A Multicomponent Motivational Intervention to Improve
Adherence Among Adolescents With Poorly Controlled Type 1
Diabetes: A Pilot Study
Catherine Stanger,1PHD, Stacy R. Ryan,2PHD, Leanna M. Delhey,1BA, Kathryn Thrailkill,3MD,
Zhongze Li,4MS, Zhigang Li,4PHD, and Alan J. Budney,1PHD
1Department of Psychiatry, Geisel School of Medicine at Dartmouth,2University of Texas Health Science
Center at San Antonio,3University of Arkansas for Medical Sciences, and4Norris Cotton Cancer Center,
Dartmouth Hitchcock Medical Center
Correspondence concerning this article should be address to Catherine Stanger, PhD, Department of
Psychiatry, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH 03756, USA.
Received November 4, 2012; revisions received April 7, 2013; accepted April 9, 2013
contingency management (CM) for adolescents with poorly controlled type 1 diabetes.
of 17 adolescents, age 12–17 years (M¼14.8, SD¼1.5), with type 1 diabetes (duration M¼6.2 years,
SD¼4.5) and mean HbA1c of 11.6% (SD¼2.5%) were enrolled. Adolescents and their parents received 14
weeks of motivational interviewing, clinic-based CM, and parent-directed CM that targeted increased blood
glucose monitoring (BGM). ResultsAdolescents significantly increased their BGM (p<.001) and showed
significantly improved HbA1c levels (glycemic control) from pre-to posttreatment
(p<.0001).Conclusions The magnitude of improvements in the frequency of BGM and glycemic control
in adolescents with type 1 diabetes is encouraging and will be tested in a randomized controlled trial.
To adapt and pilot test a multicomponent motivational intervention that includes family-based
Key wordscognitive behavior therapy; contingency management; motivational interviewing; type 1 diabetes.
Diabetes is a leading cause of death in the United States
and is associated with significant mortality and economic
cost (Centers for Disease Control and Prevention, 2008).
Although improved in recent decades, persons with diabe-
tes have mortality rates 5.6 times higher than those in the
general population (Secrest, Becker, Kelsey, LaPorte, &
Orchard, 2010). The incidence of type 1 diabetes among
teens increased significantly over the past 25 years (Vehik
et al., 2007), so that ?1 in 500 adolescents ages 12–19
have type 1 diabetes (Centers for Disease Control and
Prevention, 2008; The Writing Group for the SEARCH
for Diabetes in Youth Study Group, 2007). Unfortunately,
teens, even with intensive insulin regimens, have much
poorer glycemic control than adults (Diabetes Control
and Complications Trial Research Group, 1994).
Glycemic control (measured via HbA1c levels) is a
powerful determinant of diabetes outcomes (Diabetes
Control and Complications Trial Research Group, 1994).
In the short term, higher HbA1c is directly related to
hospitalization and increased costs (Menzin et al., 2010).
Blood glucose monitoring (BGM) frequency is a robust
predictor of glycemic control (Guilfoyle, Crimmins, &
Hood, 2011; Helgeson, Honcharuk, Becker, Escobar, &
Siminerio, 2011). BGM adherence is a promising target
for teens, whose rates are generally low (Anderson et al.,
2009), because daily monitoring can be objectively mea-
sured and reinforced. Parental monitoring can also posi-
tively affect teen adherence to BGM and other aspects of
the medical regimen (Anderson, Ho, Brackett, Finkelstein,
& Laffel, 1997; Ellis et al., 2007a; Horton, Berg, Butner, &
Studies with teens provide some support for the
efficacy of individual and family-based treatments that in-
clude the goal of increasing BGM for teens (Channon et al.,
Journal of Pediatric Psychology 38(6) pp. 629–637, 2013
Advance Access publication May 22, 2013
Journal of Pediatric Psychology vol. 38 no. 6 ? The Author 2013. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
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2007; Ellis et al., 2007b; Franklin, Waller, Pagliari, &
Greene, 2006; Nansel et al., 2007; Salamon, Hains,
Fleischman, Davies, & Kichler, 2009; Wysocki et al.,
2008). However, across these studies, BGM frequency re-
mained low (<3? daily; ?6? daily is recommended for
teens with poor glycemic control) (Diabetes Care, 2010),
with treatment gains often lasting <6 months (Alam, Sturt,
Lall, & Winkley, 2009). In addition, only small to moder-
ate effect sizes on HbA1c (ES¼0.13–0.35) (Alam et al.,
2009) were observed, with mean HbA1c remaining
>8.5%, well above the recommended target of <7.5%
(Silverstein et al., 2005). Thus, more effective interventions
are needed to improve BGM adherence and glycemic con-
trol among teens with type 1 diabetes who consistently are
not at the American Diabetes Association (ADA) blood glu-
To address this problem, motivational interviewing
(MI) and cognitive behavior therapy (CBT) were combined
with a family-based contingency management (CM) inter-
vention. The MI intervention has been tested with teens
with type 1 diabetes in a prior trial (Channon et al., 2007).
The MI, CBT, and CM interventions were originally devel-
oped to treat adolescent substance abuse (Stanger, Budney,
Kamon, & Thostensen, 2009) and were adapted for ado-
lescents with poorly controlled type 1 diabetes to target
teen coping skills, BGM frequency, and parental monitor-
ing. Others have also reported success adapting substance
use interventions for teens with type 1 diabetes (Channon
et al., 2007; Ellis et al., 2005; Raiff & Dallery, 2010).
Similar behavior analytic principles can be applied to
address the challenging behaviors and enhance motivation
to change in teens who are not effectively managing their
type 1 diabetes and those who abuse substances. Our par-
allel intervention for teen substance abuse has been dem-
onstrated to motivate change in teen behavior (promote
compliance with substance abstinence goal) in the context
of low motivation and poor parental monitoring (Stanger
et al., 2009). The current pilot study was conducted to
determine the feasibility and outcomes of this MI/
CBTþCM intervention for improving the management of
poorly controlled type 1 diabetes in adolescents.
Motivational Interviewing/Cognitive Behavior
Motivational interviewing (MI) has targeted a broad range
of health behaviors, including adherence in teens with di-
abetes (Channon et al., 2007; Rollnick, Mason, & Butler,
1999). In a randomized trial, the MI intervention selected
for the current study resulted in small, but significant,
improvements among adolescents with type 1 diabetes in
HbA1c and quality-of-life measures up to 12 months later
(Channon et al., 2007). In the current study, the Channon
MI intervention was supplemented with CBT skills adapted
from an evidence-based curriculum developed for teens
with substance use problems (Webb, Scudder, Kaminer,
& Kadden, 2001). This CBT curriculum includes several
general coping skills designed to improve decision making.
The combination of MI and CBT has been shown to be
more effective than CBT alone for adults with diabetes,
supporting the potential utility of combined MI/CBT inter-
ventions for teens with diabetes (Ismail et al., 2008).
Further, in the substance abuse literature, MI and CBT
have been frequently combined with CM, and this combi-
nation of study treatments has repeatedly been found to
improve long-term outcomes relative to single-modality in-
terventions (Budney, Moore, Rocha, & Higgins, 2006;
Higgins, Silverman, & Heil, 2008).
Incentives/Contingency Management (CM)
CM involves the systematic reinforcement of desired behav-
iors (e.g., BGM). Ten of 11 randomized trials showed that
incentives led to greater medical adherence than tested
alternatives for blood pressure control, appointment atten-
dance, and immunization rates (Giuffrida & Torgenson,
1997). Tangible incentives have also been effective in im-
proving healthy habits such as losing weight (Volpp et al.,
2008a), lowering cholesterol (Bloch et al., 2006), adhering
to daily medication (Volpp et al., 2008b), and promoting
tobacco, alcohol, and drug abstinence (Higgins et al.,
2008). The proposed incentive intervention rearranges
the consequences of BGM by providing immediate rewards
for monitoring, and immediate negative consequences for
not monitoring. The use of incentives to increase BGM
among teens with type 1 diabetes has been reported in
one case series (Raiff & Dallery, 2010). In this study,
four teens increased daily monitoring from an average
1.7 times daily to 5.7 times daily over 5 days, when mon-
etary incentives were available for submitting videos over
the internet that documented BGM. A recent study offered
adults with type 2 diabetes increasing incentives for reduc-
ing HbA1c by 1 or 2 percentage points (or to 6.5%) at a 6-
month follow up assessment, and showed mean reductions
of 0.45 percentage points, which was not significant rela-
tive to usual care (Long, Jahnle, Richardson, Loewenstein,
& Volpp, 2012). These results suggest that more frequent
incentives may be necessary as well as targeting a specific
self-care behavior that might lead to improved glycemic
control (e.g., BGM).
Stanger et al.
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