MAKALAH ANALISA “STEEL MAGNOLIAS 1989”

TUGAS MATA KULIAH KEPERAWATAN KELUARGA

Oleh:

Kelompok 4/ Kelas E

Rohibul Fahmi 162310101273

Friska Ayu Purwantiwi 162310101274

Ari Wijaya 162310101276
Nabillah Linda K. P 162310101280
Fathkiyatur R. 162310101291

PROGRAM STUDI SARJANA KEPERAWATAN

FAKULTAS KEPERAWATAN

UNIVERSITAS JEMBER

2018
A. KEHADIRAN KELUARGA

1. Gambaran Singkat Tentang Film

Di dalam film tersebut menceritakan tentang Shelby Eatenton adalah seorang

perawat disalah satu rumah sakit di tempat tinggalnya. Shelby merupakan putri
pertama dari pasangan Drum Eatenton dan M’Lynn Eatenton. Shelby dan
keluarganya tinggal di Amerika bersama kedua adiknya. Adik Shelby bernama
Jonathan Eatenton dan Tommy Eatenton. Shelby Eatenton di diagnosis Diabetes tipe
1 pada usia muda. Sejak usia muda Shelby sering mengalami kejang jika kadar gula
darah di dalam tubuhnya menurun. Shelby memiliki kekasih sekaligus calon
suaminya yang bernama Jackson Latcheris. Jackson ingin menikah dengan Shelby
dan menerima segala kekurangannya. Jackson menginginkan jika dia dan Shelby
menikah, mereka akan memilih mengadopsi seorang anak di dalam keluarga
kecilnya, karena mengingat akan penyakit yang dialami Shelby (Diabetes tipe 1).
Suatu hari ketika keluaga Eatenton mepersiapkan pernikahan putrinya, yaitu Shelby
dan Jackson. Keluarga Eatenton beserta kerabat dekat datang da mebantu
mempersiapkan acara pernikahan. Semua keluarga dan kerabat mendukung Shelby
menikah dengan Jackso karena jackso merupakan lelaki yang baik untuk shelby.
Dalam mempersiapkan acara pernikahan Shelby semua keluarga terlihat antusias dan
bahagia.

Suatu ketika ketika Selby berada di salon untuk mempersiapkan acara

pernikahannya, Shelby mengalami kejang akibat kekurangan kadar gula darang di
dalam tubuhnya atau Hipoglikemia. Ibu dan kerabat keluarganya dengan cepat dan
tanggal dalam menangani masalah kesehatan Shelby tersebut. Setelah resmi menjadi
istri Jackson, ibu Shelby tidak ingin Shelby hamil, karena dapat mengganggu
kesehatannya namun setelah beberapa lama menikah Shelby memberitahu ibunya
bahwa ia hamil. M’lLynn tidak senang akan kabar yang Shelby dari putrinya. Namun
Shelby tetap kuat akan pendiriannya bahwa dia ingin memiliki anak meskipun hanya
dalam waktu 30 menit. Akhirnya Shelby melahirkan anak laki – laki yang bernama
Jackson Latcheris JR. Suatu ketika saat Shelby dan putranya bermain, Shelby
mengalami hipoglikemi dan menyababkan dirinya tak sadarkan diri. Kemudian saat
Jackson pulang melihat anaknya menagis dan istrinya tak sadarkan diri, Jackson
langsung membawa Shelby kerumah sakit. Shelby mengalami koma, setelah
keluarganya berusaha dengan optimal, keluarga shelby pun menyerah dan
memutuskan untuk melakukan Euthanasia kepada putrinya Shelby.

Pemeran-pemeran dalam film

No. Nama Peran

1. Drum Eatenton Ayah
2. M’Lyun Eatenton Ibu
3. Shelby Eatenton Anak
4. Jonathan Eatenton Anak
5. Tommy Eatenton Anak
6. Jackson Latcheris Menantu (suami Shelby)
7. Jackson Latcheris JR Anak dari Shelby dan Jackson
2. Ecomap

Religius Fasilitas kesehatan

M D

J S JO T

JR

Lingkungan Sosial
Keterangan :

= laki laki

= perempuan

= menikah

= tinggal serumah

= Interaksi Kuat

= Interaksi sedang

= Interaksi lemah
= Meninggal
 Analisis Ecomap

Di dalam film ini menceritakan Shelby adalah seorang wanita yang terdiagnosis
penyakit diabetes tipe 1 di usia mudanya. Shelby putri dari pasangan Drum Eatenton
dan M’Lynn Etenten yang bernama Shelby Aetenton. Shelby memiliki 2 adik laki –
laki yang bernama Jonathan Eatenton dan Tommy Eatenton. Shelby memiliki kekasih
yang bernama Jackson Latcheris dan akhirnya menikah. Pernikahan Shelby dan
Jackson dilaksanakan di rumah Shelby, pernikahan yang meriah dan disambut dengan
antusias oleh keluarga serta kerabat dekat keluarga Shelby. Setelah menikah Shelby
dan Jackson memiliki seorang anak laki laki yang bernama Jackson Latcheris JR.
Saat sakit shelby terlihat mendapatkan pengobatan pada suatu Rumah sakit sehingga
hubungan interaksi keluarga tersebut dengan fasilitas kesehatan sangat kuat.
Demikian pula interaksi dengan religius keluarga tersebut mempunyai ikatan yang
sangat kuat, terbukti saat Shelby dan Jackson menikah pada sebuah gereja, dan juga
saat upacara pemakaman Shelby. Keluarga tersebut juga mempunyai interaksi yang
sangat kuat pada lingkungan sekitar.
B. PENILAIAN KELUARGA DAN PRIORITAS KEBUTUHAN
1. Kondisi fisik dan psikososial
a. Kondisi fisik
Shelby merupakan seorang yang sedang mederita diabetes. Pada awal
pernikahan kondisinya terlihat baik-baik saja, namun pada saat shelby
hamil, terlihat pada lengan tangannya pembuluh darahnya membesar dan
terlihat bengkak pada lengan tangannya juga terlihat ada memar dan itu
terjadi pada saat shelby melakukan cuci darah. Shelby akan melakukan
transplatasi ginjal dikarenakan ginjal Shelby sudah tidak berfungsi dengan
baik dan Shelby mengatakan bahwa ibunya akan mendonorkan salah satu
ginjalnya untuk Shelby. Pada saat Shelby berada di rumah dan mengurus
anaknya, tiba-tiba Shelby tak sadarkan diri dan Jackson membawa Shelby
ke rumah sakit. Shelby yang berada di rumah sakit mengalami koma dan
terpasang alat bantu pernafasan. Dalam akhir ceritanya dokter meminta
persetujuan keluarga agar melepas semua alat bantu untuk Shelby
dikarenakan semua alat yang terpasang untu Shelby tidak memberikan
respon untuk Shelby dan akhirnya Shelby dinyatakan meninggal di rumah
sakit.
b. Kondisi psikososial dari Shelby yaitu ia sangat cemas pada saat di diagnosa
menderita diabetes, ia tidak menerima keadaannya yang menderita
diabetes. Shelby sangat marah pada dirinya sendiri, pada saat shelby
menikah dengan Jackson, Shelby sangat mengkhawatirkan dan cemas pada
dirinya yang menurut dokter ia tidak bisa hamil di karenakan ia menderita
diabetes. Namun, setelah pernikahannya ternyata Shelby hamil dan hal itu
membuat keluarganya terutama ibunya tidak percaya dan ibunya sangat
cemas ketika Shelby mengatakan bahwa dirinya sedang hamil.
2. Faktor Lingkungan, Faktor Sosiokultural (Nilai keyakinan dan Spiritual)
a. Faktor Lingkungan
Dalam film tersebut lingkungan yang ditempati adalah lingkungan rumah,
salon kecantikan, tempat beribadah (Gereja) dan supermarket.
 b. Faktor Sosiokultural
Dalam film ini mengikuti budaya barat dengan bahasa yang digunakan
sehari-hari adalah bahasa inggris. Dalam film memperlihatkan pada saat
pernikahan Shelby dan Jackson dilakukan di suatu tempat beribadah yaitu
di sebuah Gereja.
3. Status gizi dan obat-obatan :
a. Status gizi : Shelby terlihat baik-baik saja. Namun dalam film terlihat
bahwa Shelby suka meminum jus, makanan yang manis dan minuman
bersoda.
b. obat obatan yang digunakan : dalam film diperlihatkan bahwa Shelby
menggunakan alat ventilator dan alat bantu pernafasan.
4. Penggunaan sumber perawatan kesehatan atau pengobatan alternatif
a Sumber Perawatan Kesehatan : dalm film diperlihatkan bahwa Shelby
melakukan pemeriksaan kepada dokter dan di diagnosa menderita
diabetes. Pada akhir film diperlihatkan Shelby sedang melakukan
perawatan di rumah sakit. Dokter dan tenaga kesehatan di rumah sakit
tersebut sangat memperhatikan keadaan Shelby. Namun pada saat di
rumah sakit Shelby terpasang alat bantu pernafasan dan tubuh Shelby
tidak dapat merespon. Pada akhirnya dokter dan keluarga memutuskan
untuk melepas semua alat bantu untuk Shelby dan Shelby dinyatakan
meninggal.
b Pengobatan Alternatif : dalam film Shelby mengatakan bahwa dirinya
sedang melakukan cuci darah dan akan melakukan transplatasi ginjal.
5. Diagnosa medis : Diabetes
6. Bagaimana kondisi klien mempengaruhi keluarga dan reaksi mereka
Keluarga Shelby sangat cemas pada saat Shelby dinyatakan menderita
diabetes, keluarga sangat khawatir pada saat dokter menyatakan bahwa
Shelby tidak bisa hamil dikarenakan kondisinya yang sedang menderita
diabetes.
7. Persepsi keluarga tentang kesehatan
Dalam flim ini diperlihatkan gaya hidup keluarga Shelby sangat baik,
namun dalam film terlihat bahwa keluarga Shelby senang memakan makanan
yang manis dan juga senang konsumsi minuman bersoda.
8. Kekuatan keluarga
Kekuatan keluarga Shelby yaitu sangat kuat, keluarga Shelby selalu
mendukung Shelby dan selalu memberikan motivasi kepada Shelby agar
Shelby selalu kuat menghadapi semua masalah dalam hidupnya terutama
pada saat Shelby di diagnosa menderita diabetes.
C. Analisa Data
Data Diagonosa Rencana Tindakan Jurnal
Maladaftif Keperawatan Keperawatan Keperawatan / Rujukan
Terapi
Keperawatan

Tidak adanya Pelemahan Intervensi Terapi Keluarga

dukungan dari koping keperawatan
1. Menentukan pola
ibu (M’lynn) keluarga Tn. D yang disarankan
komunikasi dalam
kepada anaknya dalam untuk
keluarga
(Shalby) yang menghadapi menyelesaikan
ingin penyakit masalah : 2. Mengidentifikasi
mempunyai diabetes bagaimana keluarga
Terapi
anak dari ia mellitus tipe 1 menyelesaikan
Keluarga
sendiri Nn. S b.d masalah
dikarenakan perilaku 1. Tentukan
3. Memfasilitasi
M’lynn sangat pola komunikasi
protektif dari diskusi keluarga
khawatir jika dalam keluarga
individu
akan 4. Membantu
pendukung 2. Identifikasi
mengganggu anggota keluarga
yang tidak bagaimana
kesehatannya mengklarifikasi apa
sesuai dengan keluarga
mereka butuhkan
kebutuhan menyelesaikan
dan
otonomi klien masalah
d.d Tidak harapan satu sama
3. Fasilitasi
adanya lain
diskusi keluarga
dukungan dari 5. Gunakan strategi
ibu (M’lynn) 4. Bantu terminasi dan
kepada anaknya anggota evaluasi
(Shalby) yang keluarga
ingin mengklarifikasi
mempunyai apa yang
anak dari ia mereka
sendiri butuhkan dan
dikarenakan harapan satu
 M’lynn sangat sama lain
khawatir jika
5. Gunakan
akan
strategi
mengganggu
terminasi dan
kesehatannya
evaluasi

Disaat Risiko Pengurangan 1. Menggunakan

pernikahan gangguan kecemasan pendekatan yang
shabby,M’lynn perlekatan tenang dsan
1. Gunakan
mengingingkan pada keluarga meyakinkan
pendekatan
Shabby untuk Tn. D terhadap 2. Berada disisi
yang tenang
sesekali pelepasan Nn. S klien untuk
dsan
yang akan meningkatkan rasa
berkunjung meyakinkan
menikah dengan aman dan
kerumah
Tn. J b.d 2. Berada disisi mengurangi
orangtuanya
perpisahan klien untuk ketakutan
ketika Shabby
orang tua meningkatkan
tinggal bersama 3. Mendorong
dengan anak rasa aman dan
suaminya keluarga untuk
mengurangi
mendampingi klien
ketakutan
dengan cara yang
3. Dorong
tepat
keluarga untuk
mendampingi 4. Membantu klien
klien dengan untuk
cara yang tepat mengidentifikasi
4. Bantu klien situasi yang
untuk memicu kecemasan
mengidentifikasi
5.
situasi yang
Mempertimbangkan
memicu
kemampuan klien
kecemasan
dalam mengambil
5.
keputusan
Pertimbangkan
 kemampuan
klien dalam
mengambil
keputusan

E. jurnal terapi keluarga

Judul Film : steel magnolias (1989)

Masalah Keluarga : film ini bercerita tentang keluarga dengan diabetes tipe 1. Klien
adalah seorang wanita yang baru menikah yang tidak disetujui oleh ibunya unuk memiliki
anak karena memiliki penyakit diabetes tipe 1

Terapi Keluarga : terapi keluarga dalam jurnal tersebut yaitu melakukan edukasi tentang
dukungan keluarga terhadapap klien dengan diabetes tipe 1 mengenai kepatuhan pengobatan
dan kontrol pengobatan diabetes

Indikasi Terapi Keluarga : untuk keluarga dengan pasien diabetes dengan tipe 1

Kontra Indikasi Terapi Keluarga : tidak ada kontra indikasi

Persiapan Terapi Keluarga : perawat mengumpulkan seluruh anggota keluarga untuk

menyampaikan edukasi terhadap keluarga yang memiliki anggota keluarga dengan penyakit
diabetes.

Prosedur Terapi Keluarga :

1. Pra Interaksi : lakukan pengkajian data dan catat kesehatan dari klien,
identifikasi identitas klien, lakukan pendekatan pada anggota keluarga klien agar
mudah saat melakukan pengkajian dan juga memberikan edukasi terhadap anggota
keluarga
2. Orientasi : melakukan salam dan senyum kepada klien dan anggota
keluarga klien. Memperkenalkan nama perawat kepada klien dan juga anggota
keluarga. Melakukan identifikasi identitas klien dan juga anggota keluarga klien.
 Menjelaskan maksud dan tujuan tindakan yang akan dilakukan perawat kepada klien
dan anggota keluarga klien. Kontrak waktu, tempat, dan kesediaan keluarga untuk
menerima tindakan dari perawat.
3. Kerja : perawat memberikan intervensi dengan mengedukasikan
mengenai bagaimana meningkatkan hubungan orang tua dan remaja serta dampak dan
resiko keterlibatan keluarga dalam mengasuh remaja dengan penyakit diabetes tipe 1,
perawat memberikan intervensi kepada keluarga dan remaja dengan mengontrol
metabolik, dan kepatuhan terhadap pengobatan serta efek utama jika memberikan
dukungan orang tua kepada remaja untuk patuh pada pengobatan dan kepatuhan untuk
mengontrol metaboliknya yang buruk. Orang tua dan remaja berpartisipasi dengan
mendiskusikan pemberian pendidikan dan strategi untuk pemecahan masalah agar
kepatuhan pengobatan dan kontrol metabolik bisa terkontrol dan mengurangi efek
buruk jangka panjang penderita diabetes tipe 1.
4. Terminasi : melakukan evaluasi subjective. Melakukan evaluasi objective.
Berikan pesan yang positif. Mengingatkan klien untuk selalu melakukan latihan terapi
agar terbiasa dan juga mendapatkan kemajuan dengan terapinya.
5. Evaluasi Terapi Keluarga : bagaimana keadaan fisik klien. Sikap klien setelah pasien
menerapkan terapi dukungannya tersebut. Menanyakan bagaimana perasaan pasien
setelah menerapkan terapi dukungan keluarga mengenai kepatuhan pengobatan dan
kontrol diabetes.
E. CRITICAL APRAISAL

Penulis Jurnal Wysocky, PhD

Michael A. Harris, PhD
Lisa M. Buckloh, PhD
Deborah Mertlich, MSW
Amanda Sobel Lochrie, PhD
Alexandra Taylor, MA
Michelle Sadler, BSN, CDE
Nelly Mauras, MD
Neil H. Putih, MD,CDE

Judul Jurnal Effects of Behavioral Family Systems Therapy for

Diabetes on Adolescents Family Relationships,
Treatment Adherence, and Metabolic Control
Nama Jurnal, Edisi dan Behavioral Family Therapy in Diabetes,2006
Tahun

Tujuan Penelitian Penelitian ini bertujuan untuk memberikan bukti bahwa

pengembangan dan validasi perilaku dan psikologis
serta intervensi yang dapat meningkatkan komunikasi
keluarga,, pemecahan ,masalah, dan bagaimana resolusi
konflik yang dapat meningkatkan manajemen diabetes
dikalangan remaja dan keluarga

Metode Penelitian Penelitian ini menggunakan sampel dari dua tempat yaitu
pusat pediatric di Southeastern dan Midwestern Amerika
Serikat. Yang diambil sebagai sampel remaja dengan
usia antara 11 dan 16 tahun yang tinggal bersama
keluarga. Dengan kriteriua mereka mengalami masalah
dengan manajemen diabetes. Sebelum prosedur
dilakukan mereka mengisi dan mendatangani informed
consent. Surat tersebut diberikan kepada 577 keluarga
 namun yang hanya masuk kedalam kriteria sebanyak 104
sampel yang layak untuk mendapatkan treatmen tersebut.
Dari 104 keluarga yang memenuhi merupakan 61
keluarga dari Southeastern dan 43 keluarga dari
Widwestern. Kemudian saat terapi sampel di pisahkan
menjadi 3 grup dengan pemilihan secara random. 3 grup
tersebut yakni Standart Care (SC), Educational Support
(ES) dan Behavioral Family Systems Therapy for
Diabetes (BFST-D). Penelitian tersebut berlangsung
selama 18 bulan terhitung sejak awal pendaftaran.

Hasil dan Pembahasan Hasil dari penelitian tersebut menunjukkan bahwa uji
coba terkontrol yang membandingkan antara SC untuk
diabetes, 12 sesi multifamily ES dan juga 12 sesi BFST-
D menunjukkan bahwa BFST-D menghasilkan manfaat
yang signifikan terhadap remaja dan keluarga dalam hal
manajemen diabetes. Hasil ini terlihat ketika
menggunakan skor PARQ secara signifikan terlihat
terjadi peningkatan lebih besar terhadap hubungan orang
tua dengan remaja atau orang tua dengan klien. Dan
menggunakan skor DRC terlihat menghasilkan
penurunan konflik keluarga terkait diabetes saat hasil
tersebut dibandingkan dengan SC atau ES

Implikasi Keperawatan Sebagai perawat kita diharapkan dapat memberikan

edukasi dan juga selalu mengingatkan keluarga untuk
selalu memberi dukungan terhadap klien yang
mengalami diabetes dukungan tersebut seperti
mengontrol kepatuhan pengobatan, mendukung
psikologi klien dll . Dengan terapi ini perawat dapat
mengetahui seberapa kuat hubungan antara keluarga
dengan klien dalam melakukan terapi manajemen
diabetes Sehingga terapi dapat di lakukan secara optimal
dan juga keluarga dapat menerapkannya.
 6. DAFTAR PUSTAKA

,2006. Effects of Behavioral Family Systems Therapy for Diabetes on Adolescents

Family Relationships, Treatment Adherence, and Metabolic Control. Behavioral Family
Therapy in Diabetes
Effects of Behavioral Family Systems Therapy for Diabetes
on Adolescents’ Family Relationships, Treatment Adherence,
and Metabolic Control
Tim Wysocki,1 PHD, Michael A. Harris,2 PHD, Lisa M. Buckloh,1 PHD, Deborah Mertlich,2
MSW, Amanda Sobel Lochrie,1 PHD, Alexandra Taylor,1 MA, Michelle Sadler,2 BSN, CDE,
Nelly Mauras,1 MD, and Neil H. White,2 MD, CDE

Downloaded from https://academic.oup.com/jpepsy/article-abstract/31/9/928/994333 by guest on 18 November 2018

1
Nemours Children’ s Clinic, and 2Washington University, St. Louis School of Medicine

Background Behavioral family systems therapy (BFST) for adolescents with diabetes has
improved family relationships and communication, but effects on adherence and metabolic con-
trol were weak. We evaluated a revised intervention, BFST for diabetes (BFST-D). Methods
One hundred and four families were randomized to standard care (SC) or to 12 sessions of either
an educational support group (ES) or a BFST-D over 6 months. Family relationships, adherence,
glycosylated hemoglobin (HbA1c), and health care utilization were measured at baseline and after
treatment. Results BFST-D significantly improved family conflict and adherence compared
to SC and ES, especially among those with baseline HbA1c ≥9.0%. BFST-D and ES significantly
improved HbA1c compared to SC among those with baseline HbA1c ≥9.0%. Conclusions
The revised intervention (BFST-D) improved family conflict and treatment adherence signifi-
cantly, while both ES and BFST-D reduced HbA1c significantly, particularly among adolescents
with poor metabolic control. Clinical translation of BFST-D requires further study.

Key words adolescence; diabetes; family therapy.

Family conflict, parent–adolescent communication, and
problem-solving skills have been associated with diabe-
tes outcomes among adolescents in cross-sectional
(Anderson, Miller, Auslander, & Santiago, 1981;
Bobrow, AvRuskin & Siller, 1985; Miller-Johnson et al.,
1994; Wysocki, 1993) and prospective (Gustafsson,
Cederblad, Ludvigsson & Lundin, 1987; Hauser et al.,
1990; Koski, Ahlas & Kumento, 1976) studies. Thus,
the development and validation of behavioral and psy-
chological interventions that improve family communi-
cation, problem solving, and conflict resolution is
warranted and could enhance diabetes management
among adolescents and their families.
Behavioral family systems therapy (BFST) is a flexi-
ble, multicomponent, family-focused intervention that
targets family communication and problem solving,
extreme beliefs of parents and adolescents that impede
communication, and systemic barriers to problem solv-
ing (Robin & Foster, 1989). The effectiveness of BFST
has been verified in several studies (Barkley, Guevremont,
Anastopoulos, & Fletcher, 1992; Foster, Prinz, & O’Leary,
1983; Robin, Seigel, Kopeke, Moye, & Tice, 1994). In a
previous randomized controlled trial with families of
adolescents with type 1 diabetes (Wysocki et al., 2000),
10 sessions of BFST over a 3-month interval yielded last-
ing improvements in parent–adolescent relationships
and family communication skills as measured by parent
and adolescent report (Wysocki et al., 2000) or by direct
observation of structured family interactions (Wysocki
et al., 1999). These benefits persisted for 12 months
(Wysocki et al., 2001), and BFST was rated as more
acceptable, applicable, and effective than was an educa-
tional support group (ES) (Wysocki et al., 1997). But,
BFST did not impact glycemic control or treatment

All correspondence concerning this article should be addressed to Tim Wysocki, PhD, Center for Pediatric Psychology
Research, Nemours Children’s Clinic, 807 Children’s Way, Jacksonville, Florida 32207. E-mail: twysocki@nemours.org.

Journal of Pediatric Psychology 31(9) pp. 928–938, 2006

doi:10.1093/jpepsy/jsj098
Advance Access publication January 9, 2006
Journal of Pediatric Psychology vol. 31 no. 9 © The Author 2006. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org

adherence (Wysocki et al., 2000, 2001). This second ran-
domized trial, as reported here, sought to determine
whether a revised intervention with diabetes-specific
behavioral components, BFST for Diabetes (BFST-D),
would have more robust effects on treatment adherence
and diabetic control. Concurrently, various researchers
reported the effectiveness of other intervention strategies
with this clinical population (see Hampson et al., 2001
for a review). Drawing on this recent work, the BFST
intervention was adapted by incorporating diabetes-specific
elements of many of these approaches into BFST-D.
The following hypotheses were evaluated for this
article:
Hypothesis 1: Relative to SC and ES, families in
BFST-D will exhibit significantly more improve-
ment in parent–adolescent relationships (PARQ
scores) and diabetes-related conflict (DRC scores)
after 6 months of treatment.
Hypothesis 2: Relative to SC and ES, adolescents in
BFST-D will show significantly more improvement
in medical adherence (DSMP scores) after 6 months
of treatment.
Hypothesis 3: Relative to SC and ES, adolescents in
BFST-D will achieve significantly greater reduction
in HbA1c, indicating better metabolic control, after
6 months of treatment.
Hypothesis 4: Relative to SC and ES, adolescents in
BFST-D will have significantly fewer hospitalizations
and emergency room visits during the 6 months of
study intervention.
Methods
Participants and Settings
Recruitment occurred at two pediatric centers in the
Southeastern and Midwestern United States. Recruit-
ment objectives were to enroll a clinically appropriate
sample of adolescents and their families who were expe-
riencing significant problems with diabetes manage-
ment. Parents and adolescents signed institutionally
approved informed consent and assent forms, respec-
tively, before any research procedures occurred.
Inclusion criteria were: adolescent age between 11
and 16 years inclusive; type 1 diabetes or insulin-treated
type 2 diabetes for at least 2 years; HbA1c ≥ 8.0% (which
has been defined as the threshold for clinical action by
the American Diabetes Association, 2005); agreement to
participate from all adult caregivers living with the ado-
lescent; willingness to accept randomization; intent to
continue diabetes care at the enrolling center for
Behavioral Family Therapy in Diabetes 929
18 months; and intent for the adolescent to remain living
in the same home for 18 months. Exclusion criteria
were: adolescent diagnosis of another systemic chronic
disease except well-controlled asthma or Hashimoto’s
thyroiditis; enrollment in self-contained special educa-
tion; psychiatric admission of the adolescent within the
prior 6 months; caregiver who was illiterate or not fluent
in English; residence of adolescent in foster care, group
home, or correctional facility; no telephone service;
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current diagnosis of psychosis, major depression, or
substance abuse disorder in an adult caregiver; or open
case with a child protection agency regarding child
abuse or neglect.
Figure 1 provides a summary of participants’
progress through the various stages of the trial in the
format recommended by the Consolidated Standards for
Reporting Clinical Trials (CONSORT) (Begg et al.,
1996). An introductory letter was mailed to 577 fami-
lies, and telephone follow-up was achieved with 438
(76%) of them. Of these, 48 (11%) were determined to
be ineligible by interview, while many others declined
participation before their eligibility could be ascertained.
A sample of 104 eligible families entered the study, 61 at
the Southeastern site and 43 at the Midwestern site, for a
recruitment rate of 27% of families who had not been
found to be ineligible. Demographic characteristics of
the sample are summarized in Table I and analyzed in
the Results section.
Charts Assessed for Eligibility
(n=577)
Telephone or Direct Contact Made
(n=436)
Determined Ineligible
(n=48)
Randomized
(n=104)
SC ES BFST-D
(n=32) (n=36) (n=36)
Lost to Follow-up Lost to Follow-up Lost to Follow-up
(n=3) (n=1) (n=8)
Complete Data
(n=29)
Complete Data
(n=35)
Complete Data
(n=28)
Figure 1. Flow diagram of participants’ progress through the study per
the CONSORT criteria.
930 Wysocki et al.

Table I. Demographic Characteristics of the Three Groups at Baseline exercise plan. Adolescents and families were referred to
Variable SC ES BFST-D qualified psychologists or psychiatrists not associated with
Youth age (years) 14.2 ± 1.9 14.4 ± 1.9 13.9 ± 1.9
the research team for services as needed.
Diabetes duration (years) 5.9 ± 4.0 5.5 ± 3.2 5.1 ± 3.0
Educational Support (ES)
HbA1c (%) 9.5 ± 1.5 9.7 ±1.6 9.6 ± 1.6
In addition to the SC medical regimen, ES families attended
Hollingshead SES index 40.3 ± 14.2 40.1 ± 11.6 40.4 ± 13.7
Gender
12 multifamily meetings within 6 months for diabetes edu-
Male 16 (50%) 20 (56%) 21 (58%) cation and social support. ES was designed to emulate a
Female 16 (50%) 16 (44%) 15 (42%) common mental health service for families of chronically ill

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Race/ethnicity teens and to serve as an alternative therapy comparison and
Caucasian 17 (53%) 27 (75%) 22 (61%) a control for the differential professional attention received
African-American 11 (34%) 9 (25%) 12 (33%) by the SC and BFST-D groups. Experienced diabetes nurses
Hispanic 2 (6%) 0 1 (3%) served as facilitators at each site and received extensive
Other 2 (6%) 0 1 (3%) training before conducting ES sessions. Groups of three to
Family composition five families completed a 12-session series together,
Intact 13 (41%) 15 (42%) 16 (43%)
attended by the parents and adolescents with diabetes. Ses-
Blended 4 (13%) 5 (14%) 7 (19%)
sion content followed the chapters of an American Diabetes
Single parent 11 (34%) 12 (33%) 11 (32%)
Association curriculum for teens (Johnson, 2000). The
Other 4 (13%) 4 (11%) 2 (5%)
Insulin modality
same materials and session outlines were used at both sites,
Injections 25 (78%) 27 (75%) 27 (75%) and the facilitators spoke weekly by telephone to ensure
Insulin pump 7 (22%) 9 (25%) 9 (25%) cross-site consistency. Family communication and conflict
For continuous variables, the values are mean ± 1 SD. For categorical variables, resolution skills were excluded from session content
the values are the number and percent of participants in each category. because these were specifically targeted by BFST-D. Ses-
sions included a 45-min lecture by a health professional on
Experimental Design 1 of the 12 topics, followed by 45 min of family interaction
A three-group, randomized treatment design was used about that topic led by the facilitator.
with four repeated measures at baseline, after treatment
(6-months), and follow-up at 6 and 12 months after Behavioral Family Systems Therapy for Diabetes
treatment. This article reports only the baseline and (BFST-D)
immediate posttreatment results as the sample continues In addition to the SC medical regimen, families in this
in follow-up at this time. Following the baseline evalua- group received 12 BFST-D sessions over 6 months. Sessions
tion, as described below, families were randomized were conducted by one of three psychologists at the south-
(stratified by baseline HbA1c) to standard care (SC), ES, eastern site or a licensed clinical social worker at the Mid-
or BFST-D for the next 6 months. The three experimen- western site and were attended by the youth with diabetes
tal conditions are described below. and their caregivers who were participants. Therapists were
trained and certified as proficient in BFST-D by two experi-
Standard Care (SC) enced, licensed psychologists (the first two authors) before
Diabetes care for all study participants reflected the prevail- enrollment of families. Methods described later in the arti-
ing clinical practices at each site during the study. Treating cle assured treatment integrity throughout the study.
physicians selected an HbA1c target for each adolescent BFST-D consisted of four components: problem-
that was as close to the upper limit of normal (6.5%) as was solving training, communication training, and cognitive
considered safe and feasible. HbA1c was measured before restructuring and functional-structural family therapy.
each clinic visit and reviewed during the visit. Daily insulin Problem-solving training provided families with a struc-
replacement was achieved via multiple subcutaneous injec- tured problem-solving approach with discrete steps con-
tions or insulin pump. Adolescents were asked to perform sisting of: problem definition, generation of solutions,
self-monitoring of blood glucose (SMBG) three or more group decision making, planning, implementation and
times daily. Quarterly clinic visits were scheduled with a monitoring of the selected solution, and renegotiation or
pediatric endocrinologist or other qualified clinician. A refinement of ineffective solutions. Communication skills
certified diabetes educator (CDE) provided basic and training included instructions, feedback, modeling, and
advanced diabetes education to families. Adolescents were rehearsal targeting common parent–adolescent commu-
offered a meal plan based on carbohydrate counting or an nication errors. Cognitive restructuring methods tar-
exchange system and encouraged to follow a personalized geted family members’ irrational beliefs, attitudes, and

attributions about one another’s behavior that could
impede effective parent–adolescent communication. Func-
tional and structural family therapy interventions targeted
anomalous family systemic characteristics (e.g., weak
parental coalitions and cross-generational coalitions) that
could impede effective problem solving and communica-
tion. Families received the intervention components that
were appropriate to their needs as determined by baseline
assessments and ongoing observations in therapy. Sessions
consisted of family problem solving and conflict resolution
discussions. Therapists participated actively, frequently
providing instructions, feedback, modeling, and rehearsal.
Behavioral homework was assigned at each session and
reviewed at the next session. Each session included deliv-
ery of some didactic information and emphasized teaching
the family to acquire and apply the targeted skills at home.
The revised BFST-D intervention utilized in this study
included these diabetes-specific adaptations:
1. All families targeted for treatment two or more
diabetes-related problems that were identified as
barriers to diabetes management or control.
These behaviors were identified during the first
two BFST-D sessions.
2. Explicit training in behavioral contracting was
provided (Carney, Schechter, & Davis, 1983;
Epstein et al., 1981; Schafer, Glasgow & McCaul,
1982; Wysocki, Green & Huxtable, 1989). These
studies have confirmed that behavioral contract-
ing improves adolescents’ adherence to specific
targeted aspects of the diabetes regimen. Behav-
ioral contracts were evaluated and refined as
needed in subsequent sessions.
3. All families received advanced education in using
SMBG data to modify insulin, diet, or exercise to
improve diabetic control. The CDE and therapist
conducted BFST-D sessions 6 and 7 jointly. The
CDE provided education and training in using clin-
ical algorithms for these purposes. The therapist
helped families use their improved communication
and problem-solving skills to facilitate this. Treat-
ments with similar components have improved dia-
betic control (Anderson, Wolf, Burkhart, Cornell,
& Bacon, 1989; Delamater et al., 1990).
4. Parents simulated living with diabetes for 1 week
between sessions 7 and 8. Satin, La Greca, Zigo, &
Skyler (1989) showed that this intervention pro-
duced broad cognitive and affective benefits, and it
is compatible with the BFST incorporation of cog-
nitive restructuring methods. This included multi-
ple daily injections of sterile saline on the child’s
Behavioral Family Therapy in Diabetes 931
insulin schedule; daily blood glucose checks on
the child’s schedule; monitoring and regulating
carbohydrate intake; and managing one simulated
hypoglycemic event (parents were notified by the
therapist to indicate onset of “hypoglycemia”).
5. Therapists could extend the intervention to other
social networks affecting the youths’ diabetes care
by involving peers, siblings, teachers, or others
and conducting sessions in other locations if nec-
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essary (Henggeler, Schoenwald, & Pickrel, 1995).
Participation Incentives
Participants were paid to promote adherence to the study
tasks. Each family was paid $100 ($50 for parents and
$50 for youth) for completing the scheduled evaluations.
Each ES and BFST-D family received another $100, dis-
tributed in the same way, if they attended all 12 sched-
uled intervention sessions for their respective groups.
These incentives resulted in >90% retention of the study
sample in our previous work (Wysocki et al., 2001).
Measurement Methods and Schedule
Measures were collected at a baseline evaluation preceding
randomization. Some measures were collected at baseline
only for evaluation as moderators of treatment outcome,
and those are not described in detail here since they were
not included in the analyses for this article. These measures
included the Brief Symptom Inventory (DeRogatis, 1977),
Millon Adolescent Clinical Inventory (Millon, Millon, &
Davis, 1997) and the Family Assessment Device (Kabacoff,
Miller, Bishop, Epstein, & Keitner, 1990). Analyses perti-
nent to these measures will be the topic of a future report.
The General Information Form yielded demo-
graphic and medical information and the data that were
needed to calculate the Hollingshead index of social sta-
tus (1975, unpublished manuscript).
The following measures were collected at baseline
and at the end of treatment (6 months):
The Parent–Adolescent Relationship Questionnaire
(PARQ)
PARQ assesses the primary constructs of the behavioral
family systems model (Robin, Koepke & Moye, 1990). It
yields norm-referenced standard scores for three factor
analytically derived scales: overt conflict/skill deficits,
extreme beliefs, and family structure. There are separate
forms for adolescents (314 true–false items) and parents
(280 items). Internal consistency ranged from .73 to .89
for this sample. The proportions of study participants
whose scores were at or above a clinical cut-off of T = 65
on “overt conflict/skill deficits” were 2.8% for adolescents,
932 Wysocki et al.
2.0% for mothers, and 7.1% for fathers. For “extreme
beliefs,” the corresponding proportions of scores above
the clinical cut-off were 9.2, 2.0, and 4.3%, respectively.
Finally, for “family structure,” clinically significant
scores were obtained for 4.7, 3.8, and 1.7% of adoles-
cents, mothers, and fathers, respectively.
The Diabetes Responsibility and Conflict Scale (DRC)
DRC assesses parent–child division of diabetes responsi-
bilities and family conflict about 15 diabetes-related
tasks (Rubin, Young-Hyman, & Peyrot, 1989). Internal
consistency ranged from .86 to .92 for this sample.
The Diabetes Self-Management Profile (DSMP)
DSMP is a structured interview for the assessment of diabe-
tes treatment adherence that was adapted from methods
developed by Hanson, Henggeler, & Burghen (1987). The
revised interview incorporates introductory comments
designed to normalize the difficulty of regimen adherence.
Questions were re-worded to enhance the ability to capture
flexible diabetes self-management as it is currently prac-
ticed (e.g., insulin pump therapy). The revised interview
(Harris et al., 2000) consisted of 24 adherence questions
regarding 5 regimen domains (insulin, blood glucose test-
ing, diet, exercise, and management of hypoglycemia).
Internal consistency based on the present sample was .79
with 6-month test–retest reliability of .58. Scoring reliability
across independent raters was .95. Total scores did not dif-
fer between parents and adolescents interviewed separately,
and the correlation between parent and adolescent scores
was r = .45 (p < .001). Baseline DSMP total scores corre-
lated significantly with HbA1c levels with r = .29 (p < .01).
Glycosylated Hemoglobin (HbA1c)
HbA1c was measured quarterly at routine clinic visits with
the DCA-2000 system (Bayer Diagnostics, Tarrytown, NY,
USA). Assays completed at the two sites had been stan-
dardized against a reference laboratory, and the results
confirmed its accuracy and consistency. The equivalence
of DCA-2000 and reference laboratory measurements was
also confirmed in a recent study (Diabetes Research in
Children Network Study Group, 2005).
Assurance of Procedural Consistency and Integrity
Several methods ensured cross-site consistency of study
procedures. A detailed operations manual described
each study procedure. A previously prepared BFST manual
was revised to reflect the BFST-D changes. The ES inter-
vention was also guided by a manual (Johnson, 2000).
Clinicians implementing the BFST-D and ES interven-
tions spoke weekly by phone to plan intervention delivery.
Additional efforts assured the integrity of BFST-D. A
second therapist rated videotapes of each BFST-D
session for treatment fidelity. The ratings were discussed
in weekly phone conferences and deviations were
resolved. The vast majority of ratings affirmed the integ-
rity of the BFST-D intervention. Virtually all issues that
were raised reflected legitimate differences in clinical
judgment rather than violations of the written protocol.
Data Management and Statistical Analysis Plans
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Research assistants checked all measures for appropriate
completion before families left the evaluation session and
corrected any administration errors. Data were then
entered into a computer data file on a local area network
at one of the centers. Data were checked for normality of
distributions and for outliers or data entry errors before
analyses. Statistical analyses began by comparing the
groups at baseline on demographic and outcome vari-
ables. Since baseline HbA1c was correlated significantly
with many of the outcome measures obtained at baseline,
the general analysis plan for each outcome measure was
to treat experimental groups (SC, ES, and BFST-D) and
baseline HbA1c (above or below the median value of
9.0%) as between-subjects factors in repeated measures
analyses of variance. The number of adolescents in each
group with HbA1c <9.0% and ≥ 9.0%, respectively, was
SC: 16 and 16; ES: 17 and 19; and BFST-D: 18 and 18. For
analyses of treatment effects on HbA1c, the dependent
variable was change in HbA1c from baseline to 6 months.
To reduce the number of statistical comparisons, PARQ,
DRC, and DSMP scores from adolescents and parents
were combined to form family composite scores for these
measures that were then submitted to statistical analyses.
In all of these cases, family members’ scores were signifi-
cantly correlated, with r-value ranging from .37 to .63.
Results
Sampling and Randomization
Table I summarizes baseline demographic characteris-
tics of the three groups. There were no statistically sig-
nificant between-group differences at baseline on patient
age, duration of diabetes, socioeconomic status, or of the
distributions of gender, race/ethnicity, family composi-
tion, or parental marital status. The sample included the
following proportion of families in each Hollingshead
socioeconomic stratum: lower: 4.8%; lower middle:
21.2%; middle: 38.5%; upper middle: 24.0%; and upper:
11.5%. The groups also did not differ significantly at
baseline with respect to HbA1c or scores on the PARQ,
DRC, or DSMP. Members of racial and ethnic minorities
comprised 37% of the sample. Among the 104 families

who were randomized, 92 (29 SC, 35 ES, and 28 BFST-D)
completed the baseline and 6-month evaluations
reported in this article. The 12 dropouts did not differ
significantly at baseline from those who completed the
study in terms of any outcome measure analyzed for this
paper. Compared to those who completed the study,
dropouts had significantly lower SES (mean Hollings-
head index = 41.5 versus 30.7) and were significantly
less likely to be living with both biological parents (45
versus 25%). There were no statistically significant dif-
ferences across sites or therapists on any of the outcome
measures at baseline or 6-month follow-up.
Hypothesis 1 (Family Relationships and Conflict)
Table II summarizes that change in PARQ family compos-
ite T scores from baseline to 6 months did not differ signif-
icantly among treatment groups for the overt conflict/skill
deficits, extreme beliefs or family structure subscales. Nei-
ther the main effect for group nor the group × time inter-
action effect was statistically significant. Hypothesis 1 was
therefore not confirmed relative to effects on the PARQ.
Mean DRC family composite scores for each group
at baseline and 6 months, respectively, were SC: 25.9 and
29.4; ES: 29.4 and 32.1; and BFST-D: 27.5 and 26.9. The
increase in DRC scores in the SC and ES groups and
slight decrease for the BFST-D group yielded a significant
group × time interaction effect [F(2,89) = 4.31; p <.02].
Further, a significant group × time–baseline HbA1c
interaction [F(2,87) = 3.27; p <.04] indicated that this
treatment effect varied in magnitude as a function of
baseline HbA1c level. Figure 1 portrays this interaction
graphically by presenting change in family composite
DRC scores from baseline to 6 months for youths with
HbA1c above and below the median baseline level (9.0%)
for each group. BFST-D yielded significantly greater
reduction in DRC scores than either of the other two
Table II. Mean (SD) family Composite Scores on the PARQ Subscales
for Each Treatment Group at Baseline and 6 Months
PARQ scores at baseline
Overt conflict/ Extreme
Skill deficits beliefs
Treatment groups
SC 50.7 (5.9) 50.4 (7.3)
ES 50.8 (6.4) 49.7 (8.1)
BFST-D 50.8 (7.3) 51.7 (7.0)
PARQ scores at 6 months
SC 49.9 (6.3) 48.7 (8.8)
ES 49.6 (6.1) 48.8 (7.5)
BFST-D 50.0 (6.7) 48.7 (8.4)
There were no statistically significant between-group differences at baseline or
6 months and the group × time interaction effect was not statistically significant.
Behavioral Family Therapy in Diabetes 933
groups, and this effect was limited to those with baseline
HbA1c above 9.0%. Hypothesis 1 was therefore con-
firmed with respect to differential treatment effects on
DRC scores, although this effect occurred only for those
in the poorest diabetic control at baseline, and the effect
is best described as attenuation by BFST-D of worsening
conflict that occurred among the comparison groups.
Hypothesis 2 (Treatment Adherence)
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Mean treatment adherence (DSMP) scores obtained for
each group at baseline and 6 months, respectively, were
SC: 53.0 and 51.4; ES: 55.2 and 54.6; and BFST-D: 54.7
and 57.4. The main effect for groups and the group × time
interaction effect failed to achieve statistical significance.
However, there was a significant group × time × baseline
HbA1c interaction effect [F(2,89) = 3.63; p <.03]. Figure 2
illustrates change in DSMP total scores from baseline to
6 months as a function of treatment group and baseline
HbA1c. Post-hoc analyses showed that BFST-D yielded
significantly greater improvement (or less decline) in
treatment adherence relative to both of the other treat-
ment groups and within both baseline HbA1c ranges.
Hypothesis 2 was therefore confirmed with respect to
superiority of BFST-D over the other treatment groups
in terms of effects on treatment adherence.
Hypothesis 3 (Glycemic Control)
Mean HbA1c levels at baseline and 6 months, respec-
tively, were SC: 9.5 and 9.2%; ES: 9.7 and 8.9%, and
BFST-D: 9.6 and 8.8%. Neither the main effect for groups
nor the group × time interaction effect were significant. But,
6-Month Change in DRC Family Composite Score
Baseline HbA1c Levels
<9.0% >9.0%
7
5
3
SC
1
ES
-1 BFST-D
-3
Family
structure -5
-7
(Lower scores = less family conflict)
49.7 (6.6)
49.2 (7.6)
Figure 2. Mean change in diabetes-related conflict (DRC) scores from
51.3 (7.3) baseline to 6 months for the standard care (SC), educational support
group (ES), and behavioral family systems therapy for diabetes (BFST-D)
48.2 (7.6) groups reported separately for youths with glycosylated hemoglobin
48.0 (8.3) (HbA1c) <9.0% and ≥ 9.0%. Lower scores indicate reduced diabetes-
related family conflict. The group × time interaction effect (p < .02) and
51.9 (7.2)
group × time–baseline HbA1c interaction effect (p < .04) were
statistically significant. Post-hoc analyses showed that effects of BFST-D
were significantly greater among those with HbA1c > 9.0%.
934 Wysocki et al.
Baseline HbA1c Levels
6-Month Change in DSMP Total Score + 1SEM
<9.0% >9.0%
5 1
4
3
2 0
1 SC
0 ES
-1
-2
-3
-4
-5
(Higher scores = better adherence)
Figure 3. Mean change in the diabetes self-management profile
(DSMP) scores from baseline to 6 months for the standard care (SC),
educational support group (ES), and behavioral family systems
therapy for diabetes (BFST-D) groups reported separately for youths
with glycosylated hemoglobin (HbA1c) <9.0% and ≥ 9.0%. Higher
scores indicate improved diabetes self-management behaviors. The
group × time–baseline HbA1c interaction effect was statistically
significant (p < .03). Post-hoc analyses showed that BFST-D yielded
more improvement in DSMP scores than the ES and SC groups in
both baseline HbA1c ranges.
as illustrated in Fig. 4, the group × time × baseline HbA1c
interaction effect were statistically significant [F(2,89) =
3.17; p <.05]. Although HbA1c tended to decline somewhat
for all three treatment groups, post-hoc comparisons
showed that, among those with baseline HbA1c above 9.0%,
improvement in HbA1c was significantly greater for both
the BFST-D (–1.3%) and the ES groups (–1.1%) than for the
SC group (–0.4%). Figure 3 portrays the interactive effects
of the treatments on change in HbA1c as a function of base-
line HbA1c. The difference between the ES and BFST-D
groups did not achieve statistical significance. Hypothesis 3
was therefore partially confirmed in that BFST-D was supe-
rior to the SC group, but not the ES group, in terms of
improving metabolic control during the study. The benefits
of both ES and BFST-D were most evident for those with
poor metabolic control at baseline (Fig. 4).
Hypothesis 4 (Health Care Utilization)
Participants had 10 hospitalizations and 12 emergency
room visits during the 6-month study. Hospital admissions
for each group were SC: 4; ES: 3; and BFST-D: 3. Emer-
gency room visits for each group was SC: 4; ES: 5; and
BFST-D: 3. Inferential statistical analysis was inappropriate
due to the very low frequencies of these events and because
13 of the 22 episodes were not related directly to diabetes.
Discussion
This article reports the immediate posttreatment results
of a randomized controlled trial comparing SC for diabetes
Baseline HbA1c Levels
6-Month Change in HbA1c (%) + 1 SEM
<9.0% >9.0%
0.5
SC
-0.5 ES
BFST-D
BFST-D -1
-1.5
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-2
(Lower scores = improved metabolic control)
Figure 4. Mean change in HbA1c from baseline to 6 months for the
standard care (SC), educational support group (ES), and behavioral
family systems therapy for diabetes (BFST-D) groups reported
separately for youths with HbA1c <9.0% and >9.0%. Lower scores
indicate improved metabolic control. The group × time–baseline
HbA1c interaction effect was statistically significant (p < .05). Post-
hoc analyses showed that both BFST-D and ES yielded more
improvement in HbA1c compared to SC and that this was limited to
youths with baseline HbA1c ≥ 9.0%.
mellitus alone to augmentation of SC by 6 months of
family participation in either a 12-session multifamily
ES or to 12 sessions of BFST-D. The BFST-D treatment
had been revised in response to a previous trial in an
effort to enhance the effects of the intervention on treat-
ment adherence, glycemic control, and health care utili-
zation (Wysocki et al., 1997, 1999, 2000, 2001).
Effectiveness of this revised BFST-D intervention rela-
tive to the SC and ES conditions was evaluated by com-
paring change in four sets of outcome measures over
6 months of treatment. Overall, the results yielded sup-
port for the hypothesized effectiveness of BFST-D and
suggested that the refinements made to the previously
tested intervention did enhance the intervention’s
impact on certain diabetes outcomes. This adds to a
growing literature describing other empirically validated
interventions for this population (Anderson et al., 1989;
Delamater et al., 1990; Ellis et al., 2005; Ellis, Naar-
King, Frey, Rowland & Greger, 2003; Grey, Boland,
Davidson, Li, & Tamborlane, 2000; Hampson et al.,
2001; Laffel et al., 2003) by showing that BFST-D
yielded significant benefits to adolescents and their fam-
ilies in terms of several diabetes-specific outcomes.
Hypothesis 1 predicted that BFST-D would yield
significantly greater improvement in parent–adolescent
relationships (PARQ scores) and diabetes-related family
conflict (DRC scores) compared to SC or ES. Hypothesis 1
was partially confirmed since significant group × time
and group × time × baseline HbA1c interactions were
obtained. Diabetes-related family conflict was decreased
slightly during treatment for the BFST-D group, whereas
it increased for the SC and ES groups during the same

period. This difference, as illustrated in Fig. 2, was attrib-
utable primarily to fairly substantial treatment effects for
youths with the poorest baseline HbA1c levels and is
best described as prevention of worsening of diabetes-
related family conflict that occurred in the SC and ES
groups. The absence of corresponding effects on more
general parent–adolescent relationships (i.e., PARQ
scores) may reflect the emphasis within BFST-D on tar-
geting diabetes-specific problems rather than focusing
on more general aspects of family relationships. Also, in
distinction to the present trial, the enrollment criteria
for the previous BFST trial required that families
exceeded specific cut-off scores indicating moderate or
greater family conflict. Consequently, PARQ scores for
the present sample were comparatively lower, possibly
diminishing the capacity to detect treatment effects on
this measure. Alternatively, study participation may
have sensitized some participants to problems in family
communication or conflict resolution that were not
readily apparent to them at baseline. Each of these inter-
pretations is quite speculative at this time.
Hypothesis 2 consisted of the prediction that BFST-D
would yield more improvement in diabetes self-
management behaviors (DSMP scores) compared with
either SC or ES. The results clearly confirmed Hypothesis 2
by revealing a statistically significant main effect for
treatment group favoring BFST over SC and ES and by a
significant group × time interaction effect, as shown in
Fig. 3. DSMP scores were significantly more favorable
for the BFST-D group than the SC or ES groups within
both baseline HbA1c ranges.
Hypothesis 3 addressed the comparative effects of SC,
ES and BFST-D on change in HbA1c levels during treat-
ment. As illustrated in Fig. 4, both ES and BFST-D yielded
substantial reductions in HbA1c among those with base-
line levels above 9.0%. The magnitude of these changes is
considered to be quite significant clinically because these
reductions amount to an approximate 0.7 standard devia-
tion difference relative to baseline for the ES group and a
0.8 standard deviation difference for the BFST-D group.
Hypothesis 4 was not submitted to statistical analy-
sis because the frequencies of hospitalizations and emer-
gency room visits were so low. The recorded 10
hospitalizations and 12 emergency room visits were dis-
tributed evenly across groups, and most of these events
were not diabetes related. Further follow-up of the sam-
ple for an additional year may clarify whether these
measures of health care utilization differ among the
treatment groups over a longer interval.
Overall, the study results suggest substantial prom-
ise for the revised BFST-D intervention for reducing
Behavioral Family Therapy in Diabetes 935
family conflict about diabetes and for improving treatment
adherence and metabolic control. The observation that
these effects were more evident for families of those
youths entering the study with poor metabolic control is
encouraging, because these are the youths who often
endure prolonged maladjustment to diabetes and a
downward spiral of poor metabolic control, psychiatric
disorders, acceleration of long-term complications, and
excess health care costs (Bryden et al., 2001; Wysocki,
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Hough, Ward & Green, 1992).
Mechanisms that may account for the stronger
BFST-D treatment effects on HbA1c and diabetes-related
family conflict (DRC scores) among families of adoles-
cents with poor metabolic control at baseline remain to
be identified. Possibly, specification of treatment targets
with such adolescents and their families may be more
obvious than for those whose diabetes-management dif-
ficulties are somewhat less salient. When families
exhibit glaring problems with diabetes management,
modest behavior change may yield more pronounced
benefits that might be less evident for families with
slightly more competence. Stated another way, adoles-
cents in very poor metabolic control before treatment
may simply have had more room for improvement in
both self-management behaviors and glycemic control.
Whether these or other explanations prove accurate, it is
encouraging that adolescents with poor metabolic con-
trol enjoyed clinically meaningful treatment gains
through BFST-D.
Certain limitations of the study should be noted.
The feasibility of delivery of BFST-D in most clinical set-
tings, especially given the constraints imposed by the
health care economy, is questionable. The study was
conducted under optimal circumstances that are
unlikely to exist in typical clinical settings. Participants
were paid for completing study evaluations, intervention
sessions were provided without charge, and substantial
flexibility in appointment times was offered to make
engagement in therapy as convenient as possible. These
features are unlikely to be feasible in most pediatric set-
tings. Future research on BFST-D should focus on opti-
mizing its cost effectiveness through such mechanisms
as reducing the number of sessions, evaluating delivery
to multiple families concurrently rather than to individ-
ual families, or supplementation of BFST-D sessions via
internet or interactive telecommunication methods.
Other important limitations relate to sampling and
retention. The sample size was relatively small for a trial
of this type, and 88% of the sample completed both eval-
uations. As a consequence, the cell sizes for certain of the
interaction effects reported in this article were sometimes
936 Wysocki et al.
small, increasing the likelihood that spurious effects
would prove to be statistically significant. However, the
benefits of BFST-D to those with poor metabolic control
were confirmed across three different outcome measures
including questionnaires (DRC), structured interviews
(DSMP), and biochemical assays (HbA1c). The consis-
tency of these findings across different outcome mea-
sures and methods bolsters confidence that these were
not spurious results.
Also, the selective benefits from BFST-D accruing to
those with poor baseline metabolic control were identi-
fied through secondary data analyses and were not
stated as a priori scientific hypothesis. Confidence in
these findings and the conclusions drawn from them
would be stronger had these observed relationships been
hypothesized in advance.
Finally, the present article evaluated a complex
intervention with multiple components. Consequently,
“dismantling studies” to identify the critical elements of
BFST-D may prove difficult.
The present article addresses only the immediate
treatment effects of BFST-D on the various outcomes.
Although the previous trial (Wysocki et al., 1997, 1999,
2000, 2001) demonstrated lasting treatment effects on
measures of parent–-adolescent relationships, diabetes-
related family conflict, and treatment satisfaction, the
durability of the treatment effects reported here remains
to be confirmed. Follow-up of the present sample for an
additional 12 months after treatment will be the topic of
subsequent reports.
Acknowledgments
This study was supported by NIH grant 1-RO1-DK43802
to the first author and NIH grants P60-DK20579 and
RR00036 which support the Diabetes Research and Train-
ing Center and General Clinical Research Center at the
Washington University School of Medicine.
Received May 10, 2005; revision received July 5, 2005 and
August 1, 2005; accepted December 11, 2005
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