**5. Role of new interventions**

Woolston and colleagues[84] stated the principles for new interventions should be familyfocused with services provided in the home to enhance effectiveness. The team providing these services should be multidisciplinary in nature, in order to identify concerns from different perspectives that might benefit the family. This type of intervention should help the child and family achieve self-sufficiency and ultimately no longer require the in-home services.

An innovative approach to home-based intervention is through telehealth. Telehealth interventions permit diabetes educators and mental health providers trained in behavioral treatment of diabetes adherence to assist their patients in their home environment without contending with logistical challenges of scheduling face-to-face contact.[85][86] Telemedicine provides an immediate and efficient way for health care providers and their patients to communicate. This improved communication increases the timeliness of feedback, which makes treatment more efficient and responsive.[87]

In a review of how telehealth could be integrated into mental health care, Stamm[88] noted that one of the great strengths of telehealth is that it can overcome significant barriers to treatment, including economics and geography. These barriers are often identified in mental health, as patients report that they cannot keep their appointments because they cannot afford transportation, or because they do not have the flexibility in their job to leave work to attend sessions. Additionally, telehealth allows providers to increase their availability over a wider geographical area, since patients will no longer have to travel long distances to receive appropriate services.[89]

Two of the ways in which telehealth can be used has been used with patients with diabetes are home telemonitoring and telephone support.[90] Home telemonitoring can be further divided based on a timing distinction: real-time interaction or delayed.[92] Phone calls and videoconferencing fall into this category. Delayed telemonitoring involves data or information that is accessed by a provider after the patient initially sends the information. Telephone support is provided by the clinician but does not necessarily require electronic transmission of patient data.[92]

Video teleconferencing has been examined as a means of maintaining face-to-face contact between provider and patient. Stamm[89] noted that advances in technology are fueling improvements in the utility of these services. A review of the literature provided support for

questions that effectively measures general diabetes knowledge, nutrition, diabetes care at school, hyperglycemia/hypoglycemia, insulin pump, problem solving, blood glucose testing, and sick days diabetes care. The DART was given to both children and their caregivers and A1C levels of each child were provided. It was shown that the children's insulin pump sub-score and children's parents total DART score significantly predicted A1C levels in that higher test scores predicted lower A1C levels.[82] The PedCarbQuiz is another questionnaire that was completed by adolescents or their caregivers and measures carbohydrate and insulin-dosing knowledge. Similar to the results of the study by Heidgerken and colleagues,[82] higher scores achieved by adolescent and their caregivers on the PedCarbQuiz[83] significantly correlated with lower A1C levels. The relationship between diabetes knowledge and A1C levels underlines the importance of diabetes management education in treatment adherence. New interventions are being developed to

Woolston and colleagues[84] stated the principles for new interventions should be familyfocused with services provided in the home to enhance effectiveness. The team providing these services should be multidisciplinary in nature, in order to identify concerns from different perspectives that might benefit the family. This type of intervention should help the child and family achieve self-sufficiency and ultimately no longer require the in-home

An innovative approach to home-based intervention is through telehealth. Telehealth interventions permit diabetes educators and mental health providers trained in behavioral treatment of diabetes adherence to assist their patients in their home environment without contending with logistical challenges of scheduling face-to-face contact.[85][86] Telemedicine provides an immediate and efficient way for health care providers and their patients to communicate. This improved communication increases the timeliness of feedback, which

In a review of how telehealth could be integrated into mental health care, Stamm[88] noted that one of the great strengths of telehealth is that it can overcome significant barriers to treatment, including economics and geography. These barriers are often identified in mental health, as patients report that they cannot keep their appointments because they cannot afford transportation, or because they do not have the flexibility in their job to leave work to attend sessions. Additionally, telehealth allows providers to increase their availability over a wider geographical area, since patients will no longer have to travel long distances to

Two of the ways in which telehealth can be used has been used with patients with diabetes are home telemonitoring and telephone support.[90] Home telemonitoring can be further divided based on a timing distinction: real-time interaction or delayed.[92] Phone calls and videoconferencing fall into this category. Delayed telemonitoring involves data or information that is accessed by a provider after the patient initially sends the information. Telephone support is provided by the clinician but does not necessarily require electronic

Video teleconferencing has been examined as a means of maintaining face-to-face contact between provider and patient. Stamm[89] noted that advances in technology are fueling improvements in the utility of these services. A review of the literature provided support for

help enhance adherence and glycemic control.

makes treatment more efficient and responsive.[87]

**5. Role of new interventions** 

receive appropriate services.[89]

transmission of patient data.[92]

services.

telehealth services in increasing the likelihood of therapy attendance with no loss in treatment benefits. Preliminary data suggests that this approach may be effective in increasing adherence to medical regimens, and can be used as a tool to support ongoing therapy. Piette and colleagues[91] designed an intervention where adult patients with diabetes received biweekly telephone calls from diabetes educators to discuss diabetes care. The educators were allowed to individualize the information provided to the specific needs of each patient. They found that their intervention improved glycemic control, and reduced diabetes-related symptoms.[90] Additionally, they found that this intervention reduced patient-reported depressive symptoms, improved self-efficacy with regard to diabetes care, and reduced the number of days spent in bed. These patients also reported greater satisfaction with the level of health care provided.[91]

Polisena and colleagues[92] metaanalysis on telehealth for diabetes found that telehealth had a positive impact on both the utilization of health services as well as glycemic control. In the 26 studies they examined, they consistently found significant benefits of home telemonitoring on glycemic control, reduced hospital visits, and shorter hospital stays. The results on telephone support in the metaanalysis by Polisena and colleagues[92] were less clear although some studies found increased patient satisfaction and reported improved quality of life. A possible reason for the inconsistent findings within the telephone support was the significant variability in the strategies used.[92]

A possible strategy to address this problem in youth with T1D would be implementing Behavioral Family Systems Therapy (BFST) through telehealth. BSFT has shown to improve family relationships and communication in families with children who have diabetes.[92][93] In addition, Wysocki and colleagues[95] found that BSFT led to improved treatment adherence and metabolic control.

BSFT includes numerous strategies to improve adherence.[95][96] More specifically, BSFT has 4 treatment strategies including problem solving, communication skills training, structural family therapy for role clarification, and cognitive restructuring. The first strategy is a structured approach to problem solving. As adolescence can be a period of increased conflict between parents and teens, the use conflict resolution skills to reduce family tension can be very therapeutic. The steps in the problem solving technique are: a) define the problem, b) set a goal, c) brainstorm ways to accomplish the chosen goal, d) evaluate the ideas, e) implement the plan, and f) revise the goal.[95][96]

The second strategy in BFST is communication skills training that focuses on improving communication between parents and adolescents around diabetes related tasks and adherence. Often parents and adolescents engage in negative communication patterns, particularly during times of conflict or when negotiating adherence strategies. The communication skills training component is designed to remediate negative communication patterns within the family. This can be an idiosyncratic component, which allows the therapist to tailor interventions to the specific needs of the families. The steps in communication skills are: a) feedback, b) instruction, c) modeling, and d) behavioral rehearsal.[95][96]

The third strategy in BSFT that is useful in improving adherence and glycemic control in families with youth with T1D is the use of structural family therapy to focus on defining roles within the family. Individuals may have ideas about the roles of each family member that have not been shared with other family members. Role confusion within the family can contribute to increased communication problems and conflict. Role clarification and explicit role negotiation within the family, as explicated in structural family therapy, can be used to reduce problems in the family that adversely impact adherence and glycemic control.[95][96]

Contributing Factors to Poor Adherence and Glycemic

*Psychiatry,* Vol. 31*,* pp. 1112-1119. 1992.

pp.977-986.1993.

275. 2001.

41-54. 2002.

Vol. 26(2), pp. 123-129. 2001.

**7. References** 

Control in Pediatric Type 1 Diabetes: Facilitating a Move Toward Telehealth 151

wide variety of childhood behavioral patterns such as internalizing and externalizing, behavioral self-regulation and executive functioning, and peer-victimization may have similar relationships with regimen adherence and glycemic control in youth with T1D. The role of diabetes knowledge and the importance of it's measurement are suggested. Finally the development of new technology in diabetes care and management have been reviewed. The value of newer telehealth technologies are highlighted towards the latter sections of the review. The review demonstrates that Telehealth, used via the telephone or internet, is a cost-effective, convenient way for patients and their healthcare providers to manage and communicate about their diabetes regimen. The work by Geffken and colleagues demonstrates that telehealth can particularly useful for service delivery with families with youth with T1D. Telehealth allows treatment for families with youth with T1D with considerable barriers to their diabetes management such as those who require complex treatments and more frequent consultation with their diabetes care provider than distance or funding will allow. This review provides evidence on the value and critical inclusion of

behavioral health services and research for the treatment of families youth with T1D.

[1] M.A. Rapoff, & M.U. Barnard, "Compliance with pediatric medical regimens", *Patient compliance in medical practice and clinical trials.* New York: Raven Press, 73-98. 1991. [2] M. Kovacs, D. Goldston, S. Obrosky, & S. Iyengar, "Prevalence and predictors of

[3] Diabetes Control and Complications Research Group, "The effect of intensive treatment

[4] K.L. Lemanek, J. Kamps, & N.B. Chung, "Empirically supported treatments in pediatric

[5] A.L.Quittner, D.L. Espelage, C. Ievers-Landis, & D. Drotar, "Measuring adherence to

[6] C. L. Davis, A. M. Delamater, K. H. Shaw, A.M. La Greca, M. S. Eidson, J. Perez-

[7] Diabetes Control and Complications Trial Research Group, "Effect of intensive diabetes

complications trial", *The Journal of Pediatrics,* Vol. 125(2), pp. 177-188. 1994. [8] E. R. Mackey, & R. Streisand, "Brief report: The relationship of parental support and

*Pediatric Psychology*,Vol. 33(10), pp. 1137-1141. 2008.

pervasive noncompliance with medical treatment among youths with insulindependent diabetes mellitus" *Journal of the American Academy of Child and Adolescent* 

of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus", *New England Journal of Medicine,* Vol. 329*,*

psychology: Regimen adherence", *Journal of Pediatric Psychology,* Vol. 26, pp. 253-

medical treatment in childhood chronic illness: Considering multiple methods and sources of information", *Journal of Clinical Psychology in Medical Settings,* Vol. 7, pp.

Rodriguez, & R. Nemery, "Parenting styles, regimen adherence, and glycemic control in 4- to 10-year-old children with diabetes", *Journal of Pediatric Psychology,* 

treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes control and

conflictto physical activity in preadolescents with type 1 diabetes", *Journal of* 

The fourth strategy in BFST that can be used therapeutically to improve adherence and glycemic control in families with youth with T1D is cognitive restructuring. Cognitive restructing can used to address cognitive distortions and irrational thinking that can impair problem solving ability within the family. Cognitive distortion can contribute to the maintenance of maladaptive communication patterns and conflict between parents and adolescents, and thereby adversely impacting regimen adherence. Helping parents and adolescents to restructure or "soften" their strong unproductive belief patterns can facilitate more effective communication.[95][96]

Several studies conducted within the research program of Geffken and colleagues provide evidence for the effectiveness of telehealth family psychotherapy for youth with T1D. A case study[94] and case series[95] demonstrated decreased HbA1c in participants as well as improved family dynamics surrounding the diabetes regimen. An open trial of 27 adolescents[96] demonstrated a 0.7% reduction in HbA1c and no diabetes related hospitalizations in an at-risk sample of youth. Additionally, results from a controlled trial show improved metabolic control and family interactions.[97][98] Specifically, relative to those in the wait-list, families in immediate treatment had an average decrease in HbA1c of 1.32% and fewer disagreements around the diabetes regimen between parents and children (*p*<.05). Participants also showed improved adherence to their regimen at end of treatment (*p*<.05). After a one-month follow-up period, however, many participants did not maintain their treatment gains. Over one third had an increase of 0.6% or greater in HbA1c, suggesting that additional sessions would likely aid in maintaining treatment gains. Of the remaining youth, approximately one third maintained gains, while the remaining youth were unable to be reached for follow-up assessments. Although not systematically assessed, our non-study related interactions with these youth (i.e., consultations during their scheduled endocrinology visits) suggest that the overwhelming majority of these youth experienced partial or full relapses. Taken together, these studies demonstrate that intensive telehealth family psychological treatment using a BSFT model improves adherence to the medical regimen, glycemic control, and family dynamics.

According to Azar and Gabbay[87], telemedicine interventions have a wide range of variability. Some systems are more basic and focus phone, email or short message services to faciliatate communication between patients and their providers. In contrast other systems use complex web interfaces that can include home meter information as well as logs for diet and activitiy levels.[99] For example, Carelink, an insulin-pump monitoring system accessed online, significantly improved glycemic control equally among children in both rural and urban areas even though children in rural areas visited clinics less frequently. The Carelink system allowed children and their parents to upload and access information about their glucose levels, amount of insulin required each day, and informed patients of where their blood sugar levels were in comparison to their goal daily sugar level. If dose adjustments were necessary, the diabetes care provider emailed or called their patient to alert them of the change.[100]
