Edited by Frank J. Snoek and T. Chas Skinner
Diabetes in School-aged Children
Psychosocial development and diabetes in the school-aged child
The primary developmental tasks of the child during the elementary school years include making a smooth adjustment from the home to the school setting; forming close friendships with children of the same sex; obtaining approval from this peer group; developing new intellectual, athletic and artistic skills and forming a positive sense of self. 13,14
Psychological development in school-aged children is assessed primarily with respect to the child’s sense of self-esteem and the development of peer relationships. In a careful review of the early empirical psychosocial literature on children with diabetes, Johnson concluded that ‘most youngsters with diabetes do not have psychological problems, but among those who do, peer relationship difficulties are quite common. Among all of the personality traits assessed, the evidence for peer or social relationship problems seems the strongest’ (p. 101).9
Studies of self-esteem in school-aged children with diabetes have consistently linked low self-esteem and poor social-emotional adjustment to poorly controlled diabetes.9,10 Herskowitz-Dumont and colleagues51 found a significant association between recurrent diabetic ketoacidosis (DKA) over 8 years post-diagnosis and higher ratings of behavior problems and lower levels of social competence, as measured by psychological testing in the first year after diagnosis. Similarly, Liss et al.52 found that children who had been hospitalized with DKA in the preceding 12 months reported lower levels of self-esteem and social competence than children who had no episodes of DKA in the same period. In addition, a significantly larger proportion of the DKA group met the diagnostic criteria for at least one psychiatric disorder (88 versus 28 per cent).
Because the development of peer relationships is an important aspect of the school-age years, it is crucial to examine how diabetes interferes with social development. Several older interview studies have shed light on this topic. Bregani et al.53 emphasized that during this developmental period children with diabetes often begin to feel a heightened sense of frustration and of social stigma from their dietary restrictions. The authors pointed out that the child’s emerging self-awareness and ability to reflect on his/her diabetes and to compare him/herself with peers made the child very vulnerable to feelings of inadequacy. Similarly, Zuppinger et al.54, in interviews with 23 children with diabetes at this age, found that half of the sample identified teasing from peers and difficulty in accommodating meal schedules to school activities as the major difficulties in following the diabetic diet. Leaverton55 also suggested that the most common resentment of the child with diabetes in the elementary school years is following a planned diet, because it gives an obvious sign to peers that the child is different. In addition to food restrictions and regularity of meal timing, the need for frequent blood glucose monitoring and insulin injections can emphasize differences and make peer acceptance more difficult.16
Kovacs and colleagues56 found in a longitudinal study of school-aged children newly diagnosed with diabetes that 25 per cent of their sample of school-aged children reported being teased by peers about their diabetes. When asked about the most difficult aspects of diabetes, insulin injections and dietary issues were most commonly cited. Despite the difficult regimen and challenges to peer acceptance, children’s self-ratings indicated good self-esteem and few signs of emotional distress in the first year of life with diabetes. Children in this study also reported showing their diabetes supplies to their friends and demonstrated glucose testing, which suggested that the children were actively trying to integrate diabetes into their lives.
Because the school environment presents many opportunities for building self-esteem and developing socialization skills, it is important for the school-aged child with diabetes to participate fully in all activities with as few restrictions as possible in order to facilitate a normal school experience. Children need to understand that, although they have diabetes, they are not ‘sick’ or ‘abnormal’.16 Participation in school activities helps to minimize the child’s sense of being different from peers. Some modifications in a typical school day may need to be made to accommodate diabetes safely, such as the scheduling of lunch and gym classes to prevent hypoglycemia, but restricting the child from gym classes or school outings only emphasizes differences and may foster a sense of inferiority.57
Children with diabetes should also be encouraged to participate in as many extracurricular activities and sports as they choose and as scheduling permits. For all children, such activities can boost self-esteem and feelings of competence. This effect may be particularly important for children with chronic diseases, such as diabetes.58
Participation in school is disrupted if the child has unusually high or low blood sugars or if the child uses diabetes to avoid particular classes.58 In addition, poorly controlled diabetes can lead to frequent or prolonged absences. Such events may result in educational setbacks and interfere with peer relationships, which may contribute to lower self-esteem.16 Minimizing the occurrence of hypoglycemia during the school day is crucial in light of findings by Puczynski and colleagues,59 which indicated that memory and concentration may continue to be impaired even after the physical symptoms of hypoglycemia have subsided. These findings have important implications for classroom functioning because many students return to their studies after recovering from the physical symptoms when they may not be able to function on a cognitive level as usual. Unfortunately, this study did not determine the length of time cognitive abilities remained impaired, but it did suggest that teachers should consider whether an episode of hypoglycemia might have affected a student’s performance.
Parents and educators need to be aware that neuropsychological studies have consistently reported ‘subtle deficits’ in verbal intelligence and specific neuropsychological functions such as attention, memory and executive functions in a high-risk subgroup of school-aged children with type 1 diabetes.60-63 Children who were diagnosed under 4 years of age or who had a history of severe hypoglycemic seizures are reported to be at risk for these cognitive deficits.60-63 While these cognitive changes are consistently described as ‘subtle’, investigations have not been conducted of the practical implications of these cognitive changes with respect to the child’s academic or social functioning. One recent study demonstrated that memory functioning was not related to the school-aged child’s diabetes self-care behaviors, while memory functioning was related to the self-care behavior of adolescents who were responsible for more of their own diabetes management tasks.64
In order for children with diabetes to have as normal a school experience as possible while maintaining optimal diabetes control, it is necessary for parents and health care providers to provide information and guidance to school personnel to outline expectations for the child’s care during the school day. It is important for both educators and parents to know that current guidelines for the care of children with type 1 diabetes allow for much more flexibility in meals and snacks than was recommended in the past.65 Teachers need to be informed of parental preferences relating to what the child is permitted to eat during school hours and whether substitute foods will be provided from home. School personnel must also be informed about the treatment of out-of-range blood glucose levels, the need for snacks during physical activity and the frequency of blood glucose monitoring and insulin administration if such procedures are deemed necessary during school hours. It is essential that families meet with teachers and school nurses before the start of school to provide such information and guidelines and to facilitate cooperation between the school and the family. By communicating with the school regularly throughout the year, families can prevent conflicts, clarify expectations and feel more confident that their child is safe at school.58
Because studies suggest that participation with peers, positive self-image and regimen flexibility (especially nutritional flexibility) are critical and interrelated goals for the school-aged child with diabetes, parents should avoid unrealistic demands for adherence to a meal, insulin, or monitoring schedule that restricts the elementary-school child from active participation in age-appropriate school and peer activities. The new, revised guidelines for the care of children with type 1 diabetes which permit more liberal carbohydrate intake66 and more flexibility in timing of meals and snacks65 may help to reduce the threats to self-esteem and the social stigmatism experienced by these school-aged children with type 1 diabetes in past decades.
Next Week: Family Factors Related to Glycemic Control and Adherence.
9. Clouse RE, Lustman PJ, Freedland KE et al. Depression and coronary heart disease in women with diabetes. Psychosom Med 2003; 65: 376–383.
10. Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care 2002; 25: 464–470.
13. Piette JD, Heisler M, Wagner TH. Problems paying out-of-pocket medication costs among older adults with diabetes. Diabetes Care 2004; 27: 384–391.
14. Lin EH, Katon W, Vo Korff M et al. Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care 2004; 27: 2154–2160.
16. Cox D, Gonder-Frederick L, McCall A et al. The effects of glucose fluctuation on cognitive function and quality of life: the functional costs of hypoglycaemia among adults with type 1 or type 2 diabetes. Int J Clin Pract 2002; 129: 20–26.
51. Rubin RR, Peyrot M, Saudek CD. The effect of a diabetes education program incorporating coping skills training on emotional well-being and diabetes self efficacy. The Diabetes Educator 1993; 19: 210–214.
53. Marlatt GA, Gordon JR. Relapse Prevention: a Self-Control Strategy for the Maintenance of Behavior Change. New York: Guilford, 1985.
54. Rubin RR, Peyrot M, Saudek CD. Effect of diabetes education on self-care, metabolic control, and emotional well-being. Diabetes Care 1989; 12: 673–679.
55. Rubin RR, Peyrot M, Saudek CD. Differential effect of diabetes education on self-regulation and lifestyle behaviors. Diabetes Care 1991; 14: 335–338.
56. Peyrot M, Rubin RR. Modeling the effect of diabetes education on glycemic control. Diabetes Educator 1994; 20: 143–148.
57. PeyrotM, Rubin RR. Structure and correlates of diabetes-specific locus of control. Diabetes Care 1994; 17: 994–1001.
58. Peyrot M, Rubin RR. Persistence of depressive symptoms in diabetes. Diabetes Care 1999; 22: 448–452.
59. Peyrot M, McMurry JF. Stress-buffering and glycemic control: the role of coping styles. Diabetes Care 1992; 15: 842–846.
60. Peyrot M, McMurry JF, Kruger DF. A biopsychosocial model of glycemic control in diabetes: stress, coping and regimen adherence. J Health Soc Behav 1999; 40: 141–158.
61. Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes: an epidemiological evaluation. Diabetes Care 1993; 16: 1167–1178.
62. Grigsby AB, Anderson RJ, Freedland KE et al. Prevalence of anxiety in adults with diabetes: a systematic review. J Psychosom Res 2002; 53: 1053–1060.
63. Colton P, Olmsted M, Daneman D et al. Disturbed eating behavior and eating disorders in preteen and early teenage girls with type 1 diabetes: a case-controlled study. Diabetes Care 2004; 27: 1654–1659.
64. Grylli V, Hafferl-Gattermayer A, Schober E, Karwautz A. Prevalence and manifestations of eating disorders in Austrian adolescents with type 1 diabetes. Wein Klin Wochenscchr 2004; 116: 230–234.
65. Goodwin RD, Hoven CW, Spitzer RL. Diabetes and eating disorders in primary care. Int J Eat Disord 2003; 33: 85–91.
66. Svensson M, Engstrom I, Aman J. Higher drive for thinness in adolescent males with insulin-dependent diabetes mellitus compared with healthy controls. Acta Paediatr 2003; 92: 114–117.
For more information on this book, just follow this link to Amazon.com, Psychology in Diabetes Care (Practical Diabetes).
Copyright © 2005 by John Wiley & Sons, Ltd.