Morale Scale(23) Positive Feelings Negative Feelings Hassles Scale(24) Frequency Total Childrens Report of Parental Behavior Inventory(25) Factor 1 (Acceptance-Rejection) Factor 2 (Control) Factor 3 (Lax-Firm Discipline) Interview Development Family Health School Future Competency Medical Caregiver Relations Total

11-13 yr

14-16 yr

Mother (n = 15)

Father (n = 12)

Mother a (n = 21)

Father (n = 12)

Mother (n = 35)

-0.55 b

-0.54

0.37

-0.02

0.07

0,24

-0.28 -0.39 0.10 -0.39 0.15

0.36 -0.69 b -0.39 -0.37 0.22

0.28 0.12 -0.41 0.09 -0.48 b

-0.11 -0.15 -0.07 -0.16 0.28

-0.14 0.24 0.10 0.03 -0.08

0.12 0.22 -0,9 0.15 -0.22

0.29 0.15 -0.41 0.32 -0.12 0.10

0.06 0.03 0.28 0.23 -0.15 0.09

-0.17 -0.27 -0.35 -0.39 -0.03 -0.29

0.00 -0.09 -0.10 0.04 0.15 -0.03

-0.22 0.04 0.03 0.09 0.12 0.02

-0.03 -0.01 0.20 0.22 0.49 -0.03 0.28 0.14 0.07 0.33

-0.56 -0.06 0.44 -0.10 0.23 -0.22 0.18 -0.16 -0.30 0.15

-0.02 0.39 -0.10 0.27 -0.14 0,21 0.02 -0.43 -0.43 -0.53 b

0.36 0.25 0.04 0.10 -0.08 0.08 0.19 -0.14 0.57 0.08

-0.10 -0.09 0.19 0.19 0.08 -0.17 0.01 -0.36 b -0.13 -0.22

0.06 0.05 -0.16 -0.06 0.08 -0.07 0.17 -0.30 0.10 -0.04

-0.04 0.34

0.31 -0.40

-0.33 0.28

-0.06 -0.26

-0.18 -0.17

-0.12 -0.40

0.21 0.20

0.33 0.39

0.16 0.17

-0.09 -0.15

-0.05 -0.06

-0.22 -0.24

0.47 -0.31 0.49 b

0.39 -0.39 0.06

-0.19 0.03 -0.03

-0.20 0.22 -0.10

m

0.33 0.17 -0.15 -0.18 0.42 0.17 0.19 0.40

0.65 b 0.26 0.41 0.32 0.20 0.41

0,05 0,03 0,30 -0.04 0.05 0.55 b 0.02 0.21

Father (n = 24)

0.11 -0.08 0.17 0.10 0.26 0.11 0.23 0.17

aSet significant at p < 0.01. bTwo-tailed p < 0.05. cAvailable from Suzanne B. Johnson Ph.D., Department of Clinical Psychology and Pediatrics, University of Florida.

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were informed of the activities for which they were volunteering, and all signed informed consent. Volunteering for an d the expectation of different particiPant activity may have biased responses in un.known ways but such effects would probably be weak in an analysis of the combined sample. Each participant completed a set of paper and pencil measures and an interview. In addition blood was drawn to determine the Ghb level, an established moderate-term index of glycemic control. Occasionally the determination from a previous blood draw was used if it had been obtained in the clinic within the prior three weeks. The Isolab Fast Hemoglobin Test System (26) was used to determine total HbA i (HbAla + H b A l b + HbAlc). In addition, an aldimine eliminator was used to remove the labile glycohemoglobin fraction. Parents and children completed measures at the same time in separate, Semiprivate locations with essentially uniform circumstances for all participants. Genera ! instructions were delivered verbally. In addition, individual instructions for each measure were printed at the beginning of each form. Comprehension of instructions, especially for younger participants, was assessed by the proctor who remained available for questions related to understanding the materials.

Psychosocial Measures The measures used (Tables 2 and 3) were selected to provide information in the content areas relevant to the purposes of the larger study: 1) psychological adjustment, e.g., anxiety, depressioni 2) self-evaluative and personal orientation, e.g., self-esteem and health locus of control; 3) child behavior assessed by parent and child-perceived parent behavior; 4) family environment; and 5) knowledge Of diabetes. A structured interview was designe d to elicit information about the patient's adjustment in several life areas. Selected items were given a scaled rating by the youth and parents in separate interviews. All measures were relevant to a broad-spectrum analysis of family and individual variable relations to glycemic control although some measures did not completely overlap all three age groups. The majority of measures were standardized and normed instruments although a few select research measures were chosen for theoretical relevance to study issues.

Data Storage and Statistical Methods Data were stored in computer data files and analyzed using the Statistical Package for the Social Sciences

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(27). Analyses were as follows: 1) correlations (partialing age of patient) of measures and interview'area summary scores with the diabetes-control index, Ghb; 2) tests of age-based sets of correlations using the omnibus test of the null hypothesis (28); 3) examination of individuallY significant correlation coefficients within sets attaining overall significance levels exceeding chance (p<0.05); 4) exploration of selected covariance relationships within Sets using multiple regression analys!s.

Results Age-based sets of psychosocial variables reported by youth and parents (Tables 2 and 3) were regressed against Ghb and tested for setwise significance. Three measures administered to youth within only one age period were excluded from setwise and subsequent analyses. Also, total score variables were removed from data sets to avoid inflation of significance due to intrascale redundance. Sets that attained sign!ficance as a whole and in which correlation patterns differed from other sets across age within the class (parents or youth) offer support for the initial proposition. Conversely, setw!se nonsignificance precludes interpretation of individual Coefficients even though they may attain individual significance (28).

Data Reported By and About Youths Three age-based correlation sets (youth aged 8-10, !1-13, and 14-16 years) for data provided by and about youths were tested for setwise correlation with Ghb%. A set of 28 correlations for 15 youths aged 810 Years reached significance (p<0.01, Table 2). Individual coefficients attaining significance at p<0.05 included the Internal Locus of Control subscale of the Multidimensional Health Locus of Control Scale (15) (r= 0,71, p=0.004)and two scales Of the Diabetes Adjustment Scale (16): Diabetes Attitudes an d BodY Image Concerns (r=0.74, p=0.004) and Total Adjustment Score (r=0.66, p=0.018). Thus, the degree to which patients ascribed their health to circumstances within their Control was associated with higher Ghb (poorer glycemic control). The Ghb was also positively associated with the expression of attitudes reflective of poorer adjustment, especially in relation to body image and diabetes and its care (16). Although a set of 34 correlations computed from the data provided by 21 youth aged 11-13 years

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failed to attain setwise significance (0.05~p~0.10), four moderately high positive correlations within the subscales of the Self-Esteem Inventory (17) (General, Social, School, Total) were found and need to be rep licated through cross-validation on a new sample because self-esteem issues usually come into focus at this age. If replicable, the coefficients would suggest that conditions associated with maintaining better glycemic control (lower Ghb) in this age group may be associated with less positively expressed selfesteem. Although several individual correlations attained significance within the set of 24 Correlations for youth aged 14-16 years, the set as a whole failed to attain significance (p>0.05): A fourth correlation set, data from all youth across age, is of interest although not critical to our central hypothesis. This set attained setwise significance at p~0.001. For youth across age, interview self-reported difficulties with diabetes management/adherence, school, and medical caregivers were weakly associated with a higher level of Ghb. In a multiple regression equation simultaneously entering all three of the above variables, 0nly diabetes adherence/management retained independent significance (nonzero beta weight), although its beta weight dropped with hierarchic addition of the other variables to attain the final equation. Thus, although rated adherence to the diabetes regimen is indePe ndently predictive of Ghb, it may also mediate the school and caregiver Ghb relationships. Equally plausible is the hypothesis that less functional relations in all three interview Variables could be mediated by or be reciprocally related to poorer g!ycemic control, or all variables may be associated with a more general behavioral dysfunction factor. (The number Ofbehavior problems indicated by the mother on the Achenbach Child Behavior Checklist in fact correlated with Ghb at a significance level closely approaching acceptance, r-0.23, p=O.055.) Notwithstanding the Varied possibilities, the data suggest, not surprisingly, that poorer glyCemic control in diabetic youth may be associated with dysfunction in other life relationships. For youth across age the Internal and Total scales of the Multidimensional Health Locus of Control Scale also suggested an association of "internal" locus with poorer diabetes control (higher Ghb). Data Reported By and About Parents Six age-based correlation sets, parallel to those reported above, were tested for significance. Among

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three sets each for mother and father, one, mother of youth 11-13 years attained setwise significance (p<0.01). A number of individually significant correlations among nonsignificant sets are shown in Table 3. These correlations are also candidates for cross-validation on a new sample. Within the significant set for mothers of children 11-13 years three individual correlations were significant at the pK0.05 level. Of particular interest are Ghb relations to the perceptions of youth about parental behavior. Information from the 18 subscales of the Child's Report of Parental Behavior (25) were, prior to regression analysis, reduced by deriving factor scores for each patien t for each of the three factors originally reported for the instrument. This distilled the information into broad dimensions of theoretical relevance to the evaluations of parent behavior by children and adolescents (29). For mothers of children aged 11-13 years, Factor 3, Lax-Firm Discipline (higher score reflecting greater laxity) correlated positively with Ghb (r=0.49, ]?=0.046). Factor 1, Acceptance-Rejection, attained a correlation at slightly greater than the accepted significance level (r=0.47, p=0.057). In addition, the mothers' affirmation of the importance of set rules and procedures (Family Environment Scale, subscale Control) correlated negatively with the Ghb level (r = -0.53, p=0.016). This finding suggests that within this age group a mother's consistent direction and guidance may be associated with a greater degree of diabetes contro!. Thisrelationship, manifest within the early adolescent period, is of interest because this age grouping is a time of increasing independence for youth as well as a time when parents occasionally express doubts about their "effectiveness" as parents. That this relationship is generally attained through effective combinations Of guidance and structure is also reflected in the lack of relationship of Ghb with Factor 2, C0ntrol-Autonomy. Research has suggested (14, 30-31 ) that high scores along this dimension may reflect inordinate, counterProductive levels of parental control. The final individually significant correlation for mothers within this ag e group does suggest some "cost" in helping to maintain the vigilance and regime required for better diabetes control. Mothers' report of depressive symptoms correlated moderately and negatively with the Ghb levels (Depression Scale, r=-0.48, p=0.034). Five ancillary correlation sets of interest, but again not critical to the central hypothesis, were also tested: two across age by parent and three within age, parent combined. One set attained significance, i.e.,

September1986

data from parents combined of youth aged 11-13 years (p~0.01). Four variables in addition to those discussed above for mother alone (children aged 1113) were individually significant within this set. Factor 1, Acceptance-Rejection, from the Child's Report of Parental Behavior correlated positively with the Ghb level (r=0.40, p=0.028) as did the parent;s rating of youths' competence/adherence i n managing diabetes (r=0.55, p=0.012). The association of Factor 1 suggests that children in better glycemic control perceive parent's "acceptance" as delimited, possibly reflecting a level of parental expectation consistent with careful diabetes control. A significant negative correlation of Ghb with Family Environment, subscale Organization (r=-0.43, p=0.012) , emphasizes the contribution of a parentally affirmed family stru cture and organization to attaining diabetes control. Finally, the Anxiety subscale, Emotional instability, correlated negatively with the Ghb level (r = ' 0 . 3 8 , p=0.034), again suggesting some parental "cost" in helping adolescents maintain better diabetes control. This subscale reportedly reflects, among other things, some dissatisfaction with "the restrictions of life" and doubts about one's ability to cope (21).

Discussion Support for the central hypothesis of age-based differences of psychosocial relationships to diabetes control in our analysis is limite& Of six hypothesisrelevant correlation sets four were not statistically significant. Casting a broad net in an exploratory analysis has limitations. Using the omnibus test of the null hypothesis, a s the number of variables in a set is increased, power to detect significant Covariance in a limited subject sample is decreased. In addition, our sample :sizes varied across sets. Nonetheless some strong statistica! relationships appeared even within a subject sample as small as that for children 8-10 years of ag e . Relationships within sets attaining statistical significance do suggest some distinct characteristics within age periods. For children 8-10 years an "internal" health locus orientation is associated with poorer diabetes control, a significant association also seen within data from all ages combined. This somewhat counterintuitive finding has also been reported for a young adult diabetic sample (32). A potential interpretation offered in that study was that persons of a strongly internal health orientation, in exercising their predilection for tight diabetes management, may have experienced diabetes control as unpredict2

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able (efforts to control as futile) and therefore gave up close management practices. One alternative possibility is that persons of strongly internal orientation somehow also "screen out" expert external guidance, information, and feedback, which are also potentially important elements in diabetes self-care. Patients with poorer control within this age group also expressed attitudes toward their bodies, diabetes, and its care that were judged to suggest less welladjusted behavior (16). This fact could be an antecedent or, alternatively , a consequence to less adequate self-care and/or experienced control. Early adolescence is typically a time of increasing autonomy, exploration, and change. In this period within the present analysis relationships to diabetes control appear in variables related to the mother's style and consistency of guidance. These findings, and the data from parents combined, suggest that parents (mothers especially) who value and affirm structure, organization, and set procedures in family life, and who are consistent in their expectations, assist their offspring in the maintenance of better diabetes control. Persistence and Consistency in maintaining such guidance and structure may become more critical to diabetes control within this age period (during a transition to self-care) than in the preceding or following age periods. On the other hand the effective parental orientation at the age suggested here does not result in strong external control of the patient's behavior. The facilitative parental orientation is not paralleled by an associated degree of youth-perceived parental "control." Our data suggest that effective parent-youth transactions at this age involve detailed reciprocal relations that preserve a developing youth's autonomy, which is central to this age. Nevertheless our data hint that some parental psychologic distress is associated with the continued vigilance and the contingencies involved in the maintenance of better diabetes control during this active and rapidly changing developmental period. One outcome of effective guidance during early adolescence may be better diabetes self-management in later adolescence (transition to self-care nearly complete), although no relationships can be confirmed from our data. Several other studies have reported finding negligible psychosocial relationships with diabetes control among adolescents of similar age (3, 11-13), suggesting the need for a more focused approach to biobehavioral relations within this age period. The lack of association of parental and family variables found influential in the previous age period does suggest, however, that glycemic

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control is subject to the greater autonomy and independence of later adolescent youth. In sum, the results of our analysis suggest some relationships within t w o of our three age periods. Family transactions came into focus in early adolescence. However, because the verbal level of the Child's Report of Parental Behavior Inventory precluded its administration to subjects in our youngest age group, the Family Environment Scale was the only instrument capable of suggesting transactional patterns within that age group. Research would benefit from more specific behavioral measures for youth and their families at all age levels. This would help elucidate relationships associated with more global measures like those used here and provide a clearer picture of the behaviors (individual and transactional) underlying better diabetes control. One recent study found relationships between parent and child behavior in the home and measured adherence (3), which was in turn related to Ghb levels. Behavior-specific measures may be more clearly related to end-point criteria of diabetes control such as Ghb. Our study sample was select, being the minority of invited families (30%) who agreed to participate in an extensive set of activities. Our sample was also predominantly Caucasian and urban in character. Although a number of the individual relationships noted above deserve replication using a new crossvalidation sample of similar makeup, other findings may also emerge from studies of different populations, such as non-Anglo and rural patients. Also, because of the sample size we did not analyze for gender differences among children although ge nder relationships could emerge in samples of sufficient Size. Problems of diabetes control are common candidates for individual behavioral assessment and counseling. Our data suggest that parent and child counseling/support groups might be particularly efficient and helpful for families with diabetics approaching or in earlyadolescence. Within this age group, a confluence of developmental and behavioral trends interact with the precise requirements for diabetes care. Patterns reported here may also have implications for understanding self-care patterns in youth with other diseases. The Changing exigencies of late childhood and adolescence may also suggest a preparatory/preventive focus for families dealing with any chronic disease.

This research was supported by grant no. HD14985 from the National'Institute of Child Health and Human Development.

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References 1. Anderson BJ, Auslander WF. Research on diabetes management and the family. Diabetes Care 1980;3:696-702. 2. Orr DP, Golden M, Myers G, et al. Characteristics of adolescents with poorly controlled diabetes referred to a tertiary care center. Diabetes Care 1983;6:170-5. 3. Schafer LC, Glasgow RE, McCaul KD, et al. Adherence to IDDM regimens: Relationship to psychosocial variables and metaboliccontrol. Diabetes Care 1983;5:493-8. 4. Glasgow RE, McCaul K. Psychological issues in diabetes: A different approach. Diabetes Care 1982;5:645-9. 5. Skyler J. Psychological issues in diabetes. Diabetes Care 1981;4:656-7. 6. Mazze RS, Lucido D, Shamoon H. Psychological and social correlates of glycemic control. Diabetes Care 1984;4:63-6. 7. Dupuis A. Assessment of the psychological factol:s and responses in self-managed patients. Diabefes Care 1980;3:11720. 8. Shapiro J, Wigg D, Charles MA, et al. Personality and family profiles of chronic insulin-dependentdiabetic patients using portable insulin infusion pump therapy: A preliminary inves~ tigation. Diabetes Care 1984;7:137-42. 9. Seigler ED, LaGreca A, Citrin WS, et al. Psychological effects of intensification of diabetic control. Diabetes Care 1982;5,Suppl 1:19-23. 10. Sirnonds JF. Psychiatric status of diabetic youth in good and poor control. Int J Psychiatry Med 1976-77;7:133-51: 11. Ahlfield JE, Norman GS, Marcus SD. Adolescent diabetes mellitus: Parent/child perspectives of the effect of the disease on family and social interactions. Diabetes Care 1983;6:393-8. 12. Simonds J, Goldstein D, Walker B, et al. The relationship between psychological factors and blood glucose regulation in insulin-dependent diabetic adolescents. Diabetes Care 1981;4:610-15. 13. Lavigne JV, Traisman HS, Marr TJ, et al. Parental perceptions of the psychological adjustment of children with diabetes and their siblings. Diabetes Care 1982;5:420-6. 14. Conger JL. Adolescence and youth, 2nd edition. New York: Harper and Row. 1977. 15. Wallston KA, Wallston BS, De Vellis R. Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Educ Monogr 1978;6:166-70. 16. Sullivan BJ. Adjustment in diabetic adolescent girls: Development of the Diabetic Adjustment Scale. Psychosom Med 1979;41:119_26. 17. Coopersmith S. SEI Self-Esteem Inventories. Palo Alto, CA: Consulting Psychologists Press, Inc., 1981. 18. Achenbach TM. The child behavior profile: An empirically based system for assessing children's behavioral problems and comPetencies. !nt J Mental Health 1979;7:24-41. 19. Harter S. The Perceived Competence Scale for children. Child Dev 1982;53:87-97. 20. Krug SE, Laughlin JE. Handbook for the IPAT Depression Scale. Champaign, IL: Institute for Personality and Ability Testing, 1976. 21. Krug SE, Scheier IH, Cattell RB. Handbook for the IPAT Anxiety Scale. Champaign, IL: Institute for Personality and Ability Testing, 1976. 22. Moos RH, Moos BS. Family Environment Scale manual. Palo Alto, CA: Consulting Psychologists Press, 1981. 23. Bradburn N,Caplowitz D. Reports of happiness. Chicago: Aldine, 1965.

September 1986

PSYCHOSOCIAL CORRELATES OF GLYCEMIC CONTROL

24. Kanner AD, Coyne JC, Schaefer C, et al. Comparison of two modes of stress management: Daily hassles and uplifts versus major life events. J Behav Med 1981;4:1-39.

29.

25. Schaefer ES. Children's reports of parental behavior: An inventory. Child Dev 1965;36:413-24.

30.

26. Quik Sep® Fast Hemoglobin Test System. Drawer 4350, Isolab, Inc. Akron, OH 44321.

31.

27. Statistical package for the social sciences, 2nd edition. New York: McGraw-Hill, 1975.

32.

28. Cohen J, Cohen P. Applied multiple regression/correlation

319

analysis for the behavioral sciences. Hillsdale, CA: Lawrence Erlbaum, 1983. SchaeferES. Aconfigurationalanalysisofchildren'sreportsof parent behavior. J Consult Clin Psychol 1965:29:552-7. Baumrind D. Child care practices anteceding three patterns of school behavior. Genet Psychol Monogr 1967;75:43-88. Baumrind D. Current patterns of parental authority, Dev Psychol Monogr 1971;4:November 1, Part 2. Lowery BJ, Ducette JP. Disease related learning and disease related control in diabetics as a function of locus of control. Nurs Res 1976;25:358-62.