Objective To create a functional status outcome measure for large outcome studies that is well defined, quantitative, sufficiently rapid, reliable, minimally dependent on subjective assessments, and applicable to hospitalized pediatric patients across a wide spectrum of ages and inpatient environments. Patients and Methods The Functional Status Scale (FSS) was developed by a multidisciplinary consensus process. Domains of functioning included mental status, sensory, communication, motor, feeding, and respiratory categorized from normal (1) to very severe dysfunction (5). The Adaptive Behavior Assessment System (ABAS) II established construct validity and calibration within domains. Seven institutions provided pediatric intensive care unit (PICU) patients within 24 hours of PICU discharge, high-risk non-PICU patients within 24 hours of admission, and technology-dependent children. Primary care nurses completed the ABAS II based on patient’s functioning when the FSS was completed. Patients from 10% of the study days were used to evaluate inter-rater reliability. Data were randomly split into estimation and validation sets. Statistical analyses included Pearson correlations, construct validity, linear regression analysis, receiver operating characteristic (ROC) curve analysis for discriminant validity, and the intraclass correlation for inter-rater reliability. Results A total of 836 children with a mean FSS of 10.3 (standard deviation 4.4) were studied. Eighteen percent had the minimum possible FSS = 6, 44% had FSS ≥ 10, 14% had a FSS ≥ 15, and 6% had FSS scores ≥ 20. Each FSS domain was associated with mean ABAS II (p<.0001). Cells in each domain were collapsed and reweighted, which improved correlations with ABAS II from −0.58 to −0.62 in the estimation sample, and −0.60 to −0.63 in the validation sample (p<0.001 for improvements). Discrimination was very good for moderate and severe dysfunction (ABAS II categories) and improved with FSS weighting (area under the ROC curve > 0.8). Intraclass correlations of original and weighted total FSS were 0.95 and 0.94 respectively. Conclusions The FSS met our objectives and is well suited for large outcome studies.

Close parental monitoring of care completion can contribute to better adherence in adolescents with diabetes. General warmth and support in the absence of careful parental supervision may be insufficient to help youth achieve adequate levels of adherence.

The purpose of this study was to shorten an HIV stigma scale to make it less burdensome for HIV + youth without compromising psychometric properties. The shortened questionnaire showed good internal consistency and validity; suggesting that a 10 item measure of stigma has promise for assessing this important construct in HIV + youth.Stigma is a discrediting social label which changes the way the individual looks at him/her self and disqualifies them from full social acceptance 1 . HIV has a particular, insidious stigmatization since it is associated with factors which imbue judgment and criticism such as sexual behavior and substance use 2 . This "blaming the victim" increases the isolation and shame that the individual internalizes 3 which leads to fear of accessing services 4, 5 as well as psychosocial consequences. In a study in an urban clinic of adult HIV patients, HIV stigma using the Berger scale of stigma, was associated with depressive symptomatology and a lower quality of life 6 .The stigma felt by HIV+ youth and the consequences of this stigma have not been studied. The first step is to ensure adequate measurement of stigma in this population. Berger developed a 40-item measure for HIV+ adults (predominantly Caucasian and male). 7 The purpose of the present study was to reduce instrument burden by shortening the HIV Stigma Scale to 10 items and to test its psychometric properties in a sample of predominantly African American youth (16-25) with HIV. We hypothesized that the shortened measure would have good internal

OBJECTIVE -The aim of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could improve adherence and metabolic control and decrease rates of hospital utilization among adolescents with chronically poorly controlled type 1 diabetes. RESEARCH DESIGN AND METHODS-A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and chronically poor metabolic control (HbA 1c [A1C] Ն8% for the past year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants randomly assigned to MST received treatment for ϳ6 months. Data were collected at baseline and at 7 months posttest (i.e., treatment termination). Changes in A1C adherence, as measured by semistructured interviews and blood glucose meters and hospital admissions and emergency department visits, were assessed.RESULTS -In intent-to-treat analyses, participation in MST was associated with significant improvements in the frequency of blood glucose testing as assessed by blood glucose meter readings (F[1,125] ϭ 16.75, P ϭ 0.001) and 24-h recall interviews (F[1,125] ϭ 6.70, P ϭ 0.011). Participants in MST also had a decreasing number of inpatient admissions, whereas the number of inpatient admissions increased for control subjects (F[1,125] ϭ 6.25, P ϭ 0.014). Per protocol analyses replicated intent-to-treat analyses but also showed a significant improvement in metabolic control for adolescents receiving MST compared with control subjects (F[1,114] ϭ 4.03, P ϭ 0.047).CONCLUSIONS -Intensive, home-based psychotherapy improves the frequency of blood glucose testing and metabolic control and decreases inpatient admissions among adolescents with chronically poorly controlled type 1 diabetes. Diabetes Care 28:1604 -1610, 2005T he deterioration in adherence behavior associated with the transition to adolescence is well documented among children with type 1 diabetes (1-3). However, a subset of high-risk adolescents demonstrate more serious adherence problems, as evidenced by chronically poor metabolic control (CPMC). In addition to the health risks associated with CPMC, such adolescents consume a disproportionate share of health care dollars due to inpatient hospitalizations for diabetic ketoacidosis (DKA) (4,5). The development of effective behavioral interventions for these adolescents is therefore of high priority. Given the known declines in adherence during adolescence, several interventions have been developed to improve adherence and metabolic control among youth with type 1 diabetes (6 -9). However, there have been few clinical trials that focus exclusively on those with CPMC. Existing intervention studies targeting adolescents with CPMC (10 -15) are generally characterized by either small sample size, low recruitment rates, short intervention periods, or limited success in improving behavioral and health outcomes.Furthermore, despite the substantial descriptive literature suggesting that adolescents with CPMC are embedded within multiple syste...

ABSTRACT. Objective. The goal of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Stress was also evaluated as a mediator of the effect of MST on adherence and metabolic control.Methods. A randomized, controlled trial was conducted with 127 adolescents with type 1 diabetes mellitus and chronically poor metabolic control (hemoglobin A1c levels of >8% at study enrollment and for the past 1 year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants assigned randomly to MST received treatment for ϳ6 months. Data were collected at baseline and at a 7-month posttest (ie, treatment termination). Changes in diabetes-related stress, as measured with a self-report questionnaire, were assessed. Structural equation models were used to test the degree to which changes in stress levels mediated the ability of the MST intervention to improve adherence and metabolic control.Results. In intent-to-treat analyses, participation in MST was associated with significant reductions in diabetes-related stress. Tests for moderation found no significant effects of age, gender, or ethnicity, which suggests that the intervention was equally effective in reducing diabetes stress for all participants. However, structural equation modeling did not provide support for diabetes stress as the mechanism through which MST improved health outcomes. Rather, the final model suggested that MST improved metabolic control through increased regimen adherence.Conclusions. Intensive, home-based psychotherapy reduces diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Such stress reductions are important for the psychological wellbeing of a subset of youths with diabetes who are at high risk for future health complications. A dolescents with type 1 diabetes mellitus face a number of stressors and challenges as a result of their chronic illness. [1][2][3][4] These include the need to manage a complex medical condition that requires daily completion of multiple selfcare behaviors, the impact of diabetes on social interactions with family members, peers, and teachers, and the interference of symptoms such as hypoglycemia with daily activities.Previous studies investigated the impact of stress on health outcomes among persons with type 1 diabetes. The effects of stress on regimen adherence and metabolic control have been of particular interest. Stress has the potential to affect metabolic control directly through its impact on cortisol and other catabolic hormones that interfere with insulin metabolism. It may also affect metabolic control indirectly, by interfering with completion of self-care tasks. However, prior findings have been mixed, with some studies supporting a direct relationship between stress and metabolic control, some suggesting that adherence mediates the relationship between stress and me...

This study piloted a brief individual motivational intervention targeting multiple health risk behaviors in HIV-positive youth aged 16-25. Interviews about sexual behavior and substance use and viral load testing were obtained from 51 HIV-positive youth at baseline and post intervention. Youth were randomized to receive a four-session motivational enhancement intervention (N = 25) or to a wait-list control (N = 26). Of the eligible youth approached, 88% agreed to participate, and 80% percent of participants completed at least three of four sessions. The treatment group showed significantly greater reductions in unprotected sex acts and in viral load compared with controls. Although change scores for substance use were not significantly different between the two groups, paired t tests demonstrated that reductions in alcohol use and marijuana use were significant for the treatment group at the trend level. There were no significant differences in substance use from baseline to posttest for the control group. Findings demonstrate the potential of a brief motivational enhancement intervention to improve health risk behaviors in HIV-positive youth. Larger randomized clinical trials are warranted. Resources required for retention should not be underestimated.

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OBJECTIVE -The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated. RESEARCH DESIGN AND METHODS-A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care.RESULTS -Youth who received MST had significantly fewer hospital admissions than control subjects ( 2 ϭ 11.77, 4 d.f., n ϭ 127; P ϭ 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P ϭ 0.004), 12-month (P ϭ 0.021), 18-month (P ϭ 0.046), and 24-month follow-up (P ϭ 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions.CONCLUSIONS -The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance. Diabetes Care 31:1746-1747, 2008W e have previously reported on multisystemic therapy (MST), an intensive home-based family therapy, for youth with chronically poor metabolic control (CPMC). MST produced improvements in metabolic control and reducted indicators of serious nonadherence (DKA hospital admissions) at treatment termination (1,2). Reductions in admissions were maintained 6 months later (2). The present study investigated the effects of MST on DKA admissions at the conclusion of the trial and related cost savings. RESEARCH DESIGN ANDMETHODS -A total of 127 adolescents with CPMC and their families were recruited from endocrinology clinics at Children's Hospital of Michigan between 1999 and 2004. Eligible youth were diagnosed with type 1 diabetes for at least 1 year, had an average A1C of Ն8% during the year before study entry, and were aged 10 -17 years. Mean Ϯ SD A1C at study entry was 11.3 Ϯ 2.3%. A total of 92% of the subjects used injected insulin, and 8% used insulin pumps. Mean Ϯ SD age was 13.2 Ϯ 2.0 years, and 63% of participants were African American.A total of 64 participants were randomly assigned to MST and 63 to a control group. All families received quarterly visits with a multidisciplinary diabetes team. MST-treatment families also received 6 months of therapy (mean 5.7 months). Families were followed for 24 months total. MST targeted adherence-related problems within the family and broader community systems (1,3). These systems included family (e.g., poor parental supervision and oversight of the youth's diabetes care completion), school (e.g., inadequate communication between parents and school personnel regarding the youth's health needs), and health care system factors (e.g., barriers to keeping clinic appointments due to problems with transportation or family disorganization).The number of DKA admissions was obtained from the treating hospital's information system for the 6-month window before study entry (ba...