Type 1 diabetes is one of the leading chronic diseases of childhood, affecting approximately 167,000 youth less than 20 years of age in the United States. Families live meal to meal carefully adhering to a complex treatment plan that includes insulin injections, blood glucose monitoring, following a prescribed meal plan, and exercise. The American Diabetes Association now recommends that children < 6 year old diagnosed with type 1 diabetes strive to maintain an A1C level lower than 7.5 percent. Maintaining such tight glycemic control requires that parents carefully monitor blood glucose and eating behaviors so that they can accurately calculate insulin dosing. Home life for families of young children can be unstructured which, during the evening hours, can create logistic problems related to glycemic control. For example, if there is less than 2 hours between dinner and a bedtime snack, the bedtime blood glucose reading may be above the targeted range. Parents may not trust the elevated reading and be reluctant to deliver an insulin correction. This can result in overnight hyperglycemia, and an elevated A1C.

Even though parents of children with type 1 diabetes report that they (parents) are confident in their diabetes specific skills such as blood glucose monitoring and insulin injection within one year after diagnosis, in fact, diabetes specific self-efficacy has not been found to be correlated to child metabolic control. Mothers report feelings of intense “constant vigilance” due to fear of hypoglycemia which may lead to chronic maternal fatigue. The consequences of hypoglycemia are dangerous and parents often error on the side of under dosing with insulin to avoid the potential consequence of hypoglycemia. A nighttime routine is needed to (a) reduce snacking after dinner and (b) provide at least two hours between dinner and bedtime glucose readings. We propose that this structured evening routine is required to accurately predict the insulin needs at bedtime. Researchers are now investigating the protective mechanisms of family routines and their influence on childhood chronic illness management such asthma and type 1 diabetes. Family routines have been defined as the regularity of certain activities engaged in by a family. Evidence is mounting that family routines mediate behavioral problems and adherence in children with type 1 diabetes. In addition, authoritative parenting in which parents are able to set consistent, realistic limits on children’s behavior in a warm and sensitive manner has been linked to better diabetes-specific regimen adherence and metabolic control in young children.

A family based intervention that incorporates an educational and a behavioral component to improve both parenting skills and child evening routines may improve metabolic control by maintaining the overnight blood glucose in target range throughout the night. The purpose of the proposed study is to examine the feasibility and acceptability of a parenting/family routine intervention program for parents of young children, ages 2-5, with type 1 diabetes. The intervention contains an established and effective parent skills training curriculum, The Incredible Years, uniquely integrated with a newly developed family evening routine component e.g., family dinner time and evening routine, to promote improved metabolic control. The evening routine component was developed by Dr. Marvicsin based on her more than 20 years of clinical experience in working with these families. The team includes Dr. Peter Gerrits MD, Medical Director and Dr. Ruth Anan PhD, a psychologist specifically trained to deliver The Incredible Years curriculum. We will assess outcomes during and at one week post intervention. Outcome measures will include family routine, specifically the time between the dinner and bedtime glucose check, parent bedtime decision making, and child overnight glucose control. In addition parental fatigue will be measured. Parents’ receptiveness to the educational program will also be assessed.

The Specific Aims are:

• Specific Aim #1: Examine the feasibility of a six session parenting skills and family evening routine intervention delivered at a suburban health center. Post intervention interviews and attendance will determine suitability/preferences for mode of delivery and realism of behavioral expectations.
• Specific Aim #2: To develop preliminary evidence regarding the impact of a six-session family intervention on child evening routine and glucose control as measured by three indicators: a) having at least 2 hours between dinner and bedtime glucose readings; b) comparing bedtime blood glucose reading with morning fasting blood glucose reading ; c) parent decision making and response to bedtime snack/insulin questionnaire.
• Specific Aim #3: Examine the relationship between parental fatigue and child A1C.