Tuesday , November 21 2017
Home / Specialties / Mental Health / Psychology in Diabetes Care, 2nd Ed: Diabetes in Children, Part 6

Psychology in Diabetes Care, 2nd Ed: Diabetes in Children, Part 6

Edited by Frank J. Snoek and T. Chas Skinner

Diabetes in School-aged Children

DCMS56_CG_Image

 

1.6 Family Factors Related to Glycemic Control and Adherence

Due to the relatively small number of children under the age of 6 with diabetes, there have been few, if any, studies on how family environment variables relate to glycemic control and adherence.

For school-aged children, this area has received more attention. Waller and colleagues conducted one of the first empirical studies of families with children with diabetes under the age of 12 years.67 These authors concluded that for school-aged patients more diabetes-related family guidance and control were linked to better metabolic outcomes, and that diabetes-related parental warmth and caring were important for optimal outcomes. Liss et al. had similar findings in her study of children hospitalized with DKA, who also reported lower levels of diabetes-related warmth and caring.52  

Non-diabetes-specific family factors, such as conflict, stress and family cohesion, have also been linked to glycemic control and adherence.68–74 Viner and colleagues74 found that high levels of family stress were correlated with poorer glycemic control in children under 12 years of age. In addition, the authors found that social support buffered the impact of general family stress on the children’s glycemic control. The authors emphasized that the relationship between family stress and glycemic control is ‘…bi-directional, with poor diabetic control producing family stress, as well as family stress inducing poor control in the child (p. 420).74

In contrast, other investigations have not found relationships between general family factors and metabolic control or treatment adherence in school-aged children.75–77 Various methodological and sampling issues have been used to explain these different findings with respect to the link between family stress and metabolic outcomes in school-aged children. Kovacs et al.,77 in a longitudinal study of school-aged children newly diagnosed with diabetes, found no relationship between metabolic control and two general measures of family life — parental perceptions of the quality of family life and the quality of the marriage. These authors speculate that ‘metabolic control of children may be affected by aspects of family functioning that are too subtle to have been captured by the measures of general functioning used in this study’ (p. 413).77 Moreover, Kovacs and her colleagues also suggest that a link between metabolic control and family factors in school-aged children may be shown by studying other variables that ‘mediate the relationship of family life to metabolic control’ (p. 413),77 variables such as family behavior with respect to regimen tasks. These authors also reported that for a small subset (approximately seven per cent) of their research families’ poorer ratings of the family environment at diagnosis were related to subsequent poor metabolic control.57

A second longitudinal study of school-aged children with newly diagnosed diabetes by Jacobson, Hauser and colleagues 69,78 revealed that the child’s perception of family conflict as measured by a general family measure given at diagnosis was the strongest predictor of poor adherence to insulin administration, meal planning, exercise and blood glucose monitoring tasks over a four-year follow-up period.69 The relationship between family factors and metabolic control was not examined in this report.

The connection between conflict, adherence and glycemic control was also examined by Miller-Johnson et al.71 In this study, parent-child conflict was a significant correlate of both adherence and glycemic control. In multivariate analyses, the relationship between conflict and glycemic control was nonsignificant when adherence was entered into the model. These results indicate that conflict may interfere with glycemic control by disrupting treatment adherence. Similarly, in a recent study of parenting styles, regimen adherence and glycemic control in 4-to-10-year-olds with type 1 diabetes and their parents, ‘authoritative parenting’ characterized by parental support and affection was related to better regimen adherence and more optimal glycemic control. The authors suggest that greater parental warmth may improve adherence by reducing family conflict, increasing family cohesion or both.79 ‘Authoritative parenting’, which describes a parenting style in which conflict is minimized as parents set consistent, realistic limits on children’s behavior while displaying warmth and sensitivity to their child’s needs and feelings, has been linked to improved behavioral outcomes in the general child development research literature as well as in these empirical studies in school-aged children with type 1 diabetes.80 Finally, family environments that are more structured and rule governed are associated with better glycemic control in school-aged children with type 1 diabetes, but not in adolescents.81

1.7 Family Involvement in the Diabetes Management of a School-Aged Child

One area of importance for families and health care providers concerns issues of transferring diabetes care responsibilities from the parent to the child.82 The expanding skills and increased cognitive abilities of the elementary school child make it seem reasonable to transfer more and more daily diabetes care responsibilities. However, there is a growing consensus among recent empirical studies that children and adolescents given greater responsibility for their diabetes management make more mistakes in their self-care, are less adherent and are in poorer metabolic control than those whose parents are more involved.83–88 Studies using diabetes-specific instruments have consistently found that older children assuming greater responsibility for the tasks of the treatment regimen are in poorer metabolic control than those who assumed less responsibility.85,89–91

In her important review of the empirical literature on family responsibility sharing in diabetes, Follansbee92 concluded ‘Cumulatively, these studies yield important information about the role of parent-child interaction in influencing youngsters’ assumption of diabetes management. It seems that interdependence, rather than independence, is a worthwhile goal’ (p. 350).92

From these studies, it has become increasingly clear that parental involvement in diabetes management is required throughout the school-age developmental period. Each family needs to negotiate its own acceptable pattern of parent-child teamwork, based on factors such as child temperament and parent availability. By identifying shared responsibility rather than child independence as the expectation for school-age children with diabetes, the health care team can help make parent involvement seem less inappropriate to the child or family. It is imperative that the family hears a clear message that diabetes management tasks must be protected from the child’s normal drive to achieve independent mastery.

1.8 Treatment Issues for School-aged Children

The goals of diabetes therapy for school-aged children are to avoid severe metabolic decompensation (diabetic ketoacidosis), maintain normal height and weight, minimize the debilitating symptoms of either severely high or low blood glucose levels, establish and maintain a healthy psychosocial environment for the child and family and maintain the involvement of family members in carrying out daily injections and blood sugar monitoring. At this age, children may be more able developmentally and intellectually to recognize and appropriately treat hypoglycemia. Thus, as the child exits the preschool period, the diabetes team can now work together with the family towards improved glycemic control, with lower target blood glucose values. A recent study using the well-validated Child Health Questionnaire (CHQ) reported that psychosocial indices of well-being were better for children 5-11 years of age with type 1 diabetes who were in good control (HbAlc less than 8.8 per cent), while physical indices of well-being did not differ between youngsters in good control and those in poor control (HbAlc greater than 8.8 per cent).93 Data from Sweden and the US document that there is a limit to the extent to which lowering HbAlc may improve psychosocial and physical quality of life in children with diabetes, with severe episodes of hypoglycemia associated with the lowest health-related quality of life in children and their parents.94–96 Thus, while attempting to improve glycemic control, it is also important for the health care providers to develop treatment regimens that are minimally interruptive to the child’s school day and that balance within the child’s life the risks of hypoglycemia with the benefits of optimal control.

Overall, the diabetes treatment team must try to teach problem-solving skills to the parent(s) and child to allow flexibility in the diabetes treatment plan. Similar to the preschool period, diabetes management therapy for the school-aged child is often reactive rather than predictive. During the elementary school years the family continues to be the ‘patient’. Parents are an important part of every medical office visit, and parents maintain telephone communication for follow-up at home. At the same office visit, the child and family may see more than one member of the diabetes care team. Because the child grows rapidly during this developmental period, frequent adjustments are needed in the meal plan. Therefore, school-aged children should see the nutritionist at least once each year. The mental health specialist on the team can be especially important in the prevention and negotiation of conflicts over diabetes care issues between the parents and others (such as school personnel) while the child is away from home. To ensure a safe school environment for the child, members of the health care team must be willing to help families communicate guidelines and expectations to school personnel. Diabetes information sheets, with the phone number of the team, should be available for families to provide to the schools.

Next Week: Disease Course and Risk Factors: Implications for Clinical Practice

References

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.

57. PeyrotM, Rubin RR. Structure and correlates of diabetes-specific locus of control. Diabetes Care 1994; 17: 994–1001.

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 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.

73. Beck AT, Beamesderfer A. Assessment of depression: the Depression Inventory. Med Probl Psychopharmacother 1974; 7: 151–169.

74. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psych Meas 1977; 3: 385–401.

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

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.