This article introduced the DPSI and provided an evaluation of several psychometric properties of this measure. These contributions begin to fill a gap in the available measurement tools that have been validated for use in this clinical population by providing a method of quantifying skills of youths with T1DM and their adult caregivers in responding to unwanted glycemic fluctuations. To the extent that these skills may represent a key mediator of behavioral effects on diabetes outcomes, the DPSI provides a valuable tool for further research on these relationships. The measure yielded approximately normal score distributions for both caregivers and youths, and demonstrated sufficient variability to enable analyses of the measure's statistical associations with other variables of interest. The reliability of the measure, as assessed by indices of internal consistency, item-total correlations, inter-rater agreement, and test–retest reliability, was marginally acceptable. Since the DPSI items targeting correction of hypoglycemia and hyperglycemia focus on distinct diabetes management skills, it is not surprising that the resulting estimates of internal consistency and item-total correlations were not particularly high. Evidence of the validity of the DPSI was provided by significant correlations between youths’ age and DPSI scores, between caregivers’ DPSI scores and concurrent HbA1C measurements, and, with youths’ age controlled, scores on the DFRQ.
While the analyses that were performed yielded only modest support for the psychometric properties of this structured interview, the mixed effects modeling analyses that were completed suggest that this is a promising direction for psychological assessment in pediatric T1DM and that further refinement of the instrument is certainly warranted. Specifically, the mixed effects modeling analysis showed that low DPSI scores among caregivers were particularly predictive of poor glycemic control over the ensuing 9 months. Thus, families in which caregivers lack sufficient skill for responding to and managing blood glucose fluctuations may be at special risk for unacceptable diabetes outcomes and this association was quite durable over time. This observation suggests that there may be a threshold for problem-solving skills in parents necessary for adequate diabetes management. Consequently, efforts to identify caregivers with deficient diabetes problem-solving skills and to provide them with targeted education may be particularly beneficial in terms of ultimate effects on their children's diabetes outcomes.
The corresponding relationship between youths’ DPSI scores and HbA1C
levels revealed minimal evidence of associations similar to those found with caregivers. Youths’ diabetes problem-solving skills were related to their current HbA1C
levels only after the contributions of pertinent parental behaviors were accounted for statistically. Youths’ diabetes problem-solving skills were unrelated to their subsequent levels of glycemic control. On the surface, this effect would seem to be somewhat counter-intuitive. However, the psychological and educational research literature on pediatric diabetes is replete with reports of no relationship between diabetes knowledge or skills and measures of glycemic control or treatment adherence (see Johnson, 1984
for reviews). There are several plausible explanations for why caregivers’ diabetes problem-solving skills would be more strongly associated with diabetes outcomes than would youths’ skills.
Thomas, Peterson, and Goldstein (1997
) reported that, although older youths demonstrated more sophisticated diabetes problem-solving skills in social situations, compared with younger children they were more likely to avoid utilization of their diabetes problem-solving skills in favor of behaviors that are perceived by them as more likely to yield peer affiliation and acceptance. Thus, adolescents who face social dilemmas pitting optimal diabetes management against peer affiliation and acceptance will tend to behave in accord with the latter priority. Similarly, Wysocki, Hough, Ward, Allen, and Murgai (1992
) found that active use of self-monitored blood glucose data for treatment decisions was associated significantly with parental diabetes knowledge, but not with youth knowledge. A second possible explanation is that most youths in this age range may continue to rely heavily on parental involvement in decision making regarding treatment adjustments in response to blood glucose monitoring results. If youths do rely more heavily on their caregivers’ diabetes problem-solving skills than on their own skills, it is reasonable to expect that youths’ skills will account for minimal variance in diabetes outcomes and that youths whose caregivers have deficient skills will tend to struggle with diabetes management. Another possible explanation for this pattern of findings is that, since caregivers’ DPSI scores were significantly higher than youths’ scores, it is possible that few youths had sufficiently well-developed diabetes problem-solving skills to equip them to make active, appropriate treatment decisions in a timely manner without parental support or guidance. As with caregivers, there may be a minimum threshold for problem-solving skills to be effective. Youths with DPSI scores in the upper tertile had a mean score of 7.66, which overlaps that achieved by caregivers in the middle (M
= 6.86) and highest (M
= 8.43) tertiles of the caregiver distribution. Since children of these caregivers achieved similar, better HbA1C
levels compared to those in the lowest tertile, it seems implausible that similar DPSI scores obtained by youths would not also equip them to maintain similar levels of glycemic control. Another possible explanation might be that youths with extremely stable glycemic control may have fewer opportunities to engage in and practice problem solving than those with less stable glycemic control. If true, this could dilute a possible association between youths’ problem-solving skills and indices of glycemic control. While all of these possible interpretations of our findings are interesting and plausible, it remains for future research to determine if any are valid conceptualizations.
The present study has a number of limitations that should be taken into account when interpreting these results. Foremost among these is that several psychometric properties of the DPSI proved to be rather marginal. While the present findings reveal some promise for a measure of this type, further refinement of the measure appears warranted, perhaps including a more extensive collection of diabetes vignettes and empirically driven retention of those that prove to be most strongly associated with diabetes management behaviors and outcomes. The present study evaluated diabetes problem-solving skills in children as young as 9 years of age, but perhaps the findings suggest that these skills do not emerge until somewhat later in development. Supplementation of vocal presentation of vignettes with visual aids could possibly enhance youths’ comprehension of the diabetes problems. Finally, it is possible that a revised scoring system that enables more fine-grained quantification of problem-solving skills could result in a measure that is more consistently associated with other relevant variables.
The primary clinical implication of the findings reported here is that youths with T1DM from families in which the primary diabetes caregiver has deficient diabetes problem-solving skills may be at elevated risk of poor glycemic control. If confirmed by further research, this observation implies that active efforts to identify these caregivers may be fruitful if these families can either be provided with effective remedial education targeting these specific skills or provided with additional consultation and support to enable them to compensate for these skill deficiencies. An additional clinical implication of the present findings derives from the suggestion that youths may not adequately utilize the diabetes problem-solving skills they have acquired. The absence of an association between youths’ DPSI scores and either their measured adherence (DSMP scores) or glycemic control (HbA1C
) suggests that interventions that promote youths’ utilization of problem solving skills in either naturalistic or realistically simulated circumstances (Gross, Heimann, Shapiro, & Schultz, 1983
; Kaplan, Chadwick, & Schimmel, 1985
) may be particularly valuable. Taken as a whole, the present findings support the targeting of diabetes problem-solving skills in behavioral and psychological interventions that seek to facilitate effective family management of pediatric T1DM.