Home / Specialties / Mental Health / Psychology in Diabetes Care, 2nd Ed., Part 10

Psychology in Diabetes Care, 2nd Ed., Part 10

Dec 26, 2011

Edited by Frank J. Snoek and T. Chas Skinner

Diabetes in Adolescents



2.2 Familial Interventions (Part 1) 

First, the descriptive literature of the family environment in supporting the young person with diabetes is probably the most extensively researched area on adolescent and childhood diabetes.

To provide a means of integrating the very disparate operationalizations used in the research, two dimensions that family researchers, reviewers and theorists have consistently identified will be used. The labels more usually used for these dimensions are family support and family control. Family support comprises behaviors that foster in an individual feelings of comfort and belonging, and that he or she is basically accepted and approved of as a person by the parents and family. Family control reflects an environment that directs the behavior of an individual in a manner desirable to the parents, to the power base in the family.44

Although the dimension of family support generates inconsistent results in relation to glycated hemoglobin, with roughly equal numbers of cross-sectional studies supporting an association 49,52–58 and failing to support this association, 45,46,59–67 and longitudinal studies also producing mixed results.23, 55, 63, 71 In contrast, most support a significant association between family support and psychological adjustment,45–49 although two smaller studies report no significant association between family support and adjustment.50,51 In relation to self-care the literature consistently supports an association,46,53,54,62,68–73 with no identified studies failing to find an association between some aspect of family support and self-care behavior. The inconsistent results for family support and glycemic control are probably a result of its effect being mediated by self-care, whereas other variables have direct effects, 54 such as stress, which may mask the indirect targeted increasing support with the family.

However, family conflict, a concept related to support, has been targeted in a recent intervention program. The fact this has been done remains curious, given the inconsistent results in the published literature.55,61,70 with prospective data71 reporting that changes in conflict were not associated with changes in adherence over the four years of their prospective longitudinal study. This may be a result of conflict over minor issues being common and even normative in adolescence, with some commentators arguing that conflict in the family is essential for the development of young people’s interpersonal skills.74–76 However, it is important to remember that extreme levels of conflict and/or conflicts that remain continually unresolved are likely to disrupt the family and impact on poor control. Therefore, communication and conflict resolution may be a more critical issue as highlighted by Bobrow and colleagues,77 who examined the interaction between mothers and adolescent daughters with diabetes.

However, if conflict resolution is the key problem then interventions designed to provide families with the skills and strategies to resolve conflicts with resulting benefits for the family as a whole and for the management of diabetes would be helpful. One research group has attempted this using Behavioral–Family Systems Therapy (BFST).78–81 The program involves four therapy components. (i) Problem-solving training provides families with a behavioral contracting approach to conflict resolution with training in problem definition; generation of alternative solutions; group decision-making, planning, implementation and monitoring of the selected solution and renegotiation or refinement of the ineffective solutions. (ii) Communication skill training includes instructions, feedback, modeling and rehearsal, targeting common parent–adolescent communication problems. (iii) Cognitive restructuring methods were used to identify and change family members’ irrational beliefs, attitudes and attributions that may have impeded effective parent adolescent communication and conflict resolution. (iv) Functional and structural family therapy interventions targeted anomalous family systemic characteristics (e.g. weak parental coalitions or cross-generational coalitions) that may have impeded effective problem solving and communication. The psychologists used standard behavior therapy techniques of instruction, feedback, modeling and rehearsal along with behavioral homework (i.e. encouraging families to practice targeted skills at home). Although the program resulted in significant improvements in parent–adolescent relationships and adherence, there were no gains in psychological adjustment or metabolic control.79–81 These mixed results pose more questions than they answer on the role of conflict and diabetes outcomes. All that can be said for certain at the moment is that the research on family conflict continues to generate conflicting, contradictory and confusing results.

Research on the dimension of family control also generates inconsistent results, with some studies reporting a significant association46,48,49,51,58–62,66,82–84 whilst others do not support an association.45,46,52,53,55,60,62–65,70,85–90 This inconsistency may be a result of researchers looking for linear effects, when non-linear effects are more probable.84 Alternatively, the lack of consistency in results may be a consequence of the lack of specificity in the measures of family control measures. Research that has looked at the degree of parental involvement in diabetes care has produced noticeably consistent results. The greater the responsibility for diabetes care activities (e.g. injecting insulin, deciding on insulin dose, remembering to monitor blood glucose values) taken by the adolescent with diabetes, and the less the parental involvement, the worse the control.5,58,64,66,91–94 More detailed examination of parent and child perceptions of responsibility indicated that where no-one was taking responsibility for diabetes care tasks the young person with diabetes was in worse diabetes control.95 This handing over of responsibility not only needs to be negotiated and managed, but also needs to match the maturity of the individual and their ability to take responsibility.7,94

These hypotheses have now been tested with intervention studies that specifically targeted this process of negotiating responsibility, combined with self-management education. 96–98 These studies have demonstrated that this is an issue that could be readily integrated into normal diabetes care and consultations without increasing diabetes-related conflict, and can be delivered in a group or individual format and support improved glycemic control and self-care. This approach has now been replicated by a second research group in the UK.99,100   FACTS (Families, Adolescents and Children’s Teamwork Study), developed in response to the need for a family-centered, skills-based education program without parents and their children having to attend the hospital for any more visits. There are three or four families in each group with separate sessions for children (11 years or less) and young people (12–16 years). The sessions are fully integrated into routine clinical care and occur at the diabetes center on the same day as the child’s usual 3 monthly appointment. There are four sessions per year, which allows time to consolidate new information and put it into practice before new topics are raised. This approach also helps to include those who may not otherwise volunteer for extra-curricular activities or find attending for additional visits difficult. Each session is facilitated by a health care professional who has had expert training in the delivery of group education by a health psychologist. This has enabled a structured program to be delivered by local staff while making effective use of the limited health psychologist resources available in the UK.

Session 1 (Food enjoyment with carbohydrate counting) is facilitated by a pediatric diabetes specialist dietitian. Carbohydrate counting is not presented as an all or nothing tool, or as a tool exclusively for those on pumps or multiple injections, but rather as a tool that those on less intensive insulin regimes may also wish to consider. We use real foods eaten by the children and focus on snacks, which contribute significantly to the calorie intake of young people taken either as treats, before sports or to prevent/treat hypos.

To establish what carbohydrate counting is all about and how it may be useful the group is asked what is already known about this topic. They discuss why they feel this may be of benefit in managing diabetes. Once the group has identified that carbohydrate counting may be helpful to them, the next step is for them to identify which foods contain carbohydrate. These are listed on a flip chart and divided into two columns to distinguish sugars and starches as shown. This allows for discussion and recognition of the different types of sugar, e.g. fructose, lactose, sucrose and glucose.

The children write what they have eaten for breakfast that morning on a flip chart. They identify the carbohydrate sources and discuss how these may be counted by using food labels, weighing or using handy measures to work out their portion size. Food reference tables are introduced and used as required. Children are encouraged to choose their favorite snacks from a variety of healthy and sweeter options and work out which ones are suitable snacks. The fact that 15g of carbohydrate has the same effect on blood sugar whether it comes from an apple, a Shredded Wheat or a mini Mars bar is of great interest to the children. The use of snacks before sports and to treat/prevent hypos is discussed.

The practicalities of estimating the carbohydrate content of individual portions of rice or pasta are discussed. The carbohydrate content of 100 g dry basmati rice is calculated and compared to the cooked portion. Families work together to read the labels, weigh their portion and work out the carbohydrate content of their own portion size. They are introduced to handy measures to avoid this messy process at each meal! Those who wish to continue with this at home are given food diaries and asked to calculate their average daily CHO intake. Computer analysis of their results revealed that this simple practical session resulted in effective estimation of CHO content with minimal differences between computer and parent estimates. This indicates that carbohydrate counting can be effectively taught in small groups using real life examples and practical interactive activities. The session is effective in providing accurate dietary knowledge but of course this does not prove that it results in improved insulin dose adjustment or lasting behavioral change.

Session 2 (Blood sugar testing, HbA1c and insulin dose adjustment) builds on the carbohydrate counting session through initially reviewing learning from the first session and the group’s experiences with carbohydrate counting with all efforts praised, followed by an outline of the current session contents. Thereafter, a card game is played to explore the facts and fictions of blood sugar monitoring. Individuals are encouraged to think about their own blood glucose targets and comment on how easy or difficult these are to achieve. Factors that raise and lower blood glucose are written on a flip chart, with an emphasis that although food is important it is not the only factor leading to out of range values. 

Parents and children are asked whether they know what their HbA1c value was at today’s clinic visit. Those who wish to share their results are asked what this means to them in terms of blood sugar control. A practical demonstration follows where the children pour a small amount of granulated sugar into a clear container and a larger amount of sugar into the next. Red blood cells are simulated by making small balls of red playdough, demonstrating that at greater sugar concentrations there is more sugar stuck to the red cells, giving higher levels of HbA1c. 

Basic facts about common types of insulin and injection techniques are discussed. Participants are asked to find the names of their own insulins and with help from their parents match these to the time frame over which they work using sticky labels on the flip chart. This simple exercise always reveals a surprising number of common misconceptions. Insulin absorption from different sites and the need for site rotation are discussed. 

A pattern of high blood sugars before the evening meal is written on the flip chart. Participants are then asked to come forward and circle those values that are out of range such that they can identify the pattern. The group discusses the likely causes for this pattern. They then suggest a range of solutions, which are offered to each child/young person, who then determines which one will work best for them. Regular review of diaries or blood glucose memories is encouraged at home to encourage parents to elicit their child’s opinions and to gain confidence in problem solving as a team. 

Session 3 (Teamwork and communication to support blood glucose monitoring) begins with an ice-breaker exercise as the topic moves away from more traditional education to more psychological issues. The group is asked to arrange themselves in order of height with eyes closed, or they are asked hold hands in a circle, drop hands, hold hands with two different people, while staying in same spot and then go back to your original position. Once the task is completed the group is asked, “What did you need to do?” The answers are written onto the flipchart and form the basis of this session:

  • teamwork
  • getting out of a mess
  • rely on someone else to co-operate
  • have a laugh
  • getting to know people
  • how to work out a problem with each other
  • trust each other
  • there are lots of solutions, always a way out
  • cannot always get it perfect.

Thereafter children and parents are both asked to draw a picture of doing a blood sugar test in their home. They are encouraged to share their pictures with the group:

Michael (grumpy face) – Please do I have to? 

Mom – Yes. 

Michael – Can I do it later? 

Mom – It’s always come on, come on, come on until in the end I get a grumpy face too. Once he starts doing it, it’s OK.

After sharing these pictures and describing what is happening, the group are to draw ‘what happens in your house when your blood sugar is 399’. This provides an opportunity to discuss how families react to out of range blood glucose values. The issues raised by this are discussed, with many parents and children gaining new insights into each other’s behaviors and how these affect each other’s feelings and thoughts about themselves. Throughout, no one is criticized or judged; rather, individuals views are all valued and everyone is just given time to share their views in an honest but gentle way. 

Session 4 (Interdependence: sharing responsibility and letting go) also begins with another ice breaking exercise, before asking the group to ‘Draw a train representing your diabetes team’. Everyone is again gently persuaded to share their drawings, and some specific questions are asked of both adolescents and parents, such as ‘Who’s driving the train?’; ‘In which carriage do you sit?’; ‘How do you feel about where you are?’; ‘How can you see this changing in the future?’; ‘What needs to happen to help these changes happen?’

There tends to be more agreement between the pictures drawn by the parents and adolescents in this session, compared to session 3, but here the discussion is focused on the future, and negotiating changing roles as the young person gets older. Any key points raised in the discussion are noted on a flip chart. There is no direct teaching or instruction in the session, just valuing the insights brought to the group by the participants.

The FACTS program aims to improve diabetes self-management skills, increase teamwork and reduce diabetes-related family conflict. A randomized waiting-list-controlled trial is currently underway to assess the effects of the program on quality of life and glycemic control of young people with type 1 diabetes. The preliminary data from this project are promising. With more families attending the group requesting to go on more intensive insulin regimens, although this is not the aim of the educators, the intervention group show increased agreement between parents and adolescents on diabetes management tasks, more adolescent and more parental involvement in care and improved glycemic control in the short term. 

The results of these studies replicates the data on general adolescent development, which also implicates parental involvement as the single most important predictor of positive adolescent outcomes.101 The key to understanding this approach is to acknowledge that the major developmental task of adolescence is movement away from dependence on the family, not toward complete independence but rather interdependence. Interdependence does not require the adolescents to distance themselves emotionally from parents, but requires a reorganization in which the family members renegotiate and redistribute responsibilities and obligations. 

Next Week: Individual Interventions


5. Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 2000; 160: 3278–3285.

7. de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: a meta-analysis. Psychosom Med 2001; 63: 619–630.

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

44. Dupois A. Assessment of the psychological factors and responses in self-managed patients.Diabetes Care 1980; 3: 117–120.

45. Rabin C, Amir S, Nardi R et al. Compliance and control issues in group training for diabetics. Health Soc Work 1986; 11: 141–151.

46. Cain C, Childs C. Development of a peer support group for patients using a subcutaneous insulin infusion pump. Diabetes 1982; 31 (Suppl. 1): 18A.

45. Rabin C, Amir S, Nardi R et al. Compliance and control issues in group training for diabetics. Health Soc Work 1986; 11: 141–151.

46. Cain C, Childs C. Development of a peer support group for patients using a subcutaneous insulin infusion pump. Diabetes 1982; 31 (Suppl. 1): 18A.

47. Aveline MO, McCulloch DK, Tattersall RB. The practice of group psychotherapy with adult insulin-dependent diabetics. Diab Med 1985; 2: 275–282.

48. American Diabetes Association. National standards for diabetes self-management education. Diabetes Care 2000; 23: 682–689.

49. Peyrot M, Rubin RR. Living with diabetes: the patient-centered perspective. Diabetes Spectrum 1994; 7: 204–205.

50. Rubin RR, Biermann J, Toohey B. Psyching Out Diabetes: a Positive Approach to Your Negative Emotions, 3rd ed. Los Angeles: Lowell House, 1999.

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.

52. Rubin RR, Walen S, Ellis A. Living with diabetes: a rational–emotive therapy perspective. J Rational-Emotive Cognitive–Behavioral Ther 1990; 8: 21–39.

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 selfregulation 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.

67. Rydall AC, Rodin GM, Olmsted MP et al. Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus. N Engl J Med 1997; 336: 1849–1854.

68. De Berardis G, Pellegrini F, FranciosiMet al. Identifying patients with type 2 diabetes with 100. Wing RR, Norwalk MP, Marcus MD et al. Subclinical eating disorders and glycemic control in adolescents with type 1 diabetes. Diabetes Care 1986; 9: 162–167.

101. Steel JM, Young RJ, Lloyd GG, Clarke BF. Clinically apparent eating disorders in young diabetic women: association with painful neuropathy and other complications. BMJ 1987; 294: 859–862.higher likelihood of erectile dysfunction: the role of the interaction between clinical and psychological factors. J Urol 2003; 169: 422–428.

69. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Washington, DC: American Psychiatric Association, 1994, p 327.

70. Ciechanowski PS, Katon WJ, Russo JE, Hirsch IB. The relationship of depressive symptoms to symptom reporting, self-care and glucose control in diabetes. Gen Hosp Psychiatry 2003; 25: 246–252.

71. Lustman PJ, Harper GW. Nonpsychiatric physicians’ identification of depression in patients with diabetes. Compr Psychiatry 1987; 28: 22–27.

72. Spitzer RL, Kroenke K,Williams JBWet al. Validation and utility of a self-report version of the PRIME-MD: the PHQ Primary Care Study. JAMA 1999; 282: 1737–1744.

75. Henkel V, Mergl R, Coyne JC et al. Screening for depression in primary care: will one or two items suffice? Eur Arch Psychiatry Clin Neurosci 2004; 254: 215–223.

76. Henkel V, Mergl R, Kohnen R et al. Use of brief depression screening tools in primary care: consideration of heterogeneity in performance in different patient groups. Gen Hosp Psychiatry 2004; 26: 190–198.

77. Bonsignore M, Barkow K, Jessen F, Heun R. Validity of the five-item WHO Well-Being Index (WHO-5) in an elderly population. Eur Arch Psychiatry Clin Neurosci 2001; 251 (Suppl. 2): II27–II31.

78. Lustman PJ, Griffith LS, Clouse RE et al. Effects of nortriptyline on depression and glycemic control in diabetes: results of a double-blind, placebo-controlled trial. Psychosom Med 1997; 59: 241–250.

79. Lustman PJ, Freedland KE, Griffith LS, Clouse RE. Fluoxetine for depression in diabetes: a randomized, double-blind, placebo-controlled trial. Diabetes Care 2000; 23: 618–623.

80. Lustman PJ, Griffith LS, Freedland KE et al. Cognitive behavior therapy for depression in type 2 diabetes: a randomized controlled trial. Ann Intern Med 1998; 129: 613–621.

81. Williams JW, Katon WJ, Lin EHB et al. The effectiveness of depression care management on diabetes-related outcomes in older patients. Ann Intern Med 2004; 140: 1015–1024.

82. Katon WJ, Von Korff M, Lin EHB et al. The Pathways study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004; 61: 1042–1049.

83. Rubin RR, Ciechanowski P, Egede LE, Lin EHB, Lustman P. Recognizing and treating depression in patients with diabetes. Curr Diabetes Rep 2004; 4: 119–125.

84. Lustman PJ, Griffith LS, Clouse RE. Depression in adults with diabetes: results of a 5-year follow-up study. Diabetes Care 1988; 11: 605–612.

85. Popkin MK, Callies AL, Lentz RD et al. Prevalence of major depression, simple phobia, and other psychiatric disorders in patients with long-standing type 1 diabetes mellitus. Arch Gen Psychiatry 1988; 45: 64–68.

86. Thomas J, Jones G, Scarini I, Brantley P. A descriptive and comparative study of depressive and anxiety disorders in low-income adults with type 2 diabetes and other chronic illnesses. Diabetes Care 2003; 26: 2311–2317.

87. Kruse J, Schmitz N, Thefeld W. On the association between diabetes and mental disorders in a community sample: results from the German national Health Interview and Examination Survey. Diabetes Care 2003; 26: 1841–1846.

88. Peyrot M, Rubin RR. Levels and risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care 1997; 20: 585–590.

89. McGrady A, Bailey BK, Good MP. Controlled study of biofeedback-assisted relaxation in type I diabetes. Diabetes Care 1991; 14: 360–365.

90. Zettler A, Duran G, Waadt S et al. Coping with fear of long-term complications in diabetes mellitus: a model clinical program. Psychother Psychosom 1995; 64: 178–184.

91. Okada S, Ichiki K, Tanokuchi S et al. Effects of an anxiolytic on lipid profile in non-insulindependent diabetes mellitus. J Intern Med Res 1994; 22: 338–342.

92. Lustman PJ, Griffith LS, Clouse RE et al. Effects of alprazolam on glucose regulation in diabetes. Diabetes Care 1995; 18: 1133–1139.

93. Hall RCW. Bulimia nervosa and diabetes mellitus. Semin Clin Neuropsychiatry 1997; 2: 24–30.

94. Kenardy J, Mensch M, Bown K et al. Disordered eating behaviours in women with type 2 diabetes mellitus. Eat Behav 2001; 2: 183–192.

95. Crow S, Kendall D, Praus B, Thuras P. Binge eating and other psychopathology in patients with type II diabetes mellitus. Int J Eat Disord 2001; 30: 222–226.

96. Hepertz S, Albus C, Lichtblau K et al. Relationship of weight and eating disorders in type 2 diabetic patients: a multicenter study. Int J Eat Disord 2000; 28: 68–77.

97. Mannucci E, Tesi F, Rica Vet al. Eating behavior in obese patients with and without type 2 diabetes mellitus. Int J Obes Relat Metab Disord 2002; 26: 848–853.

98. LaGreca A, Schwartz L, Satin W et al. Binge eating among women with IDDM: associations with weight dissatisfaction, adherence, and metabolic control. Diabetes 1990; 39 (Suppl. 1): 164A.

99. Stancin T, Link DL, Reuter JM. Binge eating in young women with IDDM. Diabetes Care 1989; 12: 601–603.

100. Wing RR, Norwalk MP, Marcus MD et al. Subclinical eating disorders and glycemic control in adolescents with type 1 diabetes. Diabetes Care 1986; 9: 162–167.

101. Steel JM, Young RJ, Lloyd GG, Clarke BF. Clinically apparent eating disorders in young diabetic women: association with painful neuropathy and other complications. BMJ 1987; 294: 859–862.


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.