The effect of parental expressed emotion on glycaemic control in children with Type 1 diabetes: Parental expressed emotion and glycaemic control in children

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Abstract

Objective: To measure expressed emotion (EE) in parents of young children with diabetes and to examine the relation between EE and glycaemic control in children with Type 1 diabetes in a longitudinal study over 24 months. We hypothesised that good glycaemic control, as measured by low glycated haemoglobin levels, would be predicted by high parental emotional over-involvement, low frequency of critical comments and absence of hostility. We predicted that these effects would be stronger in maternal than paternal scores. Methods: Forty-seven children attending a Paediatric Diabetes Clinic and their parents were studied over 24 months. Glycated haemoglobin was measured on three occasions, at the start of the study period, 12 and 24 months later. At 12 months, parental EE was measured using an adapted version of the Camberwell Family Interview, and child emotional and behavioural problems were measured using the parent version of the Child Behavior Checklist. Multiple regression models were used to test the hypotheses. Results: Forty-three maternal and 33 paternal interviews of adequate quality for analysis were obtained. Paternal hostility was found to be associated with elevated glycated haemoglobin measured 12 months before interview and 12 months after interview, accounting for 22% and 29% of the variation in glycated haemoglobin respectively. Conclusion: We did not find that parental emotional over-involvement or criticism predicted glycaemic control. Presence of hostility was important, but in contrast to our hypothesis, this was paternal rather than maternal hostility. We suggest that (i) relatively absent, rejecting fathers play little role in diabetes management and children perceive this negatively, or (ii) mothers who are unsupported by fathers cannot in turn support their children in diabetes care.

Introduction

Expressed emotion (EE) is a measure of a relative's attitude and behaviour towards an ill patient. It comprises five indices in relation to the patient: hostility expressed, degree of warmth shown, the number of critical or positive remarks made by the relative about the patient and emotional over-involvement of the relative. Hostility is a categorical measure (rated 0–3), critical and positive comments are both counts, and emotional over-involvement and warmth are measured on an ordinal scale of 0–5. Despite the origins of the EE constructs being poorly understood [1], [2], EE has been shown in numerous studies to be a strong predictor of outcome in a variety of psychiatric and medical conditions in different age groups [3], [4], [5], [6]. For schizophrenia, critical comments, hostility and emotional over-involvement have been found to be important predictors of outcome, as measured by relapse rates; in anorexia nervosa, critical comment count and emotional over-involvement are important predictors; and in depressive neurosis, and weight loss in overweight women, critical comment count alone is the best predictor of relapse [7], [8], [9].

EE has also been found to be associated with glycaemic control in young people with Type 1 diabetes. In older adolescents (age 12–20 years) in the UK, high levels of emotional over-involvement in relatives were associated with good glycaemic control, measured by glycated haemoglobin levels [10]. This association is in the opposite direction to that expected from previous EE research, but fits clinically with the impression of over-controlling parents whose children are not permitted to deviate from diet, exercise and blood-testing regimes and so have excellent glycaemic control, albeit at some psychological cost. More conflicting results have been found recently. Koenigsberg et al. [11] in a study of young adults aged 13–39 years with Type 1 diabetes found a significant correlation between the frequency of critical comments made during the Camberwell Family Interview, and glycaemic control, but no such association between emotional over-involvement and glycaemic control. The lack of association between emotional over-involvement and glycaemic control could be because there was a smaller proportion of high-scoring respondents for emotional over-involvement, because many of the respondents were spouses, who tend to rate lower for emotional over-involvement than do parents [12]. This may also explain the results of Wearden et al. [13] who found no associations at all between EE indices and glycaemic control in a group of adults with Type 1 diabetes, the respondents mostly rated as showing low EE.

Factors affecting glycaemic control in adolescents and children are important, as it is known that good glycaemic control prevents long-term complications [14]. The effect of EE on glycaemic control in young children has not been explored, and nor have the separate effects of maternal and paternal EE on glycaemic control. Neither has there been a longitudinal study looking at the stability of the effect of EE over time on glycaemic control.

We therefore decided: first, to measure EE in parents of children with Type 1 diabetes and, secondly, to examine the relation between EE and glycaemic control in these children over 24 months. We hypothesised that good glycaemic control, as measured by low glycated haemoglobin levels, would be predicted by high parental emotional over-involvement, low frequency of critical comments and absence of hostility. We predicted that these effects would be stronger in maternal than paternal scores.

Section snippets

Sample

The parents of all children aged 6–14 years attending the Paediatric Diabetes Clinic at The General Infirmary at Leeds (Clarendon Wing) under the care of one consultant paediatrician (PH) were invited to join the study (n=47) over 24 months [15]. Names of children with diabetes were obtained from the diabetes nurse specialist's caseload records, clinic lists and the hospital medical records department. Both existing and new cases were included, new cases being entered at least 6 weeks after

Sample

By the end of the recruitment period, there were 47 children aged 6–14 years attending the paediatric diabetes clinic; 45 of these children were recruited into the study. Two children were not included: one mother was partially literate and could not complete the questionnaires; another mother declined to participate.

There were 26 boys and 19 girls, mean age 9.8 years (range 6–16). For the social class distribution (Registrar-General's classification): Classes I to V held 3, 8, 8, 16 and 10

Sample

Findings from the Yorkshire Diabetes Register [21] suggest that this consecutive sample is representative of children in Leeds with Type 1 diabetes, 97% of 1490 new cases being found using a similar case ascertainment method. There was a significant proportion (15%) of newly diagnosed cases of Type 1 diabetes in the sample. The glycaemic control of the new cases might have been more stable than the control of other children, due to continued production of some endogenous insulin in the early

Acknowledgements

This work was supported by the British Diabetic Association Small Grant Scheme. The authors are grateful to Dr. Graham Paley for providing consensus ratings for EE, Dr. Christine Vaughn for training AWD and GP to rate EE, Jenny Grimley for transcribing the taped interviews and all the children and families of the Paediatric Diabetes Clinics at Clarendon Wing, Leeds and St. Luke's Hospital, Bradford.

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