To investigate the physical and psychological factors associated with labile diabetic control, 30 children and adolescents with recurrent diabetic ketoacidosis were included in a retrospective longitudinal review covering an 8-year period. The details of the ketoacidosis episodes and the psychosocial characteristics of the patient and his family were summarized from the medical record. Only a minority of the ketoacidosis episodes were overtly and solely related to intercurrent illness or poor compliance. A majority of the subjects studied lived in families with substantial psychosocial dysfunction, including chronic unresolved interpersonal conflict, inadequate parenting, father not in home, financial stress, and lack of family involvement with the diabetes. Many of the children displayed behavioral and personality problems. In most of these 30 cases, there was evidence that these dysfunctions existed prior to the onset of diabetes. These psychosocial problems were not immediately apparent in many instances, thus requiring more comprehensive psychosocial assessment and involvement by a social worker and/or a psychologist. Ongoing emotional support and counseling were instrumental in reversing the pattern of recurrent ketoacidosis, in coordination with care by all members of the diabetes team. The findings from this experience suggest that recurrent ketoacidosis warrants prompt evaluation from a psychosocial as well as a physical perspective.