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Psychology in Diabetes Care, 2nd. Ed, Part 9

Dec 18, 2011

Edited by Frank J. Snoek and T. Chas Skinner

Diabetes in Adolescents



2.1 Introduction- Recurrent ketoacidosis

Diabetic ketoacidosis (DKA) is the single most common cause of mortality in individuals with type 1 diabetes under the age of 40.21

In addition to the risk of fatality, recurrent DKA has a major impact on the quality of life of both the individuals with diabetes and their families, and microvascular complications may be accelerated. Research shows a number of consistent themes that enable us to identify individuals at potential risk for recurrent DKA, with about 20 per cent of individuals accounting for 80 per cent of hospital admissions for DKA.22,23

The incidence is higher in females, peaks in the early teenage years and rarely occurs in anyone diagnosed for less than 2 years. Individuals with earlier age of onset and lower socioeconomic backgrounds seem to be at increased risk, along with individuals who had existing psychopathology before diabetes onset.22,23    However, there is a distinct lack of evidence for individuals with recurrent DKA to have a subtype of brittle diabetes,24 and the main cause of DKA is insulin omission. Further long term follow-up data indicates that recurrent DKA is usually not sustained into adulthood.25,26 This leads to consideration of why some young adolescents persistently omit insulin. There are multiple reasons for this, but the literature seems to point to a relative few main candidates.

There is consistent support for psychosocial risk factors as predictive of recurrent DKA. Individuals from families low in warmth and support, where there are high levels of unresolved family conflict and a distinct lack of parental involvement in the adolescent’s diabetes care seem to be typical of this population. 26–29 Linked to this is the possibility that the young person may want to escape from the home environment, for reasons of physical, sexual or emotional abuse and or neglect. A recent classic example was a child who omitted her insulin whenever she was due to spend time with her father, her parents being divorced. With some gentle questioning by the care team, she admitted that she did not want to visit with him and the possibility of parental abuse was subsequently confirmed. With subsequent removal of paternal visitation rights the episodes of DKA ceased. 

Alternatively, weight manipulation or eating disorders have been shown to be associated with short and long term complications.30 Although the data on prevalence on eating disorder literature is rather contradictory, with some studies finding elevated rates in people with type 1 diabetes 31–33 whilst other papers do not support this finding,34–36 a recently published large study with a good control group showed no increase in rates of anorexia or bulimia, but the incidence of eating disorders not otherwise specified (EDNOS) was two to three times as prevalent in young females with type 1 diabetes.37 Given the perfectionist nature of individuals with anorexia, one would not expect these individuals to become ketotic, but those who some clinicians may consider meet the criteria for EDNOS may well have recurrent DKA, although the evidence for this is extremely limited. The problem is that so far eating disorders have proved particularly intractable and difficult to treat in diabetes. It is also possible that other psychiatric disorders may be implicated 38–40 but the data on these in relation to DKA is limited at the moment. 

A further possible cause is that the young person may go through a period of rebellion or rejection of their diabetes. The very process of learning to live with and cope with a life-limiting condition can lead to feelings of resentment and phases of rebellion. These may lead to periods of insulin omission, which are just part of the process of adapting to life with diabetes, especially during adolescence. As a young lady wrote about her life with diabetes, analogizing her diabetes to a package to be carried around at all times, 

A few months on, I became sick of being the only person able to see the big parcel in front of me, with all my attention focused on it. I was unable to enjoy what was going on around me. Why should I carry it, I asked, but no one would answer. Then I started thinking, if this was how it was going to be, forever, I didn’t want any more of it.

I tried to put it down, but couldn’t. I tried throwing it down, but it was attached to me. I then tried every way I could think of to get rid of it: kicking, pushing, even getting my friends to try and pull it away, everything failed. I then tried to totally destroy it, but it was me who suffered from the repercussions (Anon).

Occasional insulin omission may be just an oversight, as diabetes is pushed into the background of adolescent life. Forgetting was the most common reason cited by young people for omitting insulin, 41 but this is unlikely to be the cause for frequent, serious DKA.

Given these and other possible causes of insulin omission, attempting to resolve the associated problems can be difficult. A recent systematic review of educational and psychosocial interventions for adolescents with type 1 diabetes located only six studies targeted at this group of patients.18 Two studies identified by this review 42,43 report on a range of interventions being used, ranging from changing the insulin regimen, to a nurse giving injections, to family therapy. Other approaches that have been tried include more intensive management (CSII pumps), planned admissions to hospital and cognitive behavior therapy. All that can be definitely said is that these interventions seem to be of real benefit to some individuals, but not all.

It would seem that an important step in resolving recurrent DKA is a multidisciplinary assessment by person(s) with knowledge or understanding of the individual from a psychosocial perspective. Some approaches have not been considered, or published, such as the identification and treatment of depression and attention deficit hyperactivity disorder, with medication and individual or family therapy. In attempting to resolve recurrent DKA with any of these treatment modalities, it is important that diabetes drops into the background. 

Early identification and open discussion about the causation and associated problems is of paramount importance. Prevention of recurrent DKA should also be high on the health care professionals’ agenda. Steps that can be easily incorporated into routine care can serve to prevent the emergence of recurrent DKA. We must learn to identify psychopathologies as soon as possible. 

  • At diagnosis, where adolescent patients experience substantial weight loss, weight gain should be gradual and not excessive, to avoid eating disorders. 
  • Young people and families should be given opportunities to talk about their feelings and emotional responses at diagnosis and throughout their childhood and adolescence. 
  • Diabetes teams should try to include either a psychologist or someone with additional training in counseling as an integral member of the team for all young people and their families 
  • Provision of continuing ongoing diabetes education must be readily available. 
  • Early adolescent autonomy and responsibility for care should not be overly encouraged: responsibility should be given to the adolescent at their request, not the parents’ – it should be a gradual process. 
  • At times there may be a need to take a few steps back when the burden of diabetes becomes too much, especially when other issues (study, peer pressures, romantic relationships, depression etc.) take priority for the adolescent. 
  • Most importantly, do not lose contact with the adolescent who is experiencing recurrent DKA and other problems. Keep in touch by whatever means possible, phone, fax, e-mail, post, as your support is essential if damage is to be minimized and the individual is to find a way forward. 

Next Week: Diabetes in Adolescents- Familial Interventions


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21. Rubin RR. Hypoglycemia and quality of life. Can J Diabetes Care 2002; 26: 60–63.

22. Peyrot M, Matthews D, Snoek F et al. An international study of psychological resistance to insulin use among persons with diabetes. Diabetologia 2003; 46 (Suppl. 1): A89.

23. Peyrot M. Psychological insulin resistance: overcoming barriers to insulin therapy. Pract Diabetol 2004; 23: 6–12.

24. Korytkowski M. When oral agents fail: practical barriers to starting insulin. Int J Obes Relat Metab Disord 2002; 26 (Suppl 3): S18–S24.

25. Follansbee DJ, La Greca AM, Citrin WS. Coping skills training for adolescents with diabetes. Diabetes 1983; 32 (Suppl. 1): 37A.

26. Boardway RH, Delameter AM, Tomankowsky J et al. Stress management training for adolescents with diabetes. J Pediatr Psychol 1993: 18: 29–45.

27. Gross AM, Heimann I, Shapiro R et al. Children with diabetes: social skills training and hemoglobin A1c levels. Behav Modification 1983: 7: 151–164.

28. Smith KE, Schreiner BJ, Brouhard BH et al. Impact of camp experience on choice of coping strategies for adolescents with insulin-dependent diabetes mellitus. Diabetes Educ 1991: 17: 49–53.

29. ChawickMW, Kaplan RM, Schimmel LE. Social learning intervention improves metabolic control in type 1 diabetic teenagers. Diabetes 1984; 33 (Suppl. 1): 69A.

30. Mendez FJ, Melendez M. Effects of a behavioral intervention on treatment adherence and stress management in adolescents with IDDM. Diabetes Care 1997; 20: 1370–1375.

31. Shalom R, Ryan J. Support and education groups for type 1 diabetics in a college campus. Diabetes 1987; 36 (Suppl. 1): 210A.

32. Grey M, Boland EA, Davidson M et al. Short-term effects of coping skills training as an adjunct to intensive therapy in adolescents. Diabetes Care 1998; 21: 902–908.

33. Grey M, Boland EA, Davidson M, Tamborlane WV. Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life. J Pediatr 2000; 137: 107–113.

34. Wysocki T, Greco P, Harris MA et al. Behavior therapy for families of adolescents with diabetes: maintenance of treatment effects. Diabetes Care 2001; 24: 441–446.

35. Sandor J. The effect of diabetic camp on locus of control. Diabetes 1981; 30 (Suppl. 1): 49A.

36. Moffatt MEK, Pless IB. Locus of control in juvenile diabetic campers. J Pediatr 1983; 103: 146–150.

37. Scharf LS, Leach DC, Adams KM. Diabetes camp as a psychological intervention. Diabetes 1987; 36 (Suppl. 1): 109A.

38. McCraw RK, Travis LB. Psychological effects of a special summer camp on juvenile diabetics. Diabetes 1973; 22: 275–278.

39. Marrero DG, Meyers GI, Golden MP et al. Adjustment to misfortune: the use of a social support group for adolescents with diabetes. Pediatr Adolesc Endocrinol 1982; 10:213–218.

40. Anderson BJ, Wolf, FM, Burkhart MT et al. Effects of peer-group interventions on metabolic control in adolescents with IDDM: randomized outpatient study. Diabetes Care 1989; 12: 179–183.

41. Karlsen B, Idsoe T, Dirdal I et al. Effects of a group-based counseling programme on diabetes-related stress, coping, psychological well-being and metabolic control in adults with type 1 or type 2 diabetes. Patient Educ Couns 2004; 53: 299–308.

42. Pibernik-Okanovic M, Prasek M, Poljicanin-Filipovic T et al. Effects of an empowerment based psychosocial intervention on quality of life and metabolic control in type 2 diabetic patients. Patient Educ Couns 2004; 52: 193–199.

43. Warren-Boulton E, Anderson BJ, Schwartz NL et al. A group approach to the management of diabetes in adolescents and young adults. Diabetes Care 1981; 4: 620–623.

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Copyright © 2005 by John Wiley & Sons, Ltd.