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Effects of Behavioral Family Systems Therapy for Diabetes on Adolescents’ Family Relationships, Treatment Adherence, and Metabolic Control
Abstract
BACKGROUND: Behavioral family systems therapy (BFST) for adolescents with diabetes has improved family relationships and communication, but effects on adherence and metabolic control 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 > or = 9.0%. BFST-D and ES significantly improved HbA1c compared to SC among those with baseline HbA1c > or = 9.0%. CONCLUSIONS: The revised intervention (BFST-D) improved family conflict and treatment adherence significantly, while both ES and BFST-D reduced HbA1c significantly, particularly among adolescents with poor metabolic control. Clinical translation of BFST-D requires further study.
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“Teaching family members effective problem-solving and conflict-resolution skills can improve diabetes management and facilitate better glycemic management, with the potential to reduce diabetes distress (92).”
From Psychosocial care for people with diabetes: a position statement of the American Diabetes Association (2016) · cites this paper as [92]
In the citing paper
“behavioral family interventions to promote collaborative family diabetes management in early adolescence (354,355)”
From 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:Standards of Care in Diabetes—2023 (2023) · cites this paper as [355]
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“In this revision, BFST-D consisted of problemsolving training, communication training, cognitive restructuring, and functional-structural family therapy.(34,35) As predicted, BFST-D significantly improved family conflict, metabolic control, and adherence to treatment among families of adolescents with poor metabolic c…”
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“A revised version that included a greater focus on diabetes-specific behaviors and parent simulation of diabetes self-care behaviors (e.g., blood glucose testing) resulted in improved adherence and reduced conflict surrounding diabetes management (Wysocki et al., 2006).”
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“Research has shown that each of these coping strategies is effective, as is their combination (10-13).”
BackgroundRandomized Trial of Behavioral Family Systems Therapy for Diabetes
Wysocki, T., Harris, M. A., Buckloh, L. M., Mertlich, D., Lochrie, A. S., Mauras, N., & White, N. H. (2007) · Diabetes Care · doi:10.2337/dc06-1613 · Cited by 224
“We have reported elsewhere (13) that 6 months of exposure to this revised intervention, which we have termed Behavioral Family Systems Therapy for Diabetes (BFST-D), yielded immediate posttreatment gains in glycemic control, treatment adherence, and family communication in families of adolescents with suboptimal diabe…”
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“Our initial report of results from this trial (Wysocki et al., 2006) showed that BFST-D yielded significant improvements in HbA1c, treatment adherence, and T1DM-related family conflict at immediate posttreatment follow-up.”
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“have shown improvements in family conflict and regimen adherence (102) (A) as well as improved”
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“, [39]) and have had some success in improving disease-related outcomes.”
BackgroundPsychological care of children and adolescents with diabetes
Delamater, A. M. (2009) · Pediatric Diabetes · doi:10.1111/j.1399-5448.2009.00580.x · Cited by 142
Winkley, K., Upsher, R. J., Stahl, D. R., Pollard, D. J., Kasera, A., Brennan, A., Heller, S. R., & Ismail, K. (2020) · Health Technology Assessment · doi:10.3310/hta24280 · Cited by 156
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“Specifically, the recent application of behavioral family systems (Wysocki et al., 2006, 2007) and multisystemic therapy (Ellis, Podolski, Frey, Naar-King, & Moltz, 2007) shows promise for remediation of these problems.”
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“Empirically supported interventions, such as behavioral family systems therapy (Quittner et al., 2004; Robin & Foster, 1989; Wysocki et al., 2006, 2000), have demonstrated initial benefits for both improved adherence and reduced parent-teen conflict.”
BackgroundBajaj, M. S., McCoy, R. G., Balapattabi, K., Bannuru, R. R., Bellini, N. J., Bennett, A. K., Beverly, E. A., Early, K. B., ChallaSivaKanaka, S., Echouffo-Tcheugui, J. B., et al. (2025) · Diabetes Care · doi:10.2337/dc26-s005 · Cited by 210
Anderson, B. J., Holmbeck, G. N., Iannotti, R. J., McKay, S. V., Lochrie, A. S., Volkening, L. K., & Laffel, L. M. (2009) · Families Systems & Health · doi:10.1037/a0015759 · Cited by 123
“It has also been reported that family conflict with respect to diabetes management increases significantly from late childhood over the transition to adolescence (Anderson et al., 2002; Wysocki, Harris, Buckloh, Wilkinson, et al., 2006).”
Self-citationDevelopmental Changes in the Roles of Patients and Families in Type 1 Diabetes Management
Markowitz, J. T., Garvey, K. C., & Laffel, L. M. (2015) · Current Diabetes Reviews · doi:10.2174/1573399811666150421114146 · Cited by 118
“(60) conducted a 6-month behavioral intervention using Behavioral Family Systems Therapy for Diabetes (BFST-D) compared to two comparison groups (educational support; standard care).”
MethodISPAD Clinical Practice Consensus Guidelines 2014 Compendium
(2015) · Pediatric Diabetes · doi:10.1111/pedi.12239 · Cited by 117
Reed, B., Blount, R. L., & Gilleland, J. (2014) · Families Systems & Health · doi:10.1037/fsh0000039 · Cited by 110
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“Similarly, in a study with families of adolescents with instable diabetes type 1 (Wysocki et al., 2006, 2007) a positive effect was found for an adapted form of Behavioral Family Systems Therapy for Diabetics (BFST-D) when compared with standard care or multifamily educational support.”
Seeing is believing: using skype to improve diabetes outcomes in youth
Harris, M. A., Freeman, K. A., & Duke, D. C. (2015) · Diabetes Care · doi:10.2337/dc14-2469 · Cited by 101
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“A randomized controlled trial of BFST-D showed that although educational support groups and BFST-D had similar effects in improving metabolic control relative to standard care at treatment termination (13), only BFST-D had long-term effects in improving metabolic control at subsequent follow-up (14).”
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“Future research will show whether interventions within a family systems perspective (Wysocki et al., 2006) should be targeted toward greater awareness among adolescents and parents that discrepancies are a natural part of adolescent development or toward resolving discrepancies .”
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“[48–50] White (63.”
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Barriers to Oral Medication Adherence for Adolescents with Inflammatory Bowel Disease
Ingerski, L. M., Baldassano, R. N., Denson, L. A., & Hommel, K. A. (2009) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsp085 · Cited by 97
“For example, behavioral family systems therapy (BFST; (Harris, Freeman, & Beers, 2009; Robin & Foster, 1989; Wysocki et al., 2006) is one example of a family-based intervention that may help families of adolescents diagnosed with IBD effectively problem-solve around barriers impacting medication…”
BackgroundPalmer, D. L., Osborn, P. G., King, P. S., Berg, C. A., Butler, J. M., Butner, J., Horton, D., & Wiebe, D. J. (2010) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsq019 · Cited by 101
“Implicit within the diabetes literature is the notion that there may be two components of parental involvement, one focused on the emotional and supportive quality of the relationship and the other on more instrumental aspects of involvement, including monitoring and behavioral involvement (Berg et al., 2008; Ellis et…”
BackgroundCouple and Family Interventions in Health Problems
Shields, C. G., Finley, M. A., Chawla, N., & Meadors, W. P. (2012) · Journal of Marital and Family Therapy · doi:10.1111/j.1752-0606.2011.00269.x · Cited by 87
A Review of Family and Environmental Correlates of Health Behaviors in High-Risk Youth
Lawman, H. G., & Wilson, D. (2012) · Obesity · doi:10.1038/oby.2011.376 · Cited by 85
“, family conflict) despite research showing adolescents’ adherence to diabetes management is improved through family systems approaches (88).”
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“Family interventions involving parents have been found effective in enhancing treatment adherence and promoting disease outcomes in youths with diabetes [34], cystic fibrosis [35] and HIV [36].”
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Self-citationMaternal Parenting Style and Adjustment in Adolescents with Type I Diabetes
Butler, J. M., Skinner, M. A., Gelfand, D. M., Berg, C. A., & Wiebe, D. J. (2007) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsm065 · Cited by 81
“…such as those based on Behavioral Family Systems theory might be useful for improving family communication and ameliorating difficulties that arise, when parents in families with adolescents with diabetes use psychological control or age-inappropriate levels of firm control (Wysocki et al., 2006).”
Telehealth Behavior Therapy for the Management of Type 1 Diabetes in Adolescents
Lehmkuhl, H. D., Storch, E. A., Cammarata, C., Meyer, K., Rahman, O., Silverstein, J. H., Malasanos, T., & Geffken, G. R. (2010) · Journal of Diabetes Science and Technology · doi:10.1177/193229681000400125 · Cited by 74
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“…(Graves, Roberts, Rapoff, & Boyer, 2010; Kahana, Drotar, & Frazier, 2008) have been multicomponent and disease-specific (La Greca, 1990; Wysocki et al., 2006) and have often focused on teaching problem-solving skills around barriers to adherence (DeLambo, Ievers-Landis, Drotar, &…”
BackgroundBakhach, M., Reid, M. W., Pyatak, E. A., Berget, C., Cain, C., Thomas, J. F., KLINGENSMITH, G. J., & Raymond, J. K. (2019) · The Science of Diabetes Self-Management and Care · doi:10.1177/0145721719858080 · Cited by 74
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Spekhorst, L. M., Hummel, T. Z., Benninga, M. A., van Rheenen, P. F., & Kindermann, A. (2016) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1097/mpg.0000000000000924 · Cited by 71
“Previous research in other pediatric disease groups suggests that continued parental involvement in disease management is essential to maintain appropriate adherence and that premature transition of responsibility from parent to adolescent for disease management tasks may result in decreased adherence over time (37,38…”
BackgroundHerzer, M., Denson, L. A., Baldassano, R. N., & Hommel, K. A. (2011) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1097/mpg.0b013e3181f5714e · Cited by 71
“Preliminary evidence in other pediatric populations suggests that these family-based treatment components lead to better outcomes [44].”
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Monaghan, M. C., Hilliard, M. E., Cogen, F. R., & Streisand, R. M. (2010) · Patient Education and Counseling · doi:10.1016/j.pec.2010.04.007 · Cited by 71
“Most published interventions target adolescents with T1D,[6-10] whereas only two studies have evaluated interventions for parents of young children.”
BackgroundThe Nature of Family Engagement in Interventions for Children With Chronic Conditions
Knafl, K. A., Havill, N. L., Leeman, J., Fleming, L., Crandell, J., & Sandelowski, M. (2016) · Western Journal of Nursing Research · doi:10.1177/0193945916664700 · Cited by 73
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Adherence and psychopathology in children and adolescents with cystic fibrosis
White, T. J. H., Miller, J. N., Smith, G. L., & McMahon, W. M. (2008) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-008-0709-5 · Cited by 68
“Thus, in cases of family dysfunction, family therapy may improve both family function and adherence, as has been demonstrated in Type 1 diabetes [58].”
Correlates of glycemic control and quality of life outcomes in adolescents with type 1 diabetes
Ingerski, L. M., Laffel, L. M., Drotar, D., Repaske, D. R., & Hood, K. K. (2010) · Pediatric Diabetes · doi:10.1111/j.1399-5448.2010.00645.x · Cited by 66
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“Some elements of (cognitive) behavioural based parenting trainings have been evaluated scientifically with first results being promising [29-33].”
BackgroundMayer‐Davis, E. J., Maahs, D. M., Seid, M., Crandell, J., Bishop, F. K., Driscoll, K. A., Hunter, C. M., Kichler, J., Standiford, D. A., Thomas, J. M., et al. (2018) · The Lancet Child & Adolescent Health · doi:10.1016/s2352-4642(18)30208-6 · Cited by 59
Self-citationSelf-management in Type 2 Diabetes
Mulvaney, S. A., Mudasiru, E., Schlundt, D. G., Baughman, C. L., Fleming, M., VanderWoude, A., Russell, W. E., Elasy, T. A., & Rothman, R. L. (2008) · The Science of Diabetes Self-Management and Care · doi:10.1177/0145721708320902 · Cited by 58
“Recent research has indicated that family systems therapy has a beneficial effect on family relationships, but the effect on adolescent self-management behaviors and hemoglobin A1c has not been strong.(20) To address different role responsibilities, types of barriers, and contextual influences identified within this s…”
BackgroundCognitive-behavioral therapy for children with comorbid physical illness
Thompson, R. D., Delaney, P., Flores, I., & Szigethy, E. (2011) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2011.01.013 · Cited by 57
“The strongest support for CBT’s effectiveness is found in the literature examining the treatment of pain management in SCD.94 Evidence is emerging in support of the positive effects of CBT for improving medical adherence, physiologic indicators of illness, emotional adjustment, and communication skills in pediatric pa…”
BackgroundResultInfluentialNansel, T. R., Iannotti, R. J., Simons‐Morton, B. G., Plotnick, L., Clark, L. M., & Zeitzoff, L. (2009) · Diabetes Care · doi:10.2337/dc08-1968 · Cited by 57
“(10) at 6-month follow-up in response to 12 sessions of behavioral family systems therapy delivered by professional therapists over 6 months.”
BackgroundGuilfoyle, S. M., Crimmins, N. A., & Hood, K. K. (2011) · Pediatric Diabetes · doi:10.1111/j.1399-5448.2010.00735.x · Cited by 57
“interventions aimed at promoting and retaining caregiver involvement (29, 31) throughout adolescence are beneficial, particularly if they identify alternative methods of caregiver involvement that does not”
MethodWu, Y. P., Rausch, J. R., Rohan, J. M., Hood, K. K., Pendley, J. S., Delamater, A. M., & Drotar, D. (2014) · Health Psychology · doi:10.1037/hea0000034 · Cited by 59
Hommel, K. A., Hente, E. A., Odell, S., Herzer, M., Ingerski, L. M., Guilfoyle, S. M., & Denson, L. A. (2012) · European Journal of Gastroenterology & Hepatology · doi:10.1097/meg.0b013e32834d09f1 · Cited by 55
Devine, K. A., Reed, B., Loiselle, K. A., Simons, L. E., Mee, L. L., & Blount, R. L. (2011) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsr007 · Cited by 53
“In other pediatric populations, family-based interventions have been shown to improve family conflict and adherence (e.g., Anderson, Brackett, Ho, & Laffel, 1999; Wysocki et al., 2006).”
BackgroundPsychosocial interventions for the diabetic patient
Harvey, J. (2015) · Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy · doi:10.2147/dmso.s44352 · Cited by 52
Herzer, M., Vesco, A. T., Ingerski, L. M., Dolan, L. M., & Hood, K. K. (2011) · Journal of Behavioral Medicine · doi:10.1007/s10865-010-9307-3 · Cited by 56
“Further, while family-based interventions may promote better glycemic outcomes through reductions in family conflict (Anderson et al. 1990; Wysocki et al. 2006), and may identify variables that drive family conflict (e.”
BackgroundRybak, T. M., Ali, J. S., Berlin, K. S., Klages, K. L., Banks, G. G., Kamody, R. C., Ferry, R. J., Alemzadeh, R., & Diaz-Thomas, A. (2016) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsw071 · Cited by 52
Behavioral predictors of medication adherence trajectories among youth with newly diagnosed epilepsy
Loiselle, K. A., Rausch, J. R., & Modi, A. C. (2015) · Epilepsy & Behavior · doi:10.1016/j.yebeh.2015.06.040 · Cited by 50
“Evidence-based adherence interventions that target problem-solving and communication, such as Behavioral Family Systems Therapy [38], have demonstrated efficacy for improving adherence in adolescents with diabetes and cystic fibrosis [39–42].”
BackgroundLee, C. C., Enzler, C. J., Garland, B. H., Zimmerman, C. T., Raphael, J. L., Hergenroeder, A. C., & Wiemann, C. M. (2020) · Journal of Adolescent Health · doi:10.1016/j.jadohealth.2020.05.053 · Cited by 54
Parenting, autonomy and self‐care of adolescents with Type 1 diabetes
Dashiff, C. J., Vance, D. E., Abdullatif, H., & Wallander, J. L. (2008) · Child Care Health and Development · doi:10.1111/j.1365-2214.2008.00892.x · Cited by 53
“Studies of the associations of observed parent-adolescent interaction with disease management outcomes in adolescents with T1DM are sparse, but indicate an association of parent-adolescent interaction with treatment adherence (Miller and Drotar, 2007; Wysocki et al., 2006a).”
BackgroundKamody, R. C., Berlin, K. S., Rybak, T. M., Klages, K. L., Banks, G. G., Ali, J. S., Alemzadeh, R., Ferry, R. J., & Diaz-Thomas, A. (2017) · Behavioral Medicine · doi:10.1080/08964289.2017.1297290 · Cited by 47
“Currently, many evidence-based interventions to improve outcome in youth with T1D are family based, such as multisystemic therapy(55,56) and behavioral family systems therapy for diabetes (BFST-D).(57) Although targeting family functioning is vitally important, the findings of the present study further support the imp…”
BackgroundFinding the Balance: Adolescents With Type 1 Diabetes and Their Parents
Ivey, J., Wright, A., & Dashiff, C. J. (2008) · Journal of Pediatric Health Care · doi:10.1016/j.pedhc.2007.12.008 · Cited by 47
Holmes, C. S., Chen, R., Mackey, E. R., Grey, M. J., & Streisand, R. M. (2014) · Diabetes Care · doi:10.2337/dc13-1053 · Cited by 46
“(15) treated small groups of families who re-”
BackgroundDoherty, F. M., Calam, R. M., & Sanders, M. R. (2013) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jst046 · Cited by 46
Harris, M. A., Freeman, K. A., & Beers, M. (2009) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsp009 · Cited by 49
Self-citationMcGrady, M. E., Ryan, J. L., Gutierrez‐Colina, A. M., Fredericks, E. M., Towner, E., & Pai, A. L. H. (2015) · Child Care Health and Development · doi:10.1111/cch.12271 · Cited by 44
Valbrun, L., & Zvonarev, V. (2020) · Journal of Clinical Medicine Research · doi:10.14740/jocmr4066 · Cited by 51
“Moreover, BFST may improve family relationships and treatment adherence significantly, while reducing HbA1c, particularly among adolescents with poor metabolic control [51].”
BackgroundGood intentions gone awry: Assessing parental "miscarried helping" in diabetes.
Harris, M. A., Antal, H. M. A., Oelbaum, R., Buckloh, L. M., White, N. H., & Wysocki, T. (2008) · Families Systems & Health · doi:10.1037/a0014232 · Cited by 44
Self-citationHarris, M. A., Spiro, K., Heywood, M., Wagner, D. V., Hoehn, D., Hatten, A., & Labby, D. (2013) · Clinical Practice in Pediatric Psychology · doi:10.1037/cpp0000016 · Cited by 45
“…a modified version of this treatment (BFST for Diabetes, BFST-D) demonstrated significant improvements in youth glycemic control, youth treatment adherence, and diabetes-related family conflict immediately posttreatment (Wysocki et al., 2006) and over a 12-month follow-up (Wysocki et al., 2007).”
Self-citationCrosby, L. E., Barach, I. M., McGrady, M. E., Kalinyak, K. A., Eastin, A. R., & Mitchell, M. J. (2012) · Anemia · doi:10.1155/2012/492428 · Cited by 43
“Once participants identified a potential solution to try, clinic staff or a member of the research team utilized a standardized problem-solving intervention adapted from Behavioral Family Systems Therapy [40] to help participants develop a specific plan to implement the solution.”
MethodThe science of intervention development for type 1 diabetes in childhood: systematic review
Savage, E., Farrell, D., McManus, V., & Grey, M. J. (2010) · Journal of Advanced Nursing · doi:10.1111/j.1365-2648.2010.05423.x · Cited by 43
“Methods included a review of audio-recorded treatment sessions (Nansel et al. 2007, Channon et al. 2007, Ambrosino et al. 2008), video-recordings of sessions (Nansel et al. 2007, Channon et al. 2007), a method also used for one family therapy intervention (Wysocki et al. 2006).”
BackgroundMethodInfluentialThe Psychosocial Impact of Diabetes in Adolescents: A Review
Ashraff, S., Siddiqui, M. A., & Carline, T. (2013) · Oman Medical Journal · doi:10.5001/omj.2013.46 · Cited by 42
Ryan, J. L., Mellon, M. W., Junger, K. W., Hente, E. A., Denson, L. A., Saeed, S. A., & Hommel, K. A. (2013) · Inflammatory Bowel Diseases · doi:10.1097/mib.0b013e3182a82b15 · Cited by 41
“, perceived illness intrusiveness, overprotective parenting).(43,44) Our clinical observations suggest that introducing the need for psychological intervention in the context of HRQOL data is less intimidating to the patient and parents as it does not seem to be as stigmatizing as assessing for symptoms of depression…”
Background
Metadata
- Authors
- Wysocki, T., Harris, M. A., Buckloh, L. M., Mertlich, D., Lochrie, A. S., Taylor, A., Sadler, M., Mauras, N., & White, N. H.
- Affiliations
- Nemours Children’s Clinic (US)
- Washington University in St. Louis (US)
- Corresponding author
- Wysocki, Tim
- Venue
- Journal of Pediatric Psychology
- Publisher
- Oxford University Press (OUP)
- Published
- 2005-07-27
- Volume
- 31
- Issue
- 9
- Pages
- 928-938
- ISSN
- 0146-8693 (ISSN-L)
- 1465-735X
- OpenAlex
- W2135960588
- Cited by
- 299
- References
- 43
- Citations by year
- 2026: 7 · 2025: 5 · 2024: 11 · 2023: 9 · 2022: 4 · 2021: 12 · 2020: 16 · 2019: 17 · 2018: 14 · 2017: 18 · 2016: 16 · 2015: 25 · 2014: 21 · 2013: 21 · 2012: 21
- FWCI
- 6.42
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Pediatric Psychology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (5p60dk020579-35, 5r01dk043802-09)
- National Institute of Diabetes and Digestive and Kidney Diseases (P60-DK20579, 1-R01-DK43802)
- National Center for Research Resources (RR.00036)
- NIH Clinical Center
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Family Practice › Medication Adherence and Compliance
- Keywords
- adolescent diabetes, family relationships, family conflict, medication adherence, glycemic control, HbA1c, health care utilization, family therapy
- MeSH terms
- Adolescent, Child, Diabetes Mellitus, Type 1, Family, Family Relations, Female, Humans, Hypoglycemic Agents, Male, Parent-Child Relations, Patient Compliance, Surveys and Questionnaires, Self Care
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