Psychological and Behavioral Issues in Children and Adolescents with Diabetes

1. Psychological and Behavioral Issues in Children and Adolescents with Diabetes J. Keawe�aimoku Kaholokula, Ph.D. Department of Native Hawaiian Health John A. Burns School of Medicine University of Hawai�i

2. What Needs to Happen? Parents and child must: Accept the diagnosis and its implications in a realistic way. Manage their own psychological response to the diagnosis. Learn a new set of complex skills relating to diabetes management. Not allow diabetes to interfere with the attainment of normal developmental tasks.

3. Depression & Anxiety Depression and anxiety common after diagnosis. Most subside within 5 years. 27% of youths have an episode of major depression 10 years after onset of diabetes. 13% of youths have anxiety. Of parents, mostly mothers become depressed. Depression impedes diabetes self-care, family support, and normal development. Treating depression can improve diabetic control.

4. Signs of Depression Signs of depression include: Not caring about things you used to like to do. Having trouble sleeping or sleeping too much. Eating a lot more or less than usual. Losing or gaining a lot of weight without trying. Having trouble concentrating. Fatigue, nervousness, or anxiety. Frequent crying. Feeling worse in the morning than during the rest of the day. Thinking about dying or ways to hurt yourself.

5. More on Depression Depression could be expressed as anger, irritability, and behavioral problems. Decline in academic performance and onset of delinquent behavior could be signs of depression.

6. Diabetes �Burnout� Depression can result in poor self-care, or diabetes �burnout.� Most common in teens and young adults who have had the disease for a number of years. Emotions are no longer up and down, but more or less flat. Fed up with the daily frustrations of managing the disease, the constant worry about complications, and the concerns of others.

7. Eating Disorders Teens with diabetes may be more prone to eating disorders, especially females. 2x higher among females with diabetes. Possibly because diabetes demands paying closer attention to food. Anorexia Nervosa and Bulimia Teens with diabetes and eating disorders learn to manipulate their diabetes treatment to lose weight. Deliberately skip or reduce their insulin dose to cause difficulty in food absorption. Such abuse can lead to high blood glucose and DKA.

8. Eating Disorder Signs Teens with diabetes and eating disorders may show some or all of the following warning signs: Extreme fluctuations in blood glucose Frequent hypoglycemia Frequent hyperglycemia or DKA Unhealthy preoccupation with food and weight, beyond what is necessary for diabetes care Talking about losing a large amount of weight, beyond what seems appropriate Switching to an extremely low-fat or low-calorie diet Evidence of binge eating Evidence of insulin manipulation�

9. Hypoglycemia & Cognitive Functioning Results are mixed Some indication that frequent and severe hypoglycemic episodes could be associated with cognitive impairments. Hypoglycemic episodes inevitably cause a temporary deficit in the supply of glucose to the brain.

10. Risk Factors for Psychological Problems Avoidance coping (versus active coping). Too much responsibility on child. Child�s cognitive maturity versus age in determining increased responsibilities. Family conflict Lack of communication, both within families and with the diabetes team. Low socio-economic status Non-traditional family structure Poor maternal health, especially depression

11. Realistic Expectations Parents expectations about child�s responsibility for self-care. Parents assume all responsibilities for very young children. Child�s cognitive maturity versus age in determining increased responsibilities. Puberty = increase difficulty in management.

12. Improving Self-Care Attitudes & Behaviors Poor regimen adherence and glycemic control is associated with: Poor communication skills. Family conflict. Poor relationship with health care team. Regular and frequent visits = better glycemic control. Agreement between family and health care providers on goals and specific regimens prescribed.

13. Social Adjustment and Self-Esteem Parents concerned about how child will be accepted by peers. Older children concerned about being seen as different. Two critical points: Just after diagnosis Just before puberty

14. Age-Related Issues Children 6 to 8 years old: Social interests become directed outside the family. Cannot remember to do diabetes tasks on time and needs complete adult involvement. Begins to understand what diabetes is and can explain diabetes to others in simple terms. May be able to identify low blood sugars and can ask for help. May worry about being "different" and may hide the diabetes or act like he or she does not have it. A mature 8-year-old may inject insulin while supervised but is not able to draw up insulin correctly. May feel disappointed in self if blood sugars are out of range.

15. Age-Related Issues Children 9 to 11 years old: Knowledge about diabetes grows quickly and the child may know the day-to-day routine, such as what time he or she eats and takes insulin. Often appears very confident about doing diabetes tasks but is too immature to do the tasks correctly and on time. Needs an adult to oversee all diabetes management tasks. May feel peer pressure about fitting in, may worry about his physical appearance and may not want to do diabetes tasks with peers watching. The child may lie to you about blood sugar levels and food consumed at school. Not able to grasp the risk of poor control and not likely to worry about diabetes complications.

16. Age-Related Issues Child 12 to 14 years old: Increase worry about puberty, growth, and physical appearance. Hormonal changes affect blood sugar levels. May find it difficult to resist peer pressure and likely to eat off the diet plan. May become secretive and not want to discuss the diabetes care with you. The child can draw up insulin and may have the math skills to calculate insulin but is too immature and impulsive to do it on time. Your child still needs to do insulin shots with adult supervision. Meals and snacks may cause frustrations and arguments and may sneak food.

17. Age-Related Issues Children 15 to 16 years old: Teens want to spend more time away from home, and some are able to manage diabetes well for short periods of time such as a trip to the mall. Teens may be able to do nearly all of the diabetes management tasks but still need parents to check the blood sugar daily and oversee meals. May be moody and rebellious. Not likely to ask for help or admit to needing it. Need to check blood sugar before driving. Teens should demonstrate responsible diabetes management before allowing to drive.

18. Age-Related Issues Children 17 and older: Older teens are very busy with social activities, school and even jobs. May forget to do diabetes tasks so parents involvement is still needed. Can visit the physician alone to practice self-care before moving on to college or work.

19. What to Do? Develop a trusting relationship. Open line of communication. Become an advocate. Assess for psychological problems and maladaptive coping strategies. Refer for psychological/counseling services. Encourage parental support and family communication. Educate family on diabetes care and age-related psychological issues.

20. Resources American Diabetes Association www.diabetes.org Practical Psychology for Diabetes Clinicians, 2nd Edition: Effective Techniques for Key Behavioral Issues (2002), B.J. Anderson & R.R. Rubin (Eds.). Juvenile Diabetes Research Foundation www.jdrf.org