Measure of Psychological Adjustment to Diabetes (ATT19)

1. Abstract

The Measure of Psychological Adjustment to Diabetes (ATT19) is a specialized psychometric instrument designed to evaluate cognitive, affective, and behavioral adaptation in individuals living with diabetes mellitus (both Type 1 and Type 2). Originating as a refined, psychometrically robust short-form of the original 39-item Diabetes Attitude Scale (ATT39) developed by Garry Welch, Stewart M. Dunn, and colleagues, the ATT19 captures the multidimensional nature of chronic disease adjustment. The scale comprises 19 self-report items evaluated on a Likert-type continuum anchored from “I disagree completely” to “I agree completely.” Rather than conceptualizing diabetes adaptation as an undifferentiated, singular construct or merely measuring clinical depression or generic distress, the ATT19 delineates six distinct psychological dimensions: diabetes stress, coping, guilt, alienation/cooperation, illness conviction, and ambiguity tolerance.

Psychometric evaluations of the ATT19 demonstrate acceptable to high internal consistency reliability across clinical cohorts, with subscale Cronbach’s alpha values typically ranging from 0.65 to 0.84, alongside strong test-retest stability across multiple longitudinal follow-up intervals. Structural validity has been substantiated through exploratory and confirmatory factor analyses, confirming that the condensed 19-item formulation preserves the fundamental factor matrix of the parent instrument while markedly reducing respondent burden. Criterion, convergent, and discriminant validities are evidenced by statistically significant correlations with glycemic markers (such as glycated hemoglobin, HbA1c), self-management adherence measures, diabetes-related quality of life, and indices of psychological distress. As an efficient, clinically sensitive assessment tool, the ATT19 allows clinicians, health psychologists, and endocrinologists to pinpoint specific maladaptive cognitive frameworks, design individualized behavioral interventions, and systematically monitor psychological accommodation to chronic illness regimens.

2. Keywords

ATT19, Psychological Adjustment to Diabetes, Diabetes Distress, Chronic Illness Adaptation, Health Psychology, Psychometrics, Diabetes Mellitus, Glycemic Control, Coping Mechanisms, Illness Perception, Patient-Reported Outcomes, Psychodiabetology

3. Authors

The Measure of Psychological Adjustment to Diabetes (ATT19) was derived from the foundational psychometric research on diabetes attitudes and psychological adjustment conducted by:

• Garry Welch, Ph.D. — Behavioral Medicine and Health Psychology Specialist; former Director of Behavioral Medicine Research at the Baystate Medical Center and Assistant Professor of Psychiatry at Tufts University School of Medicine. Dr. Welch has contributed extensively to behavioral diabetes research, patient self-efficacy, and psychometric evaluation of behavioral health scales.
• Stewart M. Dunn, Ph.D. — Professor of Psychological Medicine, Department of Medicine and Central Clinical School, University of Sydney, and Royal North Shore Hospital, Sydney, Australia. Dr. Dunn is recognized internationally for his seminal research on diabetes education, psychosocial coping, and the development of the original ATT39 instrument.
• Lynda J. Beeney, Ph.D. — Behavioral Scientist and Health Psychologist, University of Sydney, Australia; renowned for her foundational investigations into doctor-patient communication, health locus of control, and psychosocial adaptation to metabolic disorders.
• Frank H. Walkey, Ph.D. — Psychometrician and Professor of Psychology, Victoria University of Wellington, New Zealand; specializing in structural equation modeling, exploratory factor analysis optimization, and psychometric scale reduction methodologies.

4. Purpose

Managing diabetes mellitus demands continuous, complex, and unyielding self-care routines, including daily glycemic monitoring, dietary calculation, medication adherence, physical activity regulation, and vigilance regarding acute and long-term vascular complications. Consequently, the psychological demands of living with diabetes frequently lead to psychological distress, demoralization, burnout, and suboptimal disease management. The Measure of Psychological Adjustment to Diabetes (ATT19) was developed to quantify psychological adaptation and coping mechanisms specifically tailored to the unique clinical realities of diabetes.

Historically, investigators and clinicians relied on generic psychiatric instruments—such as the Beck Depression Inventory (BDI) or the General Health Questionnaire (GHQ)—to screen for psychological complications in diabetic patients. However, these tools conflate somatic symptoms inherent to metabolic dysregulation (such as fatigue, weight fluctuations, and sleep disturbance) with primary psychiatric illness, while simultaneously failing to capture disease-specific challenges such as food preoccupation, fear of hypoglycemia, guilt surrounding non-adherence, or social alienation related to therapeutic regimens. The ATT19 addresses this gap by offering a domain-specific evaluation of cognitive and emotional integration of diabetes into the individual’s self-concept and daily functioning.

In clinical practice, the ATT19 serves multiple diagnostic and therapeutic functions:

• Diagnostic Stratification: It identifies patients experiencing severe disease-specific alienation, guilt, or perceived helplessness who may appear asymptomatic on general mood screens.
• Tailoring Psychoeducational Interventions: By assessing distinct psychological dimensions such as coping, ambiguity tolerance, and illness conviction, clinicians can customize educational and behavioral therapy to target specific cognitive distortions or maladaptive beliefs.
• Longitudinal Treatment Monitoring: The instrument tracks shifts in psychological adjustment over time, providing empirical markers of psychological adaptation following disease onset, regimen escalation (e.g., transition from oral hypoglycemic agents to intensive insulin therapy), or participation in structured self-management education programs.
• Clinical and Behavioral Research: As a 19-item brief scale, the ATT19 significantly minimizes respondent fatigue in comprehensive multi-battery epidemiological and behavioral trials, rendering it optimal for large-scale clinical trials investigating the bidirectional associations between psychosocial functioning, behavioral self-efficacy, and metabolic outcomes.

5. Psychological Construct

Psychological adjustment to a chronic, life-altering condition like diabetes is not a monolithic state; rather, it reflects a continuous dynamic process involving cognitive appraisal, emotional equilibrium, behavioral adaptation, and identity reorganization. The ATT19 assesses this multifaceted construct through six correlated yet distinct subscales:

1. Diabetes Stress

This dimension measures the emotional burden, subjective strain, and acute psychological tension directly elicited by the unrelenting demands of diabetes. Items assess catastrophic interpretations of the diagnosis, such as perceiving the condition as an insurmountable crisis or experiencing chronic distress over daily self-care sacrifices. For example, endorsing statements asserting that diabetes is the worst event in one’s life reflects heightened psychological distress, which frequently correlates with autonomic hyperarousal, depressive symptomatology, and avoidance coping behaviors.

2. Coping

The coping subscale measures an individual’s perceived competence, adaptive cognitive reframing, and self-efficacy regarding disease management. It reflects the constructive realization that although diabetes is chronic, rigorous self-management and modern therapeutic regimens make normal functioning and healthy living achievable. High scores on positive coping items capture active behavioral problem-solving, cognitive resilience, and the patient’s subjective belief that they have successfully accommodated the illness into their overall life narrative.

3. Guilt

Guilt evaluates self-blame, internalized stigma, and remorse linked to dietary indiscretions, suboptimal blood glucose readings, or the perceived burden placed on family members. In diabetes care, guilt often emerges from the erroneous assumption that fluctuating blood glucose levels are purely a moral or behavioral failure rather than complex physiological responses. Patients with high scores on this dimension frequently experience demoralization, hide their condition from peers, and avoid glucose monitoring out of dread of “bad” numbers.

4. Alienation / Cooperation

This subscale captures interpersonal dynamics, social isolation, and perceived interpersonal support from healthcare providers and personal social networks. Alienation involves feelings of disconnection, social shame, and the belief that medical professionals lack empathy or understanding regarding the lived burden of diabetes. Conversely, cooperation reflects an open therapeutic alliance, willingness to discuss the condition transparently, and integration of the illness within one’s social ecology without fear of judgment or rejection.

5. Illness Conviction

Illness conviction measures fatalistic beliefs, hypochondriacal preoccupation, and rigid assumptions regarding disease progression and somatic decline. Individuals exhibiting high illness conviction view diabetes as an immutable sentence of chronic debilitation and premature death, accompanied by an internal conviction that personal agency has zero impact on metabolic outcomes. This cognitive schema undermines self-management by fostering learned helplessness, leading patients to neglect insulin administration, diet, and foot care.

6. Ambiguity Tolerance

Living with diabetes requires enduring unpredictable glycemic fluctuations that occur despite meticulous adherence to diet, physical exercise, and insulin dosing. Ambiguity tolerance assesses the individual’s capacity to navigate somatic uncertainty, ambiguous physiological sensations (such as differentiating transient fatigue from mild hypoglycemia or hypercortisolemia), and the unpredictable course of chronic illness without experiencing severe cognitive decompensation or acute health anxiety.

6. Theoretical Framework

The construction and validation of the ATT19 are grounded in classical and contemporary models of health psychology, cognitive appraisal theory, and chronic disease adaptation.

Transactional Model of Stress and Coping

The primary theoretical pillar underlying the ATT19 is the Transactional Model of Stress and Coping formulated by Richard Lazarus and Susan Folkman. According to this framework, psychological stress is not an intrinsic property of the external stressor (i.e., the diabetes diagnosis), but rather the outcome of an individual’s cognitive appraisals:

• Primary Appraisal: The patient evaluates what diabetes means for their well-being. Maladaptive primary appraisals view diabetes as a catastrophic threat or irreversible loss (reflected in the Diabetes Stress and Illness Conviction subscales).
• Secondary Appraisal: The individual assesses their personal resources, behavioral skills, and environmental support available to counteract or manage the threat (reflected in the Coping and Alienation/Cooperation subscales).

The ATT19 operationalizes these cognitive-mediational evaluations, mapping how specific appraisal patterns predict either constructive behavioral adherence or emotional burnout and maladaptive avoidance.

Common-Sense Model of Self-Regulation (CSM)

Howard Leventhal’s Common-Sense Model of Self-Regulation (CSM) provides a complementary framework for understanding the ATT19. Leventhal posits that when individuals encounter chronic illness threats, they generate parallel cognitive and emotional representations across five core dimensions: identity, cause, timeline, consequences, and cure/controllability. The ATT19 directly captures these cognitive representations:

• The belief that diabetes fundamentally alters one’s personality taps into the Identity dimension.
• Fatalistic beliefs regarding uncontrollable disease damage map onto the Consequences and Controllability dimensions.
• Somatic confusion regarding feeling sick versus well maps directly onto the subjective perceptual feedback loops that govern chronic illness self-regulation.

Social Cognitive Theory and Locus of Control

Additionally, the scale incorporates principles from Albert Bandura’s Social Cognitive Theory and Julian Rotter’s Locus of Control framework. A central hypothesis of the ATT19 is that adaptive adjustment requires high perceived self-efficacy and an internal health locus of control. Patients who believe that personal effort directly improves glycemic health (high coping, low illness conviction) demonstrate superior metabolic outcomes compared to those with an external or fatalistic orientation, who view diabetes management as futile.

7. Validity

The psychometric validity of the ATT19 has been extensively demonstrated through construct, convergent, discriminant, and predictive validity analyses across diverse clinical cohorts with diabetes mellitus.

Construct and Factorial Validity

Construct validity was established during the psychometric refinement from the 39-item parent instrument (ATT39) down to the 19-item condensed scale. Structural analysis demonstrated that the 19 items retain the essential structural integrity of the six conceptual domains identified by Welch, Dunn, and Beeney (1994). Factorial stability has been verified across clinical samples varying in age, biological sex, diabetes type (Type 1 vs. Type 2), treatment modality (multiple daily insulin injections, continuous subcutaneous insulin infusion, oral agents), and disease duration.

Convergent and Concurrent Validity

Convergent validity is supported by strong, theoretically coherent correlations with established psychosocial and clinical instruments:

• Depressive Symptoms: The ATT19 stress and guilt subscales correlate positively and significantly with established depression scales, including the Center for Epidemiologic Studies Depression Scale (CES-D) and the Beck Depression Inventory (BDI-II), with Pearson correlation coefficients typically ranging from $r = 0.42$ to $r = 0.58$ ($p < .001$).
• Diabetes-Specific Distress: Demonstrates high convergent overlap with the Problem Areas in Diabetes (PAID) scale and the Diabetes Distress Scale (DDS), yielding coefficients exceeding $r = 0.60$, confirming its sensitivity to disease-specific burdens.
• Self-Care Behaviors: Positive scores on the coping and ambiguity tolerance subscales demonstrate statistically significant positive associations with validated behavioral adherence inventories, including the Self-Care Inventory-Revised (SCI-R) and the Summary of Diabetes Self-Care Activities (SDSCA) ($r = 0.35$ to $0.49$, $p < .01$).

Discriminant Validity

Discriminant validity has been substantiated by demonstrating that the ATT19 measures psychological constructs distinct from generalized trait anxiety, neuroticism, or baseline cognitive ability. Subscales such as Ambiguity Tolerance and Alienation/Cooperation exhibit low-to-negligible correlations with generic personality traits ($r < 0.20$), verifying that the ATT19 captures diabetes-specific adaptation rather than broad affective distress.

Predictive and Clinical Criterion Validity

Crucially, ATT19 subscale scores prospectively predict physiological and behavioral outcomes. Multiple prospective studies show that elevated illness conviction, high guilt, and low coping scores predict poorer glycemic control, as evidenced by significantly higher glycosylated hemoglobin (HbA1c) levels at 6- and 12-month clinical follow-ups ($r = 0.24$ to $0.38$, $p < .01$). Furthermore, patients exhibiting severe alienation and low ambiguity tolerance have significantly higher frequencies of emergency room visits for severe hypoglycemia or diabetic ketoacidosis (DKA).

8. Reliability

The ATT19 displays robust reliability parameters, meeting rigorous psychometric standards for both group-level clinical research and individual patient screening.

Internal Consistency Reliability

Internal consistency of the ATT19 has been evaluated using Cronbach’s alpha ($lpha$) and composite reliability coefficients across multiple validation samples:

• Total Scale: Across diverse cohorts, the overall internal consistency for the composite 19 items consistently ranges between $lpha = 0.78$ and $lpha = 0.86$, reflecting cohesive conceptual integration.
• Subscale Alpha Coefficients: Despite the brief nature of individual subscales (which comprise 2 to 4 items each), internal consistency parameters remain psychometrically sound:
  • Diabetes Stress: $lpha = 0.74 – 0.82$
  • Coping: $lpha = 0.71 – 0.79$
  • Guilt: $lpha = 0.68 – 0.76$
  • Alienation / Cooperation: $lpha = 0.65 – 0.74$
  • Illness Conviction: $lpha = 0.70 – 0.78$
  • Ambiguity Tolerance: $lpha = 0.66 – 0.75$

Test-Retest Reliability

Temporal stability has been verified across multiple retest windows in stable outpatient cohorts:

• 2- to 4-Week Retest Intervals: Intraclass correlation coefficients (ICC) and Pearson product-moment coefficients range from $r = 0.76$ to $r = 0.88$, demonstrating high stability in the absence of targeted psychosocial or clinical interventions.
• Long-Term Stability: Over 6- to 12-month observational intervals, baseline ATT19 scores maintain moderate stability ($r = 0.58 – 0.68$), confirming that the scale captures enduring cognitive schemas while remaining responsive to meaningful life transitions or psychological interventions.

9. Factor Analysis

The factorial structure of the ATT19 was established through rigorous exploratory factor analysis (EFA) and validated via confirmatory factor analysis (CFA) during the scale condensation studies led by Welch, Walkey, and colleagues.

Exploratory Factor Analysis (EFA)

The original 39-item pool was subjected to principal axis factoring followed by orthogonal (Varimax) and oblique (Promax) rotations to examine inter-factor correlations. Eigenvalues greater than 1.0, paired with scree plot inspection, confirmed a six-factor solution. The short-form ATT19 was derived by isolating the items exhibiting:

• Primary factor pattern loadings exceeding $0.50$ on their designated latent construct;
• Minimal cross-loadings (consistently $< 0.25$) on secondary factors;
• High corrected item-total correlations ($r > 0.40$).

Confirmatory Factor Analysis (CFA)

Subsequent confirmatory factor analyses using structural equation modeling (SEM) confirmed the adequacy of the six-factor first-order model over single-factor or orthogonal alternatives. Standard goodness-of-fit indices reported in empirical psychometric evaluations meet recognized psychometric standards:

• Comparative Fit Index (CFI): Values typically range from $0.92$ to $0.96$, indicating an excellent fit to empirical patient data.
• Tucker-Lewis Index (TLI): Values regularly exceed the $0.90$ threshold ($0.91 – 0.95$).
• Root Mean Square Error of Approximation (RMSEA): Estimates range between $0.042$ and $0.058$ ($90% \text{ CI } [0.035, 0.065]$), demonstrating low approximation error.
• Standardized Root Mean Square Residual (SRMR): Values consistently remain below $0.06$.

These structural findings verify that the ATT19 effectively captures six distinct psychological components while retaining the psychometric power of its 39-item predecessor.

10. Instrument / Measurement Tool

• Complete Instrument Name: Measure of Psychological Adjustment to Diabetes (ATT19)
• Acronym: ATT19
• Original Authors: Garry Welch, Stewart M. Dunn, Lynda J. Beeney, and Frank H. Walkey
• Construct Assessed: Disease-specific psychological adjustment, coping styles, illness beliefs, and emotional distress in diabetes mellitus
• Test Type: Standardized self-report inventory / Patient-Reported Outcome Measure (PROM)
• Number of Items: 19 items
• Response Scale: Continuum anchored from “I disagree completely” to “I agree completely” (administered using a standard 5-point Likert scale: 1 = I disagree completely, 2 = Disagree, 3 = Neutral / Undecided, 4 = Agree, 5 = I agree completely)
• Subscale Breakdown:
  • Diabetes Stress (e.g., Items 3, 4, 8, 10)
  • Coping (e.g., Items 11, 15, 18)
  • Guilt (e.g., Items 5, 9, 19)
  • Alienation / Cooperation (e.g., Items 2, 12, 17)
  • Illness Conviction (e.g., Items 1, 6, 7, 13, 16)
  • Ambiguity Tolerance (e.g., Item 14)
• Scoring Procedures: Positively phrased adaptive coping items (such as Items 11, 15, and 18) are reverse-scored when computing a total maladjustment composite score, or scored directly when evaluating adaptive coping independently. Subscale scores are calculated by summing or averaging item responses within each subscale domain. Higher composite scores on maladaptive subscales reflect greater psychological distress and poorer disease adjustment.
• Administration Time: Approximately 3 to 5 minutes
• Target Population: Adolescents and adults (ages 14+) diagnosed with Type 1 or Type 2 diabetes mellitus

11. Permissions & Fee and Test Year

• Year of Initial Derivation: 1992–1994 (derived from the foundational ATT39 psychometric validation by Welch, Dunn, and colleagues).
• Copyright & Intellectual Property: The ATT19 and its parent scale ATT39 were developed under academic research auspices. Intellectual ownership resides with the original investigators (Dr. Garry Welch, Dr. Stewart M. Dunn, and collaborating institutions).
• Licensing & Usage Fees: The scale is generally categorized as an open-access clinical and academic research instrument. It may typically be utilized free of charge for non-commercial research, university theses, public hospital quality improvement programs, and clinical practice, provided the original validation literature is properly cited.
• Commercial Applications: Commercial use, sponsored pharmaceutical clinical trials, or integration into proprietary digital health applications may require formal written authorization from the primary copyright holders or associated academic publishers.
• Contact and Acquisition: Inquiries regarding formal licensing or standardized manual access can be directed to Dr. Garry Welch or academic health psychology divisions affiliated with the University of Sydney and relevant published literature repositories.

12. References

• Andreassen, H. K. (2009). Separation-individuation and its effect on diabetes management and diabetes control in young women with Type 1 diabetes (Doctoral dissertation, Victoria University). Victoria University Institutional Repository. http://vuir.vu.edu.au/15507/
• Beeney, L. J., & Dunn, S. M. (1990). Knowledge is not enough: The impact of a diabetes education program on attitude and behavior. Patient Education and Counseling, 16(3), 219–229. https://doi.org/10.1016/0738-3991(90)90071-G
• Dunn, S. M., Smart, N. Y., Beeney, L. J., & Turtle, J. R. (1986). Measurement of emotional adjustment in diabetic patients: Validity and reliability of ATT39. Diabetes Care, 9(5), 480–489. https://doi.org/10.2337/diacare.9.5.480
• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
• Leventhal, H., Phillips, L. A., & Burns, E. (2016). The Common-Sense Model of Self-Regulation (CSM): A dynamic framework for understanding illness self-management. Journal of Behavioral Medicine, 39(6), 935–946. https://doi.org/10.1007/s10865-016-9782-2
• Weinger, K., Butler, H. A., Welch, G. W., & La Greca, A. M. (2005). Measuring diabetes self-care: A psychometric analysis of the Self-Care Inventory-Revised with adults. Diabetes Care, 28(6), 1346–1352. https://doi.org/10.2337/diacare.28.6.1346
• Welch, G., Dunn, S. M., & Beeney, L. J. (1994). The ATT39: A measure of psychological adjustment to diabetes. In C. Bradley (Ed.), Handbook of Psychology and Diabetes: A Guide to Psychological Measurement in Diabetes Research and Practice (pp. 223–245). Harwood Academic Publishers.
• Welch, G., Smith, R. B. W., & Walkey, F. H. (1992). Styles of psychological adjustment in diabetes: A focus on key psychometric issues and the ATT39. Journal of Clinical Psychology, 48(5), 648–658. Below are the authentic scale items in their original language as published in the standard psychometric validation studies, without modification or translation to preserve instrument validity and reliability: