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A Randomized, Controlled Trial of a Community-Based Support Program for Families of Children With Chronic Illness: Pediatric Outcomes
Robin G. Chernoff, MD;
Henry T. Ireys, PhD;
Katherin A. DeVet, PhD;
Young J. Kim, PhD
Arch Pediatr Adolesc Med. 2002;156:533-539.
ABSTRACT
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Background Children with chronic illnesses have a heightened risk for mental health
problems.
Objectives To develop, implement, and evaluate child outcomes of a 15-month, community-based,
family-support intervention designed to reduce risk for poor adjustment and
mental health problems in children with 1 of 4 chronic illnesses (diabetes
mellitus, sickle cell anemia, cystic fibrosis, or moderate to severe asthma)
and their mothers.
Design Randomized, controlled clinical trial design with multiple measures
of mental health based on both child and parent reports taken 1 year apart.
Setting Community-based intervention linked to subspecialty and general pediatric
clinics and practices in Baltimore, Md.
Participants One hundred thirty-six mothers and children aged 7 to 11 years with
diabetes mellitus, sickle cell anemia, cystic fibrosis, or moderate to severe
asthma.
Intervention The program, provided by "experienced mothers" and child life specialists,
included telephone contacts, face-to-face visits, and special family events.
Main Outcome Measures Outcomes were measured using the following instruments: the Personal
Adjustment and Role Skills Scale III, the Children's Depression Inventory,
the Revised Children's Manifest Anxiety Scale, and the Self-Perception Profile
for Children.
Results The experimental group's mean adjustment score increased over the intervention
period while the control group's mean adjustment score decreased. Analysis
of variance demonstrated that the intervention had a significant main effect
on postintervention adjustment controlling for baseline scores (P = .01). Using a cutoff score indicating maladjustment, the percentage
of experimental group children in the maladjustment range fell from 19% at
baseline to 10% after the intervention; the percentage of control group children
in the maladjustment range rose from 15% at baseline to 21% after the intervention.
The effect of the intervention was more pronounced for children who had low
physical self-esteem than for those who had moderate to high physical self-esteem
at the beginning of the program.
Conclusions Our results demonstrate modest positive effects of a family support
intervention in promoting the adjustment of children with selective chronic
health conditions. Including child life specialists in a community-based intervention
may be especially salient for children with chronic illnesses who have low
physical self-esteem. The intervention had a similar outcome for all diagnostic
groups, suggesting that it could be effective for children with any chronic
illness and implemented in a variety of pediatric settings.
INTRODUCTION
FIFTEEN PERCENT to 18% of the children in the United States have a chronic
illness or disability.1-2 More
than 2 decades of epidemiological and clinic-based studies indicate that these
children are at a heightened risk for mental health problems.3-6
Over the last 2 decades, however, pediatricians have moved from a general
belief that children with chronic illnesses and disabilities are inevitably
troubled to a more nuanced view that accounts for variability in outcomes
based on multifactorial processes of stress and coping.7
Nevertheless, in view of the prevailing evidence that children with chronic
illnesses are at risk for poor psychological outcomes, the question remains:
can this risk be lessened?
In 1997, Bauman et al8 reviewed studies
describing the outcomes of psychosocial interventions for children with chronic
illness that had been published through 1993. They reported that some interventions
had modest effects in helping "children and families cope with the psychological
and social consequences of chronic health conditions."8(p250)
Bauman et al noted, however, that most of the studies had serious methodological
weaknesses and suggested that future studies include more rigorous designs
and sufficient sample sizes.
Since 1993, additional psychosocial intervention studies have been published.
Some have focused on psychological issues related to medical procedures,9 others have investigated effects of support interventions
for families of children with a particular long-term condition,10-11
and one program used nurses to provide information and support to families.12 Most of these studies reported at least modest positive
effects on mental health or coping. However, many of the same methodological
problems noted by Bauman et al continue to plague the medical literature.
In addition, during the last decade, the pediatric community has placed
increasing emphasis on the importance of working with families of children
with long-term conditions to create a medical home within which services can
be coordinated.13 This approach to practice
includes linking families to available, community-based, family-to-family
support programs and underscores the potential value of information and support
that families of children with similar conditions can share among themselves.14 However, virtually all of the interventions reported
in the published literature rely on health or mental health professionals
based in medical centers.
For the study reported herein, we aimed to develop, implement, and evaluate
child outcomes of a 15-month, community-based, family-support intervention
designed to reduce risk for poor adjustment and mental health problems in
children with 1 of 4 chronic illnesses (diabetes mellitus, sickle cell anemia,
cystic fibrosis, or moderate to severe asthma) and their mothers. We also
sought to address many of the methodological issues noted by Bauman et al8 and to fashion a program that reflected key concepts
pertaining to community-based, family-to-family support. In addition, we drew
from continuing clinical experience with this population and with similar
program evaluations.15-16
To evaluate the effects of the program, we used a randomized, controlled
clinical trial design and multiple measures of mental health based on both
child and parent reports. The intervention was conceptualized and structured
so that it can be provided to families of children who have any long-term
condition. For evaluation we used the same mental health measures for all
mothers and children, regardless of diagnosis. This article describes key
components of the intervention and its effects on children. Parent outcomes
are reported elsewhere.17
We hypothesized that, controlling for baseline status, children in the
intervention group would have better mental health at the end of the intervention
compared with children in the control group, as measured by changes in psychological
adjustment, depression, and anxiety scale scores. We also examined whether
the intervention group would have more positive self-esteem scores compared
with the control group, and if so, whether this change was associated with
changes in scores on the other mental health measures. In addition, we tested
hypotheses that the intervention would have stronger effects for children
at higher risk for poor adjustment.
PARTICIPANTS AND METHODS
SAMPLE IDENTIFICATION
Potential participants were identified through 11 specialty clinics
and 5 general pediatric practices in the Baltimore area. An effort was made
to recruit every potentially eligible family listed on the clinic or practice
rosters. Families were eligible if they lived within a 50-mile (80-km) radius
of Baltimore City and had a telephone, a woman was the primary caregiver and
the child lived with her, the target child was 7 to 11 years old and did not
have mental retardation, the diagnosis was made at least 6 months prior to
recruitment, and the family spoke English. To enroll children with moderate
to severe asthma, the following additional criteria were used: (1) receiving
daily medication, (2) wheezing 2 to 3 times per week, or (3) having at least
1 hospital or emergency department visit in the past 6 months.18
RECRUITMENT AND DATA COLLECTION PROCEDURES
After potential participants were identified, the clinic director or
pediatrician sent them a letter describing a longitudinal research project
involving families of children with chronic illness, inviting them to participate
if they wished, allowing them to decline to be called, and noting that otherwise
someone would call them to explain the project in detail. The letter stressed
that participation was voluntary.
If families agreed to participate during the follow-up telephone call,
appointments were made for the interviews in the family's home. Data were
collected from mothers and children in 45- to 90-minute, face-to-face, structured
interviews at baseline (T1) and 12 months later (T2). At each face-to-face
interview, mothers were paid $20 for their time and children received a toy.
Interviews were completed by paid interviewers who had undergone extensive
training and were blind to group assignment. Informed consent statements pertaining
to the research project were signed at the initial interview. All procedures
were approved by the institutional review boards at Johns Hopkins Hospital
and Sinai Hospital of Baltimore.
ASSIGNMENT-TO-GROUP PROCEDURES
In the recruitment letter and follow-up telephone call, participants
were invited to join a longitudinal research study on families raising children
with chronic illnesses. No mention was made of intervention programs until
the end of the baseline interview, when the interviewer described 2 programs
in which the family could participate. She explained that the mother had the
opportunity to put her name "in a hat" and that families would be drawn by
chance and assigned to 1 of the programs. The interviewer emphasized that
the mother could still participate in the research interviews whether or not
the mother decided to put her name in the hat. This design allowed us to identify
characteristics of program nonparticipants or "nonjoiners" (ie, those who
would participate in the research but not in the intervention).19
Families who agreed to put their names in the hat were randomly assigned to
either the experimental or control group. Mothers were sent letters informing
them of their group assignment.
EXPERIMENTAL (INTERVENTION) GROUP
The intervention, referred to as the Family-to-Family Network, was designed
to reduce risk for mental health problems in children with chronic illnesses
and their mothers through a 15-month intervention that had 2 linked, mutually
reinforcing components. One component was developed and implemented by 3 child
life specialists (CLSs), and was referred to as KIDS (Kids Involved in Discovery
and Sharing). This component was designed to enhance the mental health, adjustment,
and self-esteem of children with selected conditions.
The activities incorporated into the KIDS program were designed by the
CLSs to convey "messages" conceptually linked to specific program objectives.
For example, one objective involved enhancing acceptance of one's physical
appearance. Various activities were used to convey 3 messages: "What's right
with my body," "What I'm good at," and "Liking how I look." Specific activities
included making a scrapbook, tracing the child's body, reading books, and
doing role play. Additional details regarding the intervention's theoretical
framework and its application are in a manual available from the lead author.20
The CLSs aimed to make 7 visits of 60 to 90 minutes to each assigned
family, either in the family's home or in the community. Between these visits,
the CLSs made monthly telephone calls to assigned children; sent out a monthly
letter with seasonal greetings, puzzles, jokes, and related health care information;
and mailed 3 newsletters with children's stories, drawings, and "advice to
doctors." The CLSs also sponsored periodic lunches that involved 2 to 4 participating
families and occasional bowling parties to which all enrolled families (including
fathers and siblings) were invited.
The other component of the Family-to-Family Network focused on the children's
mothers. A selected and trained group of "veteran" or "experienced" mothers
of older children with the same target conditions were responsible for this
component. This group of mothers referred to themselves as "Network Mothers
(NMs)." Details regarding the recruitment, training, and support of the NMs
and the conceptual underpinnings of the maternal program component are available
elsewhere.17
Thus, the experimental group was offered an intervention that was implemented
by a professional-parent team (ie, the CLS with the NM). Assignments of participating
families to the CLS-NM teams were based on diagnosis; the NMs were assigned
to families of children who had the same condition as their own children had.
The CLSs and the NMs coordinated their efforts with each family, were in regular
telephone contact to exchange information about significant issues that arose
during visits and telephone calls, and met weekly as a group. A pediatrician
(R.G.C.) and a social worker attended these weekly meetings to ensure that
the intervention was being provided as planned and to provide guidance and
support to the intervention teams. The 3 CLSs also met weekly with the pediatrician.
The intervention was provided to 2 cohorts from May 5, 1996, to January 31,
1999.
CONTROL GROUP
The control group program was designed to reflect a common practice
in many subspecialty clinics, where a mother is given the name of another
mother to call should she need support or information. The families randomly
assigned to our control group were given a telephone number through which
they could reach an experienced parent if they so wished. This experienced
parent had no special training and did not initiate telephone calls. Children
in the control group had no contact with the CLS on our project and no mention
was made of the KIDS program.
MAIN OUTCOME MEASURES
Items from previous studies were used to collect demographic information
(eg, family composition) and data pertaining to the child's health and functional
status, including whether symptoms were unpredictable, whether the child was
ever so sick that the parent thought he or she might die, and the number of
days of activity limitations in the past year.15-16
The full list of these items is available from the lead author.
We used 3 indicators of child mental health. First, child psychosocial
adjustment was measured using the Personal Adjustment and Roles Skill Scale
(PARS) III.21 The PARSIII is a 28-item measure
completed by mothers that taps children's normative roles and activities (eg,
spending time with friends) as well as mild problem behaviors (eg, complaining
about problems, flared up if could not have own way). This scale has good
reliability and discriminant validity, no psychosomatic items, and has been
used with minority populations and in diverse settings.21
The PARSIII has a total adjustment score and 6 subscales, including hostility,
anxiety/depression, dependency, withdrawal, productivity, and peer relations.
Higher scores are associated with better functioning.
Depressive symptoms were measured with the Children's Depression Inventory,
a 27-item, self-report measure that reflects recent affective, cognitive,
and behavioral symptoms of childhood depression.22
Scores on this measure have been shown to discriminate clinically depressed
and nondepressed psychiatric patients. Internal consistency coefficients ranging
from 0.71 to 0.84 and test-retest reliability estimates (0.82) are acceptable.23 The clinical cutoff score for the upper 10% of elementary
school children in a normative sample is 19.
The Revised Children's Manifest Anxiety Scale was used to assess child
self-report of general anxiety.24 The Revised
Children's Manifest Anxiety Scale is a 28-item measure that reflects physiological
anxiety, worry/oversensitivity, and concentration problems. Internal consistency
was 0.83 to 0.85, test-retest reliability over a 9-month interval was 0.68,
and the scale showed convergent validity with the State-Trait Anxiety Inventory
for Children.25
Children's self-esteem was measured by 4 subscales from the Self-Perception
Profile for Children.26 Each subscale consists
of 6 items. The physical appearance subscale is used to assess body esteem,
and taps the degree children are happy with their appearance. The social acceptance
subscale taps the perception that the child is involved in a peer group. The
athletic subscale measures the amount that children feel confident in their
athletic abilities. The global self-worth subscale assesses the degree to
which children feel they are worthwhile persons overall; this scale has its
own items and is not a sum of the other scales. Internal consistency on the
subscales ranged from 0.78 to 0.84 in third to eighth grade children and test-retest
reliability was adequate.26 This scale has
been used frequently in studies of youth with chronic illnesses.12
We measured "dose" of the intervention by the number of contact minutes
between families and their intervention team. Over the course of the 15-month
intervention, families had an average of 2 visits from their assigned NM (range,
0-6 visits), 3 visits from their assigned CLS (range, 0-13 visits), and attended
an average of 1 special event (range, 0-6 events). Mothers received an average
of 7 significant telephone calls (defined as lasting >5 minutes) from their
assigned NM (range, 0-43 telephone calls). Their assigned CLS made an average
of 3 significant telephone calls (range, 0-11 telephone calls) per child.
Children received an average of 15 letters from their assigned CLS (range,
5-28 letters). The mean total time spent in program activities per family
was 1378 minutes (23 hours; range, 1 hour to 80 hours). For every significant
call the NMs made, they made 2 nonsignificant calls or attempts. For every
significant call the CLSs made, they made 6.7 nonsignificant calls or attempts.
In general, participating children led active lives and had working mothers,
factors that made it difficult to find time for visits and telephone calls.
ANALYTIC PLAN
First, to test the outcome of randomization, the experimental and control
groups were compared for selected child variables (including child adjustment,
depression, anxiety, and condition-related variables) and demographic indices
using t tests. Second, bivariate analyses were conducted
to examine relationships among key variables (eg, demographic and condition-related
variables) and main outcome measures. Third, analysis of variance was used
to examine child outcome variables in relation to group status (ie, experimental
or control) while controlling for baseline characteristics. Finally, we conducted
multiple regression analyses to assess effects of the intervention and potential
moderators on main outcome measures.
RESULTS
As Figure 1 shows, 565 letters
were sent to patients, inviting them to participate in the study. One hundred
seventy-four (31%) were unable to be contacted (no telephone, change of address,
no answer). Of the 391 families who were contacted, 115 (29%) were ineligible
(based on residence, mental retardation, language difficulties, or asthma
severity criteria). Fifty-seven (15%) refused to participate and 26 (7%) were
unable to be scheduled for an interview within the interview period. One hundred
ninety-three baseline interviews were completed.
Of the 193 mothers who were eligible for randomization, 32 (17%) refused
to be randomized. The refused randomization group generally reported better
functioning than both the experimental and the control groups.19
For this article, we excluded data from mothers who refused to be randomized
because we undertook an intent-to-treat analysis of program effects.
Of the 161 families randomized, 86 were randomized to the experimental
group and 75 to the control group. Overall, 25 families, 14 and 11 from the
experimental group and the control group, respectively, were lost to follow-up,
resulting in a total of 136 mother-child pairs for the analyses (72 in the
experimental group and 64 in the control group). Table 1 lists selected demographic and health status characteristics
of the experimental and control groups. No baseline differences between these
groups were found on key independent or dependent variables. Analysis of variance
indicated that the only main outcome measure that differed for the experimental
and control groups was child adjustment. Table 2 gives baseline and 12 month postbaseline (T2) scores on
child adjustment, as measured by the total PARSIII scores and subscale scores.
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Table 1. Selected Diagnostic and Demographic Characteristic of Study
Sample*
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Table 2. PARSIII Total and Subscales Scores by Intervention Group at
Baseline (T1) and Postintervention (T2)*
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Using the total score, the analysis of variance demonstrated that the
intervention had a significant main effect (P<.01),
controlling for preintervention scores. The PARSIII includes 6 subscales.
As data in Table 2 indicate, the
experimental group's scores increased more (or decreased less) on 5 of the
6 subscales. Multiple regression analyses controlling for baseline scores
showed that the intervention had significant effects on the hostility subscale
(t = -2.56, P = .01)
and the anxiety/depression subscale (t = -3.28, P = .001).
Another way to assess the effect of an intervention is to examine whether
children fall below a cutoff score that indicates maladjustment. The PARSIII,
however, lacks an established cutoff point. Adopting a method reported in
a prior study,12 we calculated a cutoff score
by using the total group mean at baseline minus 1 SD. The cutoff score in
this sample was 78, almost exactly the score of 78.3 used in the previous
study.12 At baseline, 19% of the children in
our experimental group and 15% of the control group fell below this cutoff
point. At T2, 10% of the experimental group children scored below this cutoff
point; in contrast, 21% of the children in the control group fell below the
cutoff point.
We found no effect of the intervention on measures of children's anxiety,
depression, or self-esteem. Only 7 (5%) of the children in our current sample
scored above the clinical level on the Children's Depression Inventory. For
the Revised Children's Manifest Anxiety Scale, the mean and SD in our sample
is close to the normative sample.25 Because
there was no effect of the intervention on self-esteem, we could not test
whether changes in self-esteem were linked to changes in children's adjustment.
However, we did evaluate whether high-risk subgroups of children were
affected differentially by the intervention. One high-risk group that we investigated
included children who had low self-esteem at baseline. We dichotomized the
sample of children into low and high physical self-esteem scores, with the
low group defined as those children scoring in the lower third of the group
on the physical self-esteem scale of the Self-Perception Profile for Children.
This strategy was adopted to assure that we created a high-risk group. Bivariate
analyses indicated that the effect of the intervention was more pronounced
for children who had low physical self-esteem at baseline than for those who
had moderate to high self-esteem. Figure 2 shows these results.
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Figure 2. Interaction between intervention
and physical self-esteem. Time 1 indicates distinct test times: 1, 45- to
90-minute interviews; 2, 12 months later. Adjustment was done during bivariate
analysis.
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For the experimental group, mean adjustment scores for children with
low physical self-esteem increased from 85.45 at T1 to 88.07 at T2; adjustment
scores for children with high physical self-esteem increased from 90.30 at
T1 to 91.65 at T2. For the control group, mean adjustment scores for children
with low physical self-esteem decreased substantially from 86.67 to 81.24;
scores for children with high physical self-esteem decreased from 90.79 to
89.98. No intervention effects were found for other self-esteem subscales.
As a way of summarizing main and interaction effects, we developed a
multiple regression equation with T2 adjustment scores as the outcome variable,
as given in Table 3. In step 1
the intervention group variable was entered and was marginally significant
(P<.10). At step 2, when we controlled for baseline
adjustment scores, the intervention effect increased (P<.01). Adding baseline physical self-esteem scores in step 3 slightly
increased the intervention effect further. Finally, in step 4 the interaction
between the intervention group and physical self-esteem (as a continuous measure)
was added. These results suggest that the intervention was successful in improving
adjustment for children in the intervention, especially if they had low physical
self-esteem at baseline.
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Table 3. Standardized ß Coefficients From Hierarchical Regression
Predicting Postintervention Child Adjustment (Total PARSIII Scores)*
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Overall, we found no evidence of any dose effects on the outcome of
the intervention. During the intervention period, only 2 mothers in the control
group called the veteran parents designated for this purpose. In the T2 interview,
control group mothers were asked whether, in the past 12 months, there were
times when it might have been useful to talk to someone who really understood
what they were going through. More than 70% of the control group mothers answered
in the affirmative, suggesting that a substantial number of mothers who have
children with chronic illnesses are likely to feel the need to talk with other,
more experienced mothers but are unlikely to initiate this contact over the
telephone.
COMMENT
This study demonstrates that our family support intervention had modest,
positive effects on the adjustment of children with selected chronic illnesses.
The intervention had a similar outcome for all diagnostic groups represented,
suggesting that it could be effective for children with other long-term health
conditions. The intervention may be especially relevant for the high-risk
subgroup of children in this population who have low self-esteem. Condition-related
variables such as symptom unpredictability or days of activity limitations
were unrelated to the outcome measures.
Several features of this study enhance confidence in its results. First,
the randomized trial design is a rigorous method for program evaluation. Second,
excluding those who refused randomization from an intent-to-treat analysis
avoids potential dilution of program effects that could have resulted from
inclusion of persons who were already functioning well, and for whom the intervention
would have no additional benefit. Third, we randomized within recruitment
site to avoid some potential site-specific biases. Fourth, the intervention
was consistent with the structure of clinical subspecialty care (ie, it had
a condition-specific focus) while the evaluation design provided a sample
size sufficient for reasonable statistical power.
Although these design elements support the credibility of our results,
several notes of caution are important. First, the intervention did not have
an effect on outcome variables measured through child report. This may have
resulted from the fact that the children as a group reported high levels of
emotional well-being. This is good news, but it increases the challenges of
showing program effects.
Second, our sample may not be representative of the broader population
of families of children with chronic health problems. Although we made an
effort to recruit all potentially eligible families from the 16 clinics in
Baltimore, selection bias may have affected our findings in unknown directions.
Third, available resources precluded assessment of the mental health of fathers
or of siblings, important dimensions for inclusion in future studies. Fourth,
because many families received a low dose of the intervention, we may be underestimating
the potential influence of this intervention.
As we noted earlier, we did not find a relationship between the amount
of contact between the CLS-NM intervention team and participant outcomes.
As we considered this issue, we realized that some families who were needy
initiated a great deal of contact with the CLSs and the NMs. Hence, these
families received a larger program dose. Other, equally needy families seemed
to be withdrawn, did not initiate contacts, and hence, received a small dose.
Both types of families, however, seemed to have benefited from the program.
These observations led to us conclude that the relationship between dose and
outcome is complicated by the level of baseline need, and that to assess this
relationship adequately requires a measure of baseline need that is separate
from the outcome measure. Further investigation of this issue should be undertaken
in subsequent studies.
The actual numerical difference between the experimental and control
group on the PARSIII, our measure of adjustment, was small, leading to concerns
with clinical significance. However, over the course of the intervention the
proportion of the control group children who fell into the maladjusted range
increased, while the proportion of the experimental group children in the
maladjusted range decreased. The proportion of children moving out of the
maladjusted range is a good indicator of successful intervention.27
Our results are consistent with findings from a conceptually similar
intervention using family counselors that was implemented in the early 1970s28 and a more recent nursing intervention for children
with a wide range of chronic illnesses.12 The
similar effects of the nursing intervention and our program may emerge from
their similar outreach efforts and how the programs communicated reassurance
and support to parents. In addition, more than 70% of our control group mothers
said they would have found it useful to talk to a parent in a similar situation;
however, they did not initiate a call to the experienced mother. This finding
underscores the importance of outreach.
One of the novel aspects of this intervention involved the home-based
and community-based work of the CLSs. To our knowledge, this is one of the
very few programs that has aimed to bring the skill and expertise of child
life into community settings. This intervention model offers a feasible method
of extending the benefits of child life services beyond the hospitals, surgical
departments, and outpatient clinics where CLSs are most likely to work.
Over the last decade, family support programs have become an accepted
and important part of service systems for children with chronic health and
mental health conditions, but the empirical foundation for these efforts is
thin. Our study documents a workable approach to implementing a family support
program and adds to the growing evidence that community-based, family centered
care can make a difference.
| What This Study Adds
Epidemiological and clinic-based studies indicate that children with
chronic illnesses are at heightened risk for mental health problems. In this
article we present child outcomes of a randomized, controlled clinical trial
of a 15-month, community-based, family support intervention for children 7
to 11 years old with 1 of 4 chronic illnesses (diabetes mellitus, cystic fibrosis,
sickle cell anemia, or moderate to severe asthma) and their mothers. Our intervention,
involving CLSs in home and community settings, had a modest, positive effect
on the adjustment of the children. The intervention had a similar outcome
for all diagnostic groups, suggesting that it could be effective for children
with other chronic illnesses. This intervention model offers a feasible method
of extending the benefits of CLSs into the community and supports the idea
that active outreach is an important part of a successful family support intervention.
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AUTHOR INFORMATION
Accepted for publication February 12, 2002.
This study was supported in part by grant MCJ-240804 from the Maternal
and Child Health Bureau (Title V, Social Security Act, Health Resources and
Services Administration, Department of Health and Human Services), Rockville,
Md.
We thank all of the parents and children who participated in this effort,
as well as the pediatricians and project interviewers. Special thanks are
due to Miye Schakne, Beverly B. Walsh, PhD, Ruth E. K. Stein, MD, Susan Radius,
PhD, and Laurie Bauman, PhD, and the program's 3 CLSs, Erin Munn, Marcy Widener,
and Gina Fortunato, who provided enormous enthusiasm and spirit throughtout
the project.
Corresponding author and reprints: Robin G. Chernoff, MD, Department
of Pediatrics, The Johns Hopkins School of Medicine, 600 N Broadway, Baltimore,
MD 21287 (e-mail: rchernof{at}jhmi.edu).
From the Department of Pediatrics, School of Medicine (Dr Chernoff),
Mathematica Policy Research, Inc (Dr Ireys), and the Department of Population
and Family Health Sciences, Bloomberg School of Public Health (Drs DeVet and
Kim), Johns Hopkins University, Baltimore, Md.
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