Edited by Frank J. Snoek and T. Chas Skinner
Diabetes in Adolescents
Despite the benefits of these family-based programs, they pose a challenge for working with older adolescents if their parents do not come to clinic or for young people in families who are not supportive of their diabetes care, and so may not want to attend these sessions.
Possibly as a result of these drives there has been a growth in a number of programs designed for adolescents. The program with the longest pedigree and most robust evidence here is the work of Grey and colleagues.102–104
They have evaluated the impact of a coping skills training program as an adjunct for adolescents starting intensive insulin regimens, either multiple daily injections or continuous subcutaneous insulin infusion. The aim of the program is to increase adolescents’ sense of competence and mastery by giving training in positive coping skills for the stresses arising from intensive management. Specifically, the program taught social problem solving, social, cognitive behavior modification and conflict resolution skills using scenarios that the adolescent generated as causing problems for intensive management. The program used a professional educator for the first few group sessions, and then moved on to using a trained adolescent with diabetes to complete the program. The results of the program, evaluated using a randomized trial, are very encouraging, showing improved glycemic control and psychological outcomes in the short term, which were sustained at 1 year follow-up. However, the challenge here is that this program is designed for adolescents on intensive insulin regimens, and so may be a useful adjunct to the process of starting adolescents on intensive regimens, but restricts the applicability of this approach to all adolescents with diabetes, many of whom will be on less intensive regimens (e.g. twice a day injections).
Therefore, approaches for individuals need to be considered to provide a more productive approach. Howells and colleagues explore this approach, 105 using regular telephone calls, every 2-3 weeks, designed to provide support and assistance in using problem-solving steps: define the problem; set a realistic goal for change; brainstorm — generate likely solutions; decide which solution to try; plan, act and review. Participants were at liberty to choose the subject of the call. They were informed that diabetes management did not have to be a focus for discussion, and the calls were not used to feed back HbA1c results. Although the intervention groups showed improvements in self-efficacy this was not matched by improvements in glycemic control. This suggests that using this approach but focusing content on issues related to diabetes management, as in Grey’s group program, as well as other non-diabetes issues may be needed to show an effect on metabolic outcomes.
A second approach that is gaining increasing attention for adolescents in this (see Table 2.1 — Motivation interviewing with adolescents’ menu of strategies) area is the use of motivational interviewing.106 Motivational interviewing (MI) has been described as a directive, counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.107,108 MI has been implemented in a variety of health care settings within adult populations. The results from two systematic reviews 109,110 have found impressive effect sizes (0.33 and above) for studies delivering MI in substance misuse. The results are less conclusive for other lifestyle areas. In the published research with teenagers and MI, most studies have been in the substance misuse field, 111,112 with some pilot studies demonstrating positive results in the diabetes field.106,113
Using MI with teenagers who have diabetes seems to make sense as there is an intuitive fit with the central tenets of MI such as rapport building, directiveness and empathy, which are central to care of adolescents with type 1 diabetes. A major step in engaging adolescents in care is to gain their trust, and the ‘spirit’ of MI involves the collaboration between client and practitioner; supporting autonomy and conveying respect for the adolescent is particularly appealing in engaging young people. The central tenet of ambivalence presents a key challenge in the clinical care of adolescents. Although many young people are resilient and experience no problems with diabetes, there will be just as many who will have a turbulent time with achieving optimal glycemic control. Furthermore, the dynamics between health care provider and young person can often reflect conflicts in the adolescents’ world.
The promise that MI theory and pilot studies have suggested has recently been tested in a randomized controlled trial of MI with adolescents, using the core strategies or tools outlined in Table 2.1. To address the criticism of MI literature that there is a lack of scientific evaluation of the methods used, and issues relating to interventionist training, supervision and quality monitoring, the study used direct clinical supervision. Furthermore, to provide a more rigorous test of the MI, individuals randomized to the control group received supportive counseling from a diabetes nurse specialist.
At 12 months significant differences were found, with MI participants reporting higher life satisfaction and lower life worry, less anxiety and more positive wellbeing. The intervention group also held a higher belief in controlling for their diabetes, a higher belief that certain actions were more likely to help prevent future complications of diabetes, a higher perception that their diabetes had a small degree of impact on their lives and a higher perception of seriousness of their diabetes than controls. These changes resulted in meaningful and significant improvement in glycemic control at 24 months follow-up. Alternatively, the MI intervention may also activate the individual to be more pro-active in their diabetes management, as the change in illness beliefs would suggest, but unless they have the optimal regimen for their lifestyle and or have the requisite skills for insulin dose adjustment these motivational changes may not result in changes in metabolic markers.
Although the MI work so far with adolescents with diabetes, is only showing promise, some of the tools utilized from the menu in Table 2.1 are worth considering in more detail, as they seem to share much with other intervention programs and can be used within a diverse range of theoretical models.
First, adolescents may often have conflicting feelings, attitudes and thoughts about changing their behavior, particularly if the behavior is habitual, entrenched, and has personal valence. One useful tool is to look at the positives and negatives of current behavior and of change. The strategy aims to provide structure, raise awareness and elicit thoughts and feelings about current behavior. This is an exercise that will be familiar from other approaches and can seem to be a simple exercise. However, it needs to be carried out slowly and sensitively, with respect for the patient’s decisions on how they value their behavior(s). It is in this exercise that the adolescent’s fairly fragile sense of their independent self can become very apparent and impact on the process. For this to be a productive exercise the young person must have developed a significant degree of trust in the counselor to believe that his or her perspective will not be discounted. Virtually all other people in the person’s life have a vested interest in hearing him or her talk in a particular way about behavior. Without trust the exercise becomes a recital of risks to health which, whilst they may motivate some, may not be the crucial ingredient of change for many. This may be the first time adolescents with diabetes may have faced their ‘dilemmas’ and spoken about them honestly. The power of ambivalence will become particularly marked in this exercise and the counselor must work extremely hard to use this constructively before less constructive alternatives are adopted to reduce the dissonance.
In order to appreciate the dilemmas young people face and to start to understand the decisions they make, it is important to understand and explore their frame of reference for their diabetes management. Perception of illness shape how the young person copes with controls and adheres to the illness and plays a central role in outcomes.118 Personal illness models 119–121 are identified as patients’ cognitive representations, which will impact distally on illness-related behavior. These representations include the degree to which a person can control the illness, the cause of illness, how long the illness endures and the consequences of illness.122 Assessing degree of perception of control may be of particular importance with diabetes, for which glycemic control is significant in preventing complications.
Some adolescents will keep a tight rein on their diabetes management and will practice health-affirming behaviors to keep their diabetes management within normal limits. Others will be happy to hand over responsibility to their treatment regimen and significant others. However, diabetes is a complex metabolic disorder, and for some young people tight control, perfect lifestyle factors and supportive families do not always equal positive outcomes. Puberty has negative pharmacological effects on secretion of insulin and this will have a profound effect on their management.
Next Week: 2.3 Individual Interventions: Process of change – (Part 2)
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