Behavioral analysis and treatment of poor diabetic self-care and antisocial behavior: A single-subject experimental study

BEHAVIOR THERApy 18, 251-263, 1987

Behavioral Analysis and Treatment of Poor Diabetic Self-Care and Antisocial Behavior:

A Single-Subject Experimental Study

JAMES SNYDER

Wichita State University

A 14-year-old male adolescent who evidenced both inconsistent diabetic self-care and antisocial behavior was treated using behavioral family therapy. An extended baseline assessment o f self-care, antisocial behavior and mother-child conflict indicated a cyclic coercion-countercoercion process in which the mother 's at tempts to discipline the son's antisocial behavior resulted in the son's deliberate poor self-care until a diabetic episode occurred, terminating his mother 's disciplinary actions. Treatment sequentially focused on self-care, antisocial behavior, mother-child conflict, and school attendance and behavior. Self-monitoring and a reinforcement salary were insufficient to alter self- care; the addition of a potent punishment for poor self-care led to improved self-care and less frequent diabetic crises but increased antisocial behavior. Maternal monitoring of the son's activities and peer associates, a behavioral contract, and communica- t ion/problem-solving training resulted in a reduction in antisocial behavior and conflict, and in increased school attendance. Treatment gains were maintained at a two- mon th follow-up.

Diabetic self-regulation entails a complex set of behavioral skills which must be carefully and consistently exercised: administration of insulin, urine glucose monitoring, and modulated eating and exercise. This self-regulation is subject to a number of developmental, interpersonal, and situational influences (Wing, Epstein, Nowalk, & Lamparski, 1986).

Self-care by juvenile diabetics is particularly prone to such influences. Dia- betic self-care is often disrupted during adolescence when it becomes compli- cated with emerging issues concerning control and independence (Johnson, 1980). The management of diabetes is also functionally related to the interpersonal (familial) environment and behavioral characteristics of the diabetic individual. Diabetic symptoms and management are directly influenced by and influence the behavior of other family members (Minuchin, 1977). Glu- cose metabolism may also be destabilized by stressful environmental events via indirect psychophysiological mechanisms and subsequently complicate the symptoms and self-management of diabetes (Wing et al., 1986).

Requests for reprints should be sent to James Snyder, Depar tment of Psychology, Wichita State University, Wichita, KS 67208.

251 0005-7894/87/0251-026351.00/0 Copyright 1987 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

252 SNVOER

A theoretically interesting and practically serious combination of problems during adolescence is poor diabetic self-care and antisocial behavior. Both problems may be related to similar maladaptive family processes. Diabetic children often exert powerful control in their families. They display large psychophysiological responses to familial conflict, and the resulting symptoms serve to detour the conflict, are negatively reinforced, and preclude the solu- tion of family problems. The symptoms and management of diabetes are directly and functionally related to family interaction and socialization of the child. The diabetic child can use the diabetes to control and coerce other family members. These family members feel exploited and, in turn, attempt to exert control over the child (Minuchin, Baker, Rosman, Liebman, Millman & Todd, 1975). Similar coercive processes are descriptive of the interaction in families with antisocial children (Patterson, 1982). Parents and children in these families engage in frequent mutually aversive exchanges in an attempt to control each others' behavior. These exchanges are maintained and escalated by negative reinforcement, and are descriptive of the inept socialization practices that promote antisocial behavior.

The coercive family processes which mediate poor diabetic self-care and antisocial behavior may become intertwined and exacerbate both problems. The diabetic child can effectively disrupt parental socialization practices directly by engaging in poor self-care or indirectly by displaying a psychophysiological reaction to parent-child conflict. The resulting dual-track coercive family process is a breeding ground for antisocial behavior as well as a serious threat to the child's health.

Family therapy focusing on impaired communication and conflict resolution has been found to result in improved diabetic regulation in children whereas individual therapy is less effective (Minuchin, Rosman & Baker, 1978). Simi- larly, behavioral parent training (Patterson, 1974) and behavioral family therapy (Alexander & Parsons, 1973) effectively reduce the rates of antisocial behavior. This suggests that a behavioral family approach may effectively address the cooccurrence of these problems.

This study assesses the degree to which there is covariation between poor diabetic self-care and antisocial behavior, and to which both problems are mediated by coercive family process. It also assesses the efficacy of behavioral family intervention in the treatment of cooccurring self-care and antisocial behavior problems.

METHOD The Family

The identified client was a 14-year-old male adolescent who was referred because of repeated hypo- and hyperglycemic episodes following failure to engage in adequate self-care. His mother also reported that he engaged in frequent fighting, stealing and drug use, and did not go to school. He had Type 1, insulin dependent diabetes since age 6. His dally self-care routine entailed

BEHAVIORAL ANALYSIS 253

self-injections of insulin, self-administered urine glucose tests, and ingestion of a predetermined number of calories at predetermined times during the day. He had previously received extensive training in self-care, could easily and accurately describe the regimen, do calorie counts and exchanges, adeptly self- administer insulin, and accurately test and monitor his urine glucose levels. Up to age 12, he had consistently engaged in good self-care but, over the previous two years, there had been increasing deterioration in that care. The requisite behaviors were in his repertoire but he inconsistently performed those behaviors, especially during the early morning hours. In the previous six months, he had been hospitalized for hypo- and hyperglycemic episodes five times, three of the five in the two previous months. His mean blood glucose level on arrival at the hospital for four hypoglycemic episodes was 42 mg/100 ml: the level for one hyperglycemic episode was 324 mg/100 ml.

The client was in the 7th grade, previously having failed grades twice. At the time of referral, he was attending school less than one-half day per week. His school refusal was closely tied to deliberate poor diabetic self-care. His performance and behavior in school were problematic. In the last grading period, he received 4 F's and 3 C's. His achievement test scores ranged from the first to thirtieth percentiles. He engaged in frequent verbal and physical fights with peers, bullied younger and smaller children, was noncompliant and "mouthy" toward teachers, and was suspected of stealing.

According to his mother's report on the Child Behavior Problem Checklist (Achenbach & Edelbrock, 1983), the client was rated above the 98th percentile on delinquency, aggression, and hyperactivity scales, and above the 85th percentile on the somatic and immaturity scales. She reported his social and aca- demic competence to be below the 5th percentile. Using a version of Elliott's self-report delinquency scale (Elliott, Huizinga, & Ageton, 1982), the client reported biannual property destruction, possession of stolen goods, carrying a weapon, selling marijuana, having sex, threatening teachers, stealing outside the home, and being drunk. He reported that he strong-armed peers, used alcohol and marijuana weekly, and used tobacco daily. His antisocial behavior was serious, frequent, and cross-situational.

His mother reported a history of a diffuse anxiety-depressive disorder with multiple somatic complaints for which she was currently taking minor tran- quilizers. Her score on the Life Events Survey (Sarason, Johnson & Siegal, 1978) was three standard deviations above the norm; these stresses entailed illness and death in her family of origin, financial problems, changes at work, and worries about her son. The child's father, described as a chronic offender, had not been in the home for more than 10 years.

Mother-son interaction was primarily aversive. She nagged, cajoled, pleaded, and threatened the client about self-care, going to school, and staying out of trouble. He responded with overt refusal, name calling, and counter threats. This conflict was particularly intense in the early morning. She did not back up her threats with any kind of punishment. She failed to track his self-care, school attendance, whereabouts, activities, and peer associates, and to engage in consistent discipline.

254 Sr~YDER

Targets for Assessment and Intervention Four targets were selected for intensive assessment and intervention. (1) Diabetes self-care: entailed 11 daily activities including insulin at 7 a.m.

and 5 p.m.; urine glucose testing at 7 a.m., 11:30 a.m., and 5 p.m.; eating 600 calories at 7:30 a.m., 120 calories at 10:30 a.m., 750 calories at noon, 375 calories at 2 p.m., 750 calories at 6 p.m., and 120 calories at bedtime. The client was asked to self-monitor his dally adherence (this had previously been done as part of medical intervention in teaching self-cam) to each of these actions within 15 minutes of the designated times. He was paid 25¢ per accurate entry, with actions also being monitored by the mother and school personnel. The child, mother, and school nurse were provided with dally checklists of self-care activities. Data from these checklists were collected by means of a phone call every three days. There was 86°7o agreement between the child's report and that of others. The mean number of appropriate self-care practices over three days (as reported by the mother and the school nurse) were calculated.

(2) Mother-child aversive interaction: with their knowledge, a tape recorder was placed in the home and timed to record interaction in the kitchen between 7:30 and 8:30 a.m. when conflict was at its height. Two observers coded the total number of aversive statements made by the mother and child using the Family Interaction Coding System (Reid, 1978). The validity of this procedure has been documented by Hansen, Tisdelle, and O'Dell (1985). Rate per minute of aversive interaction was calculated by dividing the number of aversive mother and child statements by the total number of minutes ensuing between the first and last audible interaction during the hour. The rates were then averaged over three days. Intercoder agreement was assessed every fourth session. Agreement on occurrences was 79°7o.

(3) Child antisocial behavior, three overt antisocial behaviors (physical fighting in the home, physical fighting outside the home, and throwing things) and nine covert antisocial behaviors (lying, stealing in the home, stealing outside of the home, destruction of property in the home, destruction of property outside the home, tobacco use, alcohol use, marijuana use, and being out after 7 p.m. without parental permission) were monitored daily by the mother using a structured daffy checklist. These data were collected every three days by means of a phone call. The total number of child antisocial behaviors were summed over three days. The validity of this procedure is reported in Patterson (1982). On one-third of the occasions, the son's independent self- report of these behaviors was also assessed. Mother-son agreement on occurrences was 71%.

(4) School attendance: weekly school contacts were made to determine the number of hours the client had been physically present in school during the week.

The quality of the data was highly dependent on the cooperation of the respondents. The target behaviors were carefully specified and the respondents thoroughly trained before data collection. All checklists were delivered at weekly sessions and cross-checked with phone reports. Only a few minor discrepan- cies were observed. Missing data occurred on eight days of diabetes self-care,


six days of antisocial behavior, and nine days of interaction. In no case were data missing for more than one of the days comprising a three-day block, and on only two days (during treatment-dictated hospitalization) were data missing on all three variables. In the case of missing data, three-day averages of self- care and interaction were calculated using the remaining data, and three-day sums for antisocial behavior were prorated using the remaining data.

BEHAVIORAL ANALYSIS An extended baseline assessment was initiated in order to more clearly in-

vestigate the covariation of mother-son aversive interaction (conflict), diabetic self-care, and antisocial behavior. These data are plotted in Figure 1. Each data point for antisocial behavior, mother-child conflict, and self-care represents a three-day summary. This was dictated by the method of collecting maternal reports of the son's antisocial behavior and self-care. These three- day periods will subsequently be referred to simply as "periods." Each data point on school attendance is the average daily attendance time per week.

During the first six periods (18 days) of baseline (called the self-monitoring phase or SM; see Figure 1), the client's self-care was very poor (mean appropriate daily self-care = 5.6 out of 11.) A diabetic, hypoglycemic episode occurred during period 5 (indicated by the arrow in Figure 1) which resulted in a trip to the emergency room. His blood glucose level on arrival was 53 mg/100 ml. The baseline was too brief to establish covariation of the target variables, but the diabetic problem was deemed too serious to forgo additional treatment. A positive reinforcement program for appropriate self-care was initiated in which the client received 20¢ for accurately monitoring each activity and 20¢ for accurately carrying out each self-care activity (SM + REIN; see Figure 1). The intervention was implemented for 9 periods (27 days). It initially appeared to be effective, but then self-care deteriorated such that during period 12 (on the 18th day) of the SM + REIN intervention, another hypoglycemic episode occurred and necessitated a trip to the emergency room. His blood glucose level on arrival was 47 mg/100 ml. The daily number of appropriate self-care activities during the SM + REIN treatment phase was 6.3 compared to 5.6 for the SM phase. Using a C statistic which assesses vari- ability in successive data points relative to changes in slope (Tryon, 1982), no trend was found in self-care during the SM and SM + REIN phases. 1 The SM + REIN intervention appeared to be ineffective.

During the 15 periods (45 days) of SM and SM + REIN, data were simul- taneously collected on antisocial behavior, mother-child aversive statements, and school attendance. During this time, the mean three-day total of antisocial behaviors was 12.5, the mean rate per minute of mother-child aversive statements was 1.07, and daily school attendance averaged .73 hours. No trends

i All subsequent analyses reported are based on the C-statistic. The choice of a beginning point for a cycle is somewhat arbitrary. Given the critical nature of the diabetic episodes, they were used as anchor points.

256 SNYDER

MEAN NOMREO RATE/MINUTE DAILY DIABETES SELF MOTHER * CHILD

CARE PRACTICES AVERSIVE STATEMENTS

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e . -

--~, e , ~ ]

- t

. o - ~ I

TOTAL HUMBER OF ANTISOCIAL BERAVIORS--

MOTHER REPORT

i

MEAN HUMOER OF HOURS IN SCHOOL

PER RAY

i i t I

S]gU3~Jd ]UV~ SLH]I~]LVLS ]AISH3AY LU~]N N3HLOM AVO N]d :ills S]L]gVIO ~IIVG OIlF~ * H]HtOW --SNOIAVH]8 IWgOSI~NV "~GH~ NI SUOON

u]gNAN NY]N ]IflNM/]IVH ]0 ~29mN TYLOL ~0 N]BmN NV]N

Fio. I. Baseline, treatment and follow-up data on self-care, conflict and school attendance.

' l ' ' l ' ' , L L ' l l L t t l

r . . ,

~ f i ,~

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.30

FIG. 2.

SELF CARE SELF CARE t -.29 t+l

-.44 [ - 40 CONFLICT t ~ CONFLICT t+l

ANTISOCIAL t ~ ANTISOCIAL t*l Lag correlational analysis of self-care, conflict, and antisocial behavior.

were found in any of the variables over the 15 periods comprising the SM and SM + REIN interventions for self-care.

Because the SM + REIN intervention was insufficient to effect change, the initial 15 periods were considered as baseline. Lag correlational analyses of the covariation between self-care, conflict, and antisocial behavior suggested a cyclic, systematic relationship between the three variables (see Figure 2). Within a three-day period, high conflict was associated with poor self-care, and poor self-care with infrequent antisocial behavior. Poor self-care, high rate conflict and frequent antisocial behavior during one three-day period was associated with increased conflict during the subsequent three-day period, which again was associated with poor self-care and poor self-care with infrequent antisocial behavior.

These correlational data, a visual analysis of the baseline data, and inter- view information suggested a cyclic positive feedback process. At the beginning of a cycle, 2 the son would engage in relatively good self-care but frequent antisocial behavior. In response to his frequent antisocial behavior, the mother would increase her nagging and threats. This would result in an immediate reduction in appropriate self-care by the son, a countercontrol strategy. How- ever, her nagging also led to a reduction in antisocial behavior because poor self-care interfered with such behavior. Thus, her nagging was negatively reinforced. Poor self-care evoked further maternal nagging to which the son would respond with increasingly poor self-care but with reduced antisocial behavior (still reinforcing the mother). This continued until a diabetic crisis occurred which terminated the mother's nagging and threats (negatively reinforcing the son's countercontrol), and the cycle would then again begin.

2 The cycle is described in causative terms and represents clinical hypotheses which contributed to formulation of the treatment. The causal inferences are beyond the correlational nature of the data.

258 S~VDER

TREATMENT The effectiveness of behavioral family therapy was assessed using a multiple

baseline across behaviors design. Treatment consecutively focused on diabetes self-care and conflict, antisocial behavior and conflict, and school attendance.

Diabetic Self-Care Diabetic self-care continued to be the initial target of intervention because

of its dangerous nature and because it was the "trump card" played by the child to control his mother's attempts at effective parenting. Thus, at period 16 (day 46), in addition to self-monitoring and reinforcement, a punishment contingency for severely inadequate self-care (hypoglycemic or hyperglycemic episodes) was implemented (SM + REIN + PUN; see Figure 1). The mother was instructed to remind her son once, if needed, for each self-care action, but otherwise to desist from nagging, cajoling, and threatening him concerning self-care. If a hyperglycemic episode occurred, the mother was to have the child taken to the hospital where he was admitted for 36 hours in a private room with no visitors, TV, books, and minimal interaction with hospital staff. If a hypoglycemic episode occurred, the mother could inject him with glucagon (which is the appropriate treatment but has aversive side effects) and/or hospitalize him as for hyperglycemia.

It was expected that this treatment would lead to improved self-care. It was also expected to result in some reduction in mother-child conflict, but not to completely ameliorate it because of its association with antisocial behavior. Self-care did improve despite a hypoglycemic episode (followed by hospitalization for 36 hours; blood glucose level on arrival was 48 mg/100 ml) during period 25 (day 76) or one month into the SM + REIN + PUN intervention (see Figure 1). The mean number of daily appropriate self-care actions subsequent to implementing this intervention (periods 16 to 50) was 8.5 compared to 6.0 prior to this intervention (periods I to 15 or SM and SM + REIN phases). This change was significant (p < .01), and there was a trend toward continued improvement in self-care over periods 16 to 50 (p < .01). The mean number of proper daily self-care actions during the last month of treatment was 9.7.

The SM + REIN + PUN intervention for self-care also resulted in a significant reduction in mother-child conflict (p < .01). The mean rate per minute of aversive statements during periods 16 to 31 was .91 compared to a rate of 1.07 during the first 15 periods. This is still a very high level of conflict. In addition, there was significant trend (p < .05) over periods 16 to 31 indi- cating an increase in aversive interaction over time. The combined SM + REIN + PUN intervention for self-care was not sufficient to effect a large and lasting decrease in mother-son conflict.

The SM + REIN + PUN intervention for self-care also resulted in a mar- ginally significant increase (p < .10) in antisocial behavior from an initial 15 period three-day sum of 12.5 to 14.25 during periods 16 to 31. There was no change in school attendance during this time. The increase in antisocial be-

BEHAVIORAL ANALYSIS 2 5 9

havior may have been responsible for the increasing trend in the mother's nagging during this period. Improved self-care also provided the biobehavioral basis to be continuously operational for antisocial behavior.

Antisocial Behavior and Mother-Child Conflict On period 32 (day 94), treatment was initiated to reduce antisocial behavior

and mother-child conflict. This treatment focused on training the mother to closely and carefully monitor her son's whereabouts, activities, and peer associates, and to be suspicious of lying, stealing, and drug use. A behavioral contract was developed specifying the rules to be followed by the child, social and activity reinforcers contingent on rule adherence, and activity restrictions and work details contingent on rule violation. Because the son's countercontrol typically entailed intentional deterioration in diabetes self-care, the glucagon/hospitalization contingency also functioned as a backup punishment for antisocial behavior. The mother was instructed not to nag, threaten, and cajole, but rather to clearly state the rules and to consistently apply the consequences for rule adherence and violation. In the context of developing and implementing the contract, the mother and son were taught communication and conflict resolution skills.

A consistent strategy throughout this treatment phase was to "beg" the son's maturity. The notion was to use his "macho" independent self-image in the service of more responsible behavior both for his own satisfaction and as a support for his mother. Several of the activity reinforcers entailed access to legitimate jobs in which he could make money, part of which went toward his own medical care and part of which was at his persona| disposal.

Implementation of the contract led to an initial hypoglycemic episode and hospitalization (blood glucose level on arrival was 44 mg/100 ml) followed by a significant reduction in antisocial behavior (p < .01) from a sum three- day frequency of 13.4 during baseline (periods 1 to 31) to 6.6 after initiation of the monitoring, contract, and skills training intervention (Periods 32 to 50). There was a significant trend toward continued reduction in antisocial behavior over periods 32 to 50 (p < .01) such that, during the last month of treatment, the mean three-day sum frequency of antisocial behavior was 4.5. There was also a significant reduction (p < .01) in mother-child conflict after initiating the monitoring, contract, and skills training intervention (periods 32 to 50) compared to the previous periods, even when correcting for improvement resulting from the SM + REIN + PUN treatment for diabetes self-care (periods 16 to 31). The mean number of aversive statements after period 32 was .68, compared to .97 prior to period 32. There was also a trend for continued reduction in aversive statements over periods 32 to 50 (p < .01) such that during the last month of treatment the mean three-day rate of aversive statements was .36. It should be noted that both antisocial behavior and aversive statements, though significantly reduced, were probably higher than that expected normatively.

260 SNYOER

School Attendance and Behavior Finally, at week 17 (roughly coinciding with period 38), intervention was

initiated to promote school attendance. This consisted of two strategies. First, the child was transferred to a new, more structured school. The mother received daily phone reports concerning attendance and behavior, and this was added to the contract. Second, juvenile authorities were contacted and began monitoring his school attendance (like probation) with the client's explicit understanding that any unexcused long-term absence would result in adjudi- cation. This was perceived as a potent punishment by the client. The threat was real; failure to attend school not only compromised the child's future op- portunities and development but also provided the occasion for continued and more serious antisocial behavior. These strategies led to a prompt increase in attendance of .73 to 5.6 after treatment was initiated (p < .01). There was a trend for increasing attendance over weeks 17 to 21 (p < .10). Return to school probably contributed to the continued reduction in antisocial behavior. Grades for the two quarters subsequent to intervention were B's, C's, and one D.

Follow-up A plan to fade the contracted reinforcers and punishers was not implemented

as the mother declined further treatment, feeling that her problems had been solved. An 18-day (6-period) follow-up probe of all target variables was con- ducted one month after termination of treatment, and indicated maintenance effects on all variables. Anecdotal reports by the mother and son six months after treatment termination indicated a serious deterioration. The child was hospitalized for alcohol and barbiturate abuse. Mother-child conflict had increased, the son's self-care had deteriorated, and the frequency of antisocial behavior had increased.

While the lack of maintenance is problematic in terms of documenting the efficacy of the treatment, the premature termination may have resulted in a rough approximation of a return to baseline conditions. Insofar as the anecdotal reports are valid, the mother's failure to continue effective monitoring and discipline and the subsequent recurrence of problematic child behavior provide further support for a causal interpretation of the effects of treatment.

DISCUSSION Results from the correlational analysis support the notion that poor dia-

betic self-care and antisocial behavior were mediated by coercive family processes. Three biobehavioral mechanisms may have been operating. The primary mechanism entailed a coercive behavioral exchange between the mother and the son. The mother's nagging and threats were evoked by the son's antisocial behavior and maintained by a resultant reduction in the frequency of that behavior. The son's poor self-care was evoked by maternal nagging and threats, and maintained by a reduction in the nagging and threats when a diabetic episode ensued. Maternal discipline and control were effectively thwarted by deliberate poor self-care.


Two secondary mechanisms may also have been operating. The short-term decrease in antisocial behavior resulting from maternal nagging and threats may have been mediated by the son's deteriorating self-care rather than by the effectiveness of her actions per se. That is, his poor self-care in response to her nagging may have interfered with the biobehavioral homeostasis needed for frequent antisocial behavior. The son's deteriorating self-care in response to maternal nagging and threats may have been mediated indirectly as well as had a direct functional value in turning off her disciplinary attempts: high mother-son conflict may have resulted in a stress-induced glucose metabolism lability making self-care more difficult.

The efficacy of behavior family intervention was assessed using a multiple baseline design across four target behaviors: diabetes self-care, antisocial behavior, mother-child conflict, and school attendance. The correlations between the first three of these targets would usually make interpretation of data from such a design ambiguous. In part, this was mitigated by the negative correla- tion between poor self-care and antisocial behavior, and the lack of correla- tion between school attendance and the other three variables. Mother-child conflict was correlated with poor self-care and antisocial behavior in a complex way, and may be construed as a process or mediating variable. Conflict functioned as an engine that was fueled first by antisocial behavior, and then by poor self-care until a diabetic crisis occurred. This crisis shut offthe engine until antisocial behavior again started the cycle. Thus, the effects of intervention can be used to confirm the correlational behavioral analysis as well as assess the effectiveness of behavioral family therapy.

Teaching the mother effective monitoring and disciplinary practices was the primary focus of treatment. The identification and consistent use of backup reinforcement and punishment for threats was expected to reduce conflict and antisocial behavior, and to enhance self-care and school attendance. The in- troduction of backup punishment for poor self-care led to some reduction in mother-child conflict and to dramatically improved self-care, whereas self- monitoring and self-monitoring plus reinforcement, when applied alone, were insufficient to effect those changes. Although one track (the son's poor self- care in response to maternal nagging and threats) of the dual coercion process had been effectively addressed, the second track (the mother's nagging and threats in response to the son's antisocial behavior) had not been addressed and perhaps was exacerbated. Improvement in self-care led to an increase in antisocial behavior, and to a resurgence of conflict over time. This is consistent with the behavioral relationships inferred from the correlational analysis. Contract-based reinforcement of rule adherence and punishment of rule violation, improved maternal monitoring, and problem-solving and communication skills training were used to address this second track, and resulted in persistent decreases in conflict and antisocial behavior. A similar intervention, when applied to school attendance, resulted in dramatic improvement.

These effects are consistent with Patterson's (1982) formulation of coercive family processes. Behavioral change in self-care, antisocial behavior, and school attendance occurred only when parental threats were consistently backed up with effective punishment as shown by a reduction in conflict. The data sug-

262 S~XI)ER

gest that behavioral family therapy focusing on the improvement of family management skills is effective in the treatment of combined antisocial behavior and poor diabetic self-care or, more broadly, to intertwined dual coercive processes.

These changes were maintained over a two-month period. The lack of long- term maintenance is an obvious and serious weakness, and is endemic to the outcome literature in the treatment of serious, frequent antisocial behavior that begins early and persists into adolescence (Kazdin, 1985; Snyder & Pat- terson, in press). Long-term maintenance requires the continued use of effective family management practices (monitoring, discipline, problem-solving) after termination of treatment. The effort, consistency, and diligence required of family members are not simply maintained once learned and initially implemented. Reprogramming the natural environment, as in behavioral family therapy, was not sufficient for the family in this study. Family management practices, particularly new ones that require effort, may be disrupted by stressors experienced by family members from sources exogenous to the family. Simi- larly, significant pathology in the parent may preclude the sustained effort and consistency necessitated by such an intervention. Both such conditions were evident in the family in this study. A broader focus to include parental stress, psychopathology, and social support may be necessary to encourage the sustained use of new family management skills.

REFERENCES Achenbach, T., & Edelbrock, C. S. (1983). Manual for the child behavior checklist. Burlington,

VT: University of Vermont. Alexander, J. E, & Parsons, B. V. (1973). Short term behavioral intervention with delinquent

families: Impact on family process and recitivism. Journal of Abnormal Psychology, 81, 219-225.

Elliott, D. S., Huizinga, D., & Ageton, S. S. (1982). Explaining delinquency and drug use: The national youth survey project. Report No. 21. Boulder, CO: Behavioral Science Institute.

Hansen, D. J., Tisdelle, D. A., & O'DeU, S. L. (1985). Audio recorded and directly observed parent- child interaction: A comparison of observation methods. BehavioralAssessment, 7, 389-399.

Johnson, S. B. (1980). Psychosocial factors in juvenile diabetes: A review. Journal of Behavioral Medicine, 3, 95-116.

Kazdin, A. E. (1985). Treatment o f antisocial behavior in children and adolescents. Homewood, IL: The Dorsey Press.

Minuchin, S. (1977). Psychosomatic diabetic children and their families. (DHEW Publication No. ADM-77-477). Washington, DC: U.S. Government Printing Office.

Minuchin, S., Baker, L., Rosman, B., Liebman, R., MiUman, L., & Todd, T. A. (1975). A concep- tual model of psychosomatic illness in children: Family organization and therapy. Archives of General Psychiatry, 32, 1034-1038.

Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic families. Cambridge, MA: Har- vard University Press.

Patterson, G. R. (1974). Intervention for boys with conduct disorders: Multiple settings, treat- ments and criteria. Journal of Consulting and Clinical Psychology, 42, 471-481.

Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castilia Publishing Company. Reid, J. B. (1978). A social learning approach to family interventions. Vol. 2. Observation in

home settings. Eugene, OR: Castilia Publishing Company.


Sarason, I. G., Johnson, J. H., & Siegal, J. M. (1978). Assessing the impact of life changes: De- velopment of the Life Experiences Survey. Journal of Consulting and Clinical Psychology, 46, 932-940.

Snyder, J. J., & Patterson, G. R. (1987). Family interaction and delinquent behavior. In H. C. Quay (Ed.). Handbook of juvenile delinquency. New York: John Wiley & Sons.

Tryon, W. W. (1982). A simplified time series analysis for evaluating treatment interventions. Journal of Applied Behavior Analysis, 15, 423-429.

Wing, R. R., Epstein, L. H., Nowalk, M. D., & Lamparski, D. M. (1986). Behavioral self regulation in the treatment of patients with diabetes mellitus. Psychological Bulletin, 45, 78-89.

RECEZWD: September 24, 1986 F m ~ ACCEPTAt~C~: January 20, 1987

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Behavioral analysis and treatment of poor diabetic self-care and antisocial behavior: A single-subject experimental study