CHILDRENS HEALTH CARE, 35(4), 349363 Copyright 2006, Lawrence Erlbaum Associates, Inc.

Diabetes Management and Metabolic Control in School-Age Children With Type 1 Diabetes
Maureen A. Frey
Carmen and Ann Adams Department of Pediatrics Wayne State University

Deborah Ellis
Department of Psychiatry and Behavioral Neurosciences Wayne State University

Tom Templin
College of Nursing Wayne State University

Sylvie Naar-King
Carmen and Ann Adams Department of Pediatrics Wayne State University

James P. Gutai
Department of Community Medicine Wayne State University

This study investigated the effect of mothers coping resources, cognitive resources, family stress, and demographic variables on diabetes management and the mediating role of diabetes management on metabolic control among children with diabetes. Mothers (N = 59) completed self-report measures. HbA1c was obtained from the medical records. Although cognitive resources, coping resources, and family stress accounted for 30% of the variance in diabetes management, the hypothesis of

Correspondence should be sent to Maureen A. Frey, Critical Care Medicine4134 CHM, 3901 Beaubien, Detroit, MI 48201-2119. E-mail: mfrey@med.wayne.edu

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mediation was not supported. The only significant predictor of HbA1c was African American race/ethnicity. The findings identify modifiable targets for practice and highlight the increased risk for poor metabolic control for minority children.

Type 1 diabetes, the most common endocrine disorder in the pediatric population, affects 1 in every 400 to 600 children and adolescents (National Diabetes Information Clearing House, n.d.). Type 1 diabetes requires lifelong administration of exogenous insulin, daily blood glucose testing, continual attention to dietary intake, and increased physical activity to maintain adequate metabolic control. Although diabetes management and metabolic control have been extensively investigated in adolescent populations, much less is known about predictors of diabetes management and metabolic control in younger children. Yet the first years after diagnosis are critical in terms of establishing adequate patterns of diabetes management. The role of parents of young children with diabetes is also becoming increasingly important as intensive insulin therapy, with its higher level of complexity, is initiated earlier in the course of the disease. In addition, because the microvascular complications of diabetes are directly related to duration of diagnosis, young children are at increased risk for such complications compared with those diagnosed at a later age (Donaghue et al., 2003). The lack of research with school-age and preadolescent children with diabetes is a significant barrier to the development of health promotion and risk reduction interventions with this population. Accordingly, the purpose of this study is to identify predictors of diabetes management among mothers of 6- to 13-year-old children with type 1 diabetes and subsequently to determine the relationship between diabetes management and metabolic control. Descriptive studies with children and adolescents show that younger children have better metabolic control than do older children (Johnson et al., 1992; La Greca, Follansbee, & Skyler, 1990; Palta, Shen, Allen, Klein, & DAlessio, 1996). However, others have noted that many school-age and younger children show evidence of less than adequate metabolic control. For example, Davis et al. (2001) reported that 43% of their sample had a glycohemoglobin level four standard deviations above the normal range, indicating fair to poor glycemic control. Garrison and colleagues (Garrison, Biggs, & Williams, 1990) reported that 23% of their sample showed poor glycemic control for at least 1 year prior to study entry. In addition, 29% of the sample showed fair to poor regimen adherence. These studies are important because all of the participants were younger than 11 years of age. In addition, there is evidence that patterns of metabolic control are established early in the course of the disease, often within 2 years of diagnosis (Forsander et al., 1998; Jacobson et al., 1990). Both cross-sectional and longitudinal studies show that early patterns of metabolic control tend to remain stable over time (SeiffgeKrenke, & Stemmler, 2003). Studies of school-age children with diabetes are limited compared with studies of adolescents with diabetes (Anderson & Laffel, 1997). Family support for diabetes

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(Waller et al., 1986), family conflict (Jacobson et al., 1990), and family stress (Viner, McGrath, & Trudinger, 1996) have been related to metabolic control, and parent involvement with diabetes management has been related to adherence in children (La Greca et al., 1990). However, in view of the more primary role of the caregiver in the management of diabetes at this age, caregiver factors might be particularly important. Therefore, Davis and colleagues (2001) investigated parenting style in mothers of 4- to 10-year-old children with diabetes. Parental warmth was a significant predictor of adherence. However, neither adherence nor parental warmth was predictive of metabolic control. In examining maternal temperament variables related to young childrens adherence and metabolic control, Garrison et al. (1990) reported that maternal characteristics related to child outcomes in a differential manner. That is, maternal temperament was associated with metabolic control but not with adherence. Maternal temperament characteristics that were found to be associated with poor metabolic control were negative mood, high social withdrawal, high rigidity, and lower activity level. The authors concluded that further attention to individual characteristics of parents as predictors of diabetes management in children was warranted. As has been found in studies of adolescents, studies with younger children demonstrate that diabetes management has not always been closely linked to metabolic control. In one of the few studies to include children younger than 8 years of age, diabetes management, measured as a single-item parent rating of the extent to which You or your child follow the diabetes regimen, was not related to metabolic control (Auslander, Anderson, Bubb, Jung, & Santiago, 1990). Johnson and associates (1992) also failed to show a relationship between adherence and metabolic control in school-age children despite considerable methodological rigor and use of the well-established 24-Hour Recall Interview to measure adherence. A significant gap in the research is lack of attention to the cognitive ability of caregivers. Diabetes management is complex and requires considerable problem solving and decision making. The cognitive ability of adolescents is a critical factor in determining readiness for and ability to manage self-care (Brandt, 1998). Likewise, the cognitive ability of caretakers may affect their ability to make decisions regarding insulin adjustments or dietary changes. Cognitive ability is also related to health literacy or to the ability to process and act on health information. Parents with poor health literacy may struggle to carry out recommendations made by medical personnel for management of their childs care (Schillinger et al., 2002). Some of the strongest and most consistent predictors of metabolic control in children and adolescents are the sociodemographic characteristics of race/ethnicity, family income, and family composition. Poor metabolic control is associated with minority status, low family income, and single-parent headed households (Auslander, Thompson, Dreitzer, White, & Santiago, 1997; Delamater, Albrecht,

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Postellon, & Gutai, 1991; Delamater et al., 1999; Harris, Greco, Wysocki, Elder-Danda, & White, 1999; Harris & Mertlich, 2003; Overstreet, Holmes, Dunlap, & Frentz, 1996; Thompson, Auslander, & White, 2001). However, in studies in which the effects of race/ethnicity and socioeconomic status were controlled, the most significant risk factor for poor metabolic control was living in a singleparent household (Harris et al., 1999; Overstreet et al., 1996; Thompson et al., 2001). Auslander et al. (1990) also found that African American mothers reported lower adherence to diet and frequency of blood glucose testing than did European American mothers. However, there is limited research on other caregiver characteristics or behaviors that might account for differences in health outcome. Kings Conceptual System (King, 1981, 1995) provides an ecological framework for understanding and organizing factors that may influence diabetes management and metabolic control. The framework includes personal systems (individuals), interpersonal systems (families and other small groups), and social systems (large community groups). It is interactions within and between the three systems that influence behavior. Behavior, in turn, influences health outcomes. Knowledge of interactions comes from concepts such as stress, coping, resources, and health. The empirical literature has also suggested that these concepts are important in understanding diabetes management. In summary, research with caregivers of school-age children is very limited despite the acknowledged importance of diabetes management and metabolic control for this age group. Research has suggested that some parent characteristics and demographic factors may influence metabolic control directly and indirectly through management of diabetes. Accordingly, the aim of our study is to investigate the effects of family stress, mothers coping resources, mothers cognitive resources, and selected demographic variables on diabetes management in 6- to 13-year-old children with type 1 diabetes. A secondary aim was to determine if diabetes management mediated the effects of family stress, mothers coping resources, mothers cognitive resources, and selected demographic variables on metabolic control in this population. METHOD Participants Participants for this descriptive cross-sectional study were recruited from a university-affiliated pediatric diabetes clinic. Participants were seen clinically for medical visits by a multidisciplinary team at 3- to 4-month intervals. The sample consisted of 59 motherchild dyads who met the following eligibility criteria: child between 6 and 12.9 years of age, who had been diagnosed for at least 1 year with type I diabetes, and no known developmental delay or other chronic medical conditions. Given the young age of children in the sample, all children were

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managed by injected insulin rather than insulin pump. They were expected to test blood glucose three to four times per day and were provided with individualized meal plans. All maternalchild dyads were English speaking. Data were collected at the time of a regularly scheduled clinic appointment with the assistance of a trained data collector. Sixty-three percent of the eligible individuals agreed to participate. The most frequent reason for nonparticipation was the extra time during the clinic appointment needed to complete the research measures. All data were obtained by maternal report. Characteristics of the participants for the total sample and by race/ethnicity are shown in Table 1. Approximately two thirds of the sample was of minority race/ethnicity: 27% were African American, 3% were American Indian, 15% were biracial, and 15% selected Other. Three mothers, 5% of the sample, did not provide race/ethnic information. Overall, the demographics of the sample were representative of the diverse urban population served by the clinic where participants were recruited. Analyses of variance indicated no significant differences between the racial/ethnic subsamples on mothers age, mothers education, or childs age. Pearson chi-square analyses indicated no significant differences in childs gender. There was a difference in mothers marital status and family income. A significantly smaller percent of African American mothers (29%) were married compared with the European American (70%) or the Other (61%) group. Family income was also significantly lower for African Americans. The mean age of the children was somewhat skewed toward the upper end of the eligibility age range, which is consistent with the typical age of onset of type 1 diabetes. On average, children had been diagnosed with diabetes for 3 to 4 years.

TABLE 1 Sample Characteristics by Race/Ethnicity Totala African Americansb European Americansc Otherd

Characteristic

Child Age 9.45 (2.48) 10.15 (2.68) 9.49 (2.20) 9.17 (2.58) Female (%) 61 69 45 67 Duration of 3.52 (2.53) 3.59 (2.88) 4.06 (2.92) 2.99 (1.82) diabetes Mother Age 37.50 (5.80) 38.79 (7.02) 38.20 (5.56) 35.72 (4.93) Education (years) 13.56 (1.80) 13.19 (1.22) 14.30 (2.22) 13.18 (1.72) Married (%) 61 31 70 78 Income (yearly) $32,198 ($16,293) $19,893 ($16,908) $38,525 ($13,629) $34,605 ($14,000) Note. Values are mean (SD) or percentage. a N = 59. bn = 16 (27%). cn = 20 (34%). dn = 23 (39%).

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Measures

Family Inventory of Life Events and Changes (FILE; McCubbin & Patterson, 1987). The FILE is a 71-item parent-report scale designed to assess both acute and chronic stressful events in the family system over the previous 12 months. Positive responses are summed to form a total stress score. Higher scores indicate higher levels of stress. Testretest reliability of .80 and evidence of good construct validity has been reported. The scale has been extensively used with diverse populations. The Shipley Institute of Living Scale. This 60-item parent-report scale is composed of two brief subtests: vocabulary and abstract thinking, which are cognitive resources correlated with general cognitive ability (Zackery, 1991). Respondents select words with similar meaning from a list and fill in numbers or letters to logically complete given sequences (abstract thinking). The scale requires minimal assistance to complete and can be administered in small groups. High split-half (.84) and testretest (.78) reliability coefficients have been reported. The Shipley scale (Zackery, 1991) correlates highly with full-scale IQ scores as obtained by instruments such as the Wechsler Adult Intelligence ScaleRevised (Wechsler, 1981). Total scores were used in our analyses. The Coping Resources Inventory (CRI). This 60-item parent-report scale quantifies the availability of five resources for coping: cognitive, social, emotional, spiritual/philosophical, and physical (Hammer & Marting, 1988). Responses are on a 4-point scale, ranging 1 (never), 2 (rarely), 3 (always), and 4 (almost always), in the previous 6 months. Cronbachs alpha coefficients of .71 to .84 for the subscales and .91 for the scale total have been reported. In this study, Cronbachs alpha coefficients ranged from .48 to .89 for the subscales and .92 for the scale total. In this study, the total score was used in the analyses. The Diabetes Management ScaleParent Report (DMSPR). The DMSPR was used to measure diabetes management (Frey, Ellis, Naar-King, & Greger, 2004; Schilling, Grey, & Knafl, 2002). The scale taps blood glucose testing; insulin injections; dietary considerations; symptom management; exercise; and parent/adult supervision, assistance, and overall responsibility for management. Mothers were asked What percent of the time ? various components of management were completed in the past 3 months. The response scale ranged from 0% to 100%. Items are summed to obtain a total score; higher scores reflect more completed diabetes care for the child. A previous study showed that the DMSPR was sensitive to differences in both age and level of metabolic control. Internal consistency of the DMSPR in this study was .78.

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Metabolic control. HbA1c was obtained at each visit as part of standard care. The HbA1c value obtained at the time of study recruitment was used in analysis. The range of HbA1c for the sample was 5.76% to 15.99%, with a mean of 9.00% (SD = 1.95%). The demographic characteristics of race/ethnicity, family income, mothers education (highest grade completed), and marital status were obtained by mothers self-report. Income and education were considered proxy measures of socioeconomic status.
Procedures The study received human participants approval from the Institutional Review Board. All mothers provided written informed consent, and children older than 7 years of age gave verbal assent to participate. Most potential participants were notified of the study by letter or by telephone prior to a scheduled medical appointment, although some were approached in the waiting area at the time of their appointment. Mothers completed the questionnaires in the clinic and received $10 to compensate for additional time in the clinic.

Analytic Approach We used structural equation modeling (SEM) with AMOS Version 5.0 (Arbuckle & Wothke, 2003) to determine predictors of mothers diabetes management and to test for mediation. A manifest model was specified because all constructs were measured as single indicators. SEM is considered more appropriate than traditional multivariate analyses for testing mediation because it allows both the assessment of goodness of fit of a specified model and the testing of each estimated path coefficient (Satorra & Saris, 1985). In the past, use of SEM was restricted to studies with large samples. However, bootstrap analysis allows model testing with small samples by using the actual data to estimate standard error (Shrout & Bolger, 2002). The theoretical model tested is shown in Figure 1 and contains three exogenous variables and two endogenous variables. We hypothesized that maternal cognitive resources, maternal coping resources, and family stress would be predictors of diabetes management. In this model, diabetes management fully mediates the relationship between maternal and family variables and metabolic control. Demographic covariates were added to the SEM model empirically after an analysis of residuals was performed. Potential covariates were family income, mothers education (highest grade completed), childs gender, childs race/ethnicity, and family composition. Family composition was dichotomized as single parent

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Mothers Cognitive Resources Family Stress Mothers Coping Resources

FIGURE 1 Theoretical model.

Mothers Diabetes Management

Childs Metabolic Control

and two parent. Two-parent families included two biological parents, a stepparent and biological parent, and parents living with a partner. The contrasts used for race/ethnicity were African American versus all others and European American versus all others. In this analysis, residual error for each endogenous variable (diabetes management and metabolic control) was first computed. The pattern of correlation between each residual and each potential covariate was then examined. Those covariates that were significantly related to the residuals and to the exogenous/predictor variables were included in the model to reduce bias and potential confounding effects. Family income and African American race/ethnicity met these criteria. RESULTS Bivariate correlations between variables are shown in Table 2. The demographic variables of family income, family composition, and race/ethnicity were significantly intercorrelated indicating that African American children were more likely to be from single-parent lower income families compared with White and other race/ethnic children. There were no significant correlations between the predictor variables of mothers cognitive resources, mothers coping resources, and family stress. However, several demographic variables were significantly related to the predictor variables. Race/ethnicity, family income, and mothers education were significantly related to mothers cognitive resources, and family income was also related to mothers coping resources. Mothers who reported lower cognitive resources also reported lower family income, lower education, and African American race/ethnicity. Family stress (r = .30, p = .022) and coping resources (r = .30, p = .009) were significantly associated with diabetes management and diabetes management was significantly associated with metabolic control (r = .26, p = .047). Mothers who reported lower stress and higher coping resources also

TABLE 2 Correlations Among Variables Duration HgA1c Income Education Married b FILE Shipley CRI

Variable

Age

Race/Ethnicitya

Child Age Race/ethnicity Duration HbA1c Mother Income Education (years) Married FILE Shipley CRI DMSPR .09 .40** .03 .17 .10 .10 .04 .26* .08 .17 .42** .09 .03 .18 .52** .04 .48** .27 .11 .23 .04 .17 .05 .28** < .01 .21 .21 .24 .07 .10 .14 .10 .34**

.15 .37** .33**

.02 .56**

.02 .11 .10 .05 .11 .03 .19

.37** .13 .30** .06 .34** .16 .10

.16 .17

.30**

Note. FILE = Family Inventory of Life Events and Changes; Shipley = Shipley Institute of Living Scale; CRI = Coping Resources Inventory; DMSPR = Diabetes Management ScaleParent Report. a African American = 1, all others = 0. bMarried = 1, all others = 0. *p < .05. **p < .01.

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TABLE 3 Descriptive Statistics for Predictor and Outcome Variables Variable Shipley FILE CRI DMSPR Childs HbA1c M 50.03 9.42 170.63 78.58 9.00 SD 16.01 6.97 25.31 11.49 1.95 Range 17.0074.00 0.0027.00 120.00217.00 49.70100.00 5.7615.99

Note. Shipley = Shipley Institute of Living Scale; FILE = Family Inventory of Life Events and Changes; CRI = Coping Resources Inventory; DMSPR = Diabetes Management ScaleParent Report.

reported better diabetes management; children of mothers who reported better diabetes management were in better metabolic control. Race/ethnicity was also significantly related to metabolic control. The poorest metabolic control was among African American children. Descriptive statistics for predictor and outcome variables are shown in Table 3. The results of the SEM analysis are shown in Figure 2. This model was a good fit for the data, 2(5, N = 59) = 5.43, p = .37 (comparative fit index = .994, root mean square error of approximation = .038). Mothers cognitive resources, mothers coping resources, and family stress were all significantly related to diabetes management. These three variables accounted for 30% of the variance in mothers

FIGURE 2 Results of structural equation modeling.

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diabetes management. However, after accounting for the influence of child ethnicity and family income, diabetes management was only predictive of metabolic control at the trend level (p = .09) Therefore, the model did not provide support for diabetes management as a mediator of metabolic control in our sample. The model explained 38% of the variance in metabolic control. However, the only significant pathway was African American race/ethnicity.

DISCUSSION The primary purpose of this study was to gain a better understanding of diabetes management and the mediating effect of diabetes management on metabolic control in children with type 1diabetes. Prior research with mothers of children younger than age 12 has been limited to investigations of parenting style and maternal temperament, neither of which was related to adherence (Davis et al., 2001; Garrison et al., 1990). Other family and parent characteristics related to diabetes management in adolescents have not been systematically examined in younger children. Results of the study presented here suggest that mothers coping resources, cognitive resources, and report of family stress were each significant predictors of diabetes management. This is important because two of the variables, mothers coping resources and stress, are modifiable characteristics. Although cognitive ability is often not viewed as modifiable, recent research has focused on the concept of health literacy, which captures the impact of learning ability on ability to function in the health care environment. Although not investigated in parents of children with type 1 diabetes, inadequate health literacy has been related to poorer metabolic control in adults with type 2 diabetes (Schillinger et al., 2002). Health care providers can evaluate health literacy by paper-and-pencil means with brief screening instruments (Baker, Williams, Parker, & Gazmararian, 1999) or by conducting direct observations of skills taught to parents to determine whether mastery has been attained. The secondary hypothesis of the study, that the effect of mothers cognitive resources, stress, and coping resources on childrens metabolic control was mediated by the diabetes management the child received, was not supported. Rather, the variance in the childs metabolic control was predominately explained by African American race/ethnicity. This is consistent with several previous reports of poorer metabolic control among African American children and adolescents with diabetes (Auslander et al., 1997; Delamater et al., 1991; Harris et al., 1999; Harris & Mertlich, 2003). However, as noted by others, the socioeconomic variables of race, income, and single parent households are often confounded. In our analyses, although African American race/ethnicity and family income were found to be the most relevant variables to include, bivariate analyses did show strong relationships between race/ethnicity, family income and number of parents in the home.

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Other researchers have shown that the primary sociodemographic risk variable related to poor metabolic control in children and adolescents with diabetes is living in a single-parent household (Overstreet et al., 1996; Thompson et al., 2001) and have proposed that single parents have fewer resources to devote to the management and supervision of diabetes care. It is also possible that the effect of race/ethnicity on metabolic control is due to a physiological rather than a behavioral pathway. For example, obesity, other forms of insulin resistance, and atypical forms of diabetes can influence metabolic control and are more prevalent in the African American population (Libman, Pietropaolo, Arslanian, LaPorte, & Becker, 2003; Lipton et al., 2005). Results from a recent study of an intensive behavioral intervention with adolescents in chronically poor metabolic control showed that although all participants in the intervention group had improved adherence, metabolic control was improved only in those of normal weight (body mass index < 85%; Cakan, Ellis, Templin, Frey, & Naar-King, in press). Higher risk for poor metabolic control among African American youth also demonstrates the need to develop culturally sensitive interventions to promote good diabetes management Finally, the range and mean HbA1c for this sample supports the findings of previous studies that maintaining good metabolic control during the school-age and preadolescent years is a considerable problem for many families. Overall, this suggests a shift in thinking about poor adherence and poor metabolic control as problems that emerge only in the adolescent developmental period and suggests a need to focus on the early years immediately after diagnosis to promote optimal health outcomes Study limitations include shared variance resulting from a single source of data and a single method of data collection. Such shared method variance can influence statistical outcomes. There may also be sampling factors such as an overrepresentation of single-parent families among the African American subsample. Finally, socioeconomic status was not formally assessed in this study; rather, we used proxy measures such as maternal education and income.

IMPLICATIONS FOR PRACTICE Limitations notwithstanding, our findings provide some insight into diabetes management and metabolic control for younger children and underscore the need for interventions to improve metabolic control long before adolescence. The subscales of the CRI, mothers cognitive, social, emotional, spiritual/philosophical, and physical resources, represent areas that could be targeted for intervention. Because the measures of mothers coping and stress were general rather than specifically related to diabetes, this indicates that more general areas of parents lives can impact their ability to manage their childs diabetes and that interventions targeting these areas could be successful in improving disease management.

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Although we did not measure health literacy directly, the findings suggest that mothers intellectual and cognitive resources are important in carrying out diabetes management as recommended. Ongoing assessment of parents understanding and ability to manage diabetes is especially important for this age group. Successful interventions to improve regimen adherence among adults with diabetes and low health literacy have focused on changing patientprovider interactions to reduce the complexity of information exchanged during health care visits (Schillinger et al., 2003). Providers can modify the way they provide information to families in which low health literacy is suspected. In addition, the specific ways that race/ethnicity influence diabetes management and metabolic control warrants further investigation. The development of targeted interventions to improve metabolic control that recognize development differences, race/ethnic differences, and the crucial role of parents in diabetes management is critical for school-age and younger children with diabetes.

ACKNOWLEDGMENTS Deborah Ellis is now with Carmen and Ann Adams Department of Pediatrics, Wayne State University. This research was funded by the James and Lynelle Holden Fund, Childrens Hospital of Michigan, Detroit.

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