Edited by Frank J. Snoek and T. Chas Skinner
Diabetes in Toddlers and Pre-Schoolers
Psychological development and the impact of diabetes: ages 2-5 years
Diabetes during the second to fourth years of life continues to have a profound effect on the parent-child relationship.
At this developmental period, the toddler’s two central psychological tasks are (1) to separate from the parent or primary caregiver and to establish him/herself as a separate person, by developing a sense of autonomy, with more clearly defined boundaries between the child and the parent, and (2) to develop a sense of mastery over the environment and the confidence that he/she can act upon and produce results in the environment, including the people making up his/her social environment.13,14
The restrictions of diabetes management and parental fear stemming from diabetes stress the normal drive of toddlers to explore and master their environments. The toddler’s sense of autonomy can be threatened by overprotective caregivers, who may be unable to let the child out of their sight. Out of fear, the parents may scold toddlers for exploring which can lead to feelings of guilt and shame.19 The autonomy that a child does develop is often reflected in refusals to cooperate with injections or blood glucose monitoring, as well as in conflicts over food. Toddlers can learn to use food to manipulate their parents, who are afraid of hypoglycemia, causing the dinner table to become a battleground. Parents of young children with diabetes in a study by Powers et al. reported more behavioral feeding problems and mealtime parenting problems than did parents of healthy control subjects.20 These problems can lead to poor nutritional intake as well as increasing the already high level of parental stress. Although the diabetes management tasks must be carried out, parents can help foster the developing sense of autonomy by allowing the toddler to choose between two injection sites or fingers for blood samples.19
As the child reaches the preschool years, the central developmental task becomes the use of the newly established sense of autonomy to investigate the world outside the home. The child is involved in gaining a sense of gender identity, in developing new cognitive abilities that allow more cause-effect thinking, and in separating successfully from parents for the first ‘school’ experience.13,14 At this developmental stage, the child must learn to adapt to the expectations of other adults, to trust these adults to provide for his or her needs, and to begin to form relationships with peers and adults outside the family. The child takes increasing initiative to explore and master new skills in environments outside the home.
For preschool-aged children with diabetes, meeting their peers may lead to the first awareness that they are ‘different’ from other children, in terms of eating, checking blood glucose levels, or wearing medical identification jewelry. As children with diabetes recognize that they are somehow different from others, it is common for them to believe that diabetes is a form of punishment. During this developmental stage, the child is developing his or her own explanations and perceptions of the world. Because diabetes plays a large role in the child’s life, the child uses developing, but limited, ideas of causality to reason that diabetes and its painful treatment are the result of his or her bad behavior.16
Given the toddler’s and preschooler’s normal developmental tasks of establishing their independence from the parent, diabetes only fuels the parent-child conflicts so typical of these stages. Unfortunately, in previous research studies, infants and toddlers with diabetes have been grouped with children under 6 years of age, and studied as a ‘preschool sample’, yielding little data on these stages specifically. One empirical research study by Wysocki and colleagues12 has studied the psychological adjustment of very young children from the mothers’ perspective, with a sample of 20 children, 2-6 years of age, with a mean age of approximately 4 years. The authors indicated that mothers reported that their children showed significantly more ‘internalizing’ behavior problems on the standardized Child Behavior Checklist (CBCL)21 such as symptoms of depression, anxiety, sleep problems, somatic complaints or withdrawal. However, the authors emphasize that mothers did not rate their toddler and preschool children with diabetes in the clinically deviant range as measured on this standardized instrument.12
In contrast to the findings of Wysocki et al., Northam and colleagues22 found no significant deviations from normative scores on any scale of the CBCL at diagnosis or 1 year later in a sample of 18 children under 4 years of age. In both studies, there were no assessments made of the children’s behavior independent of maternal report in either study. This is important to note in light of the other major finding by Wysocki and colleagues, that mothers of very young children with diabetes reported more overall stress in their families when contrasted with a non-diabetic standardization sample, citing the child with diabetes as the source of that stress.12 Powers et al. also found higher stress levels in parents of children with diabetes compared with parents of non-diabetic children.20 Despite the cautious interpretation these authors gave to their findings, it is possible that a non-diabetic standardization sample is an inappropriate comparison group. Both Eiser23 and Garrison and McQuiston24 have suggested that these types of behavioral change in the young child and changes in parental expectations are to be expected when any chronic illness is present in the child. Therefore, it is important not to conclude from these findings that it is diabetes per se that causes the behavioral adjustment problems or that all mothers of preschoolers with diabetes see their families as severely stressed. Clearly, more research into the psychological adjustment of very young children with diabetes and their families is needed. In addition, independent assessments of adjustment need to be used, rather than relying solely on parental report, which can be affected by feelings of guilt or pity.22
Family issues: parenting toddlers and preschoolers with diabetes
As is true for infants with diabetes, when a toddler or preschooler has diabetes, the parent(s) or caregiver(s) is the real ‘patient’.3 Parents continue to be responsible for making complex, clinical decisions, and for vigilantly monitoring the child for symptoms of hypoglycemia. As the child experiences growth spurts, parents often struggle to maintain the child’s blood sugar within a safe and acceptable range: a struggle made more difficult by the child’s inability to understand the importance of the regimen, and the toddler’s inability to verbalize symptoms of high or low blood glucose. Compared to findings from a sample of older children and adolescents with diabetes, mothers of very young children report more concerns about identifying hypoglycemia, and perceive greater family disruption from diabetes.12,25
Adding to the parents’ stress, toddlers and preschoolers, who are getting physically stronger, may actively resist and refuse insulin injections, blood monitoring, or needed meals and snacks. Restraining the squirming child at injection time or forcing the child to eat may be necessary but extremely stressful for parents who begin to feel that they are ‘feeding the insulin, not the child’17. The children can now also verbalize their fear and anger about invasive procedures, which can devastate parents as these emotions are usually directed at them.17
Once children begin to test their autonomy, it is important for parents to set limits and discipline their children appropriately. Temper tantrums are common among young children, hence the phrase ‘terrible twos’, but they may also signal hypoglycemia in children with diabetes. Many parents report difficulty distinguishing diabetes-related mood swings from normal toddler behavior.17 Once hypoglycemia has been ruled out through blood glucose monitoring, parents need to set limits and have clear expectations for the child as they would for a child without diabetes. Unfortunately, feelings of guilt or pity about the child’s disease may interfere with such limit-setting.19,26
Hatton and colleagues report that anticipation of a child entering preschool and being entrusted to another’s care can cause much anxiety and concern for parents.17 Overprotectiveness and pity for a child suffering from separation anxiety can tempt parents to cancel or delay plans for preschool education or daycare, but doing so can thwart the child’s growing sense of independence and development of social skills.19
Next Week: Treatment Issues for Children Under 6 Years of Age
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Copyright © 2005 by John Wiley & Sons, Ltd.