Volume 10 Number 4, 1997, Pages 275-277
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Psychological Complications of Childhood Diabetes: Case Examples
Tim Wysocki, PhD
The management of type 1 diabetes in children and adolescents may sometimes require the involvement of a psychologist or other mental health professionals. In this paper, which was originally presented as a workshop at the American Diabetes Association Postgraduate Conference in early 1997, I have illustrated with case examples some psychological pathways that can complicate the management of diabetes. In each case, a description of the psychological assessment and therapy methods pertinent to the presenting problem and references to the relevant research literature are provided.
Case #1: A Girl With Recent Deterioration in Diabetes Control
D.N. is an 11-year-old girl who was diagnosed with type 1 diabetes at 9 years of age. She lives at home with her mother and three younger siblings and has minimal contact with her natural father. Her mother is employed variable hours as a restaurant cashier, and the maternal grandmother cares for the children during the mothers work hours.
D.N. is a slightly above-average sixth-grade student. She is reported to be successful socially, and she has no significant behavioral problems at home or at school. She has considerable responsibilities in terms of housework and helping her grandmother to care for her younger siblings.
D.N. and her family have done well with managing her diabetes until the past 8 months, during which time she was hospitalized twice in diabetic ketoacidosis and was treated in an emergency room for an episode of severe hypoglycemia. Her HbA1c increased from 6.8 to 9.2% during this period. She has recently been placed on a sliding scale insulin dosage schedule, but it has not stabilized her blood glucose control.
When D.N. and her mother were interviewed separately by a diabetes educator about her diabetes self-management responsibilities, they gave differing descriptions of who is responsible for certain key diabetes tasks. D.N. reported that she and her mother share responsibilities for drawing up insulin injections, determining the correct dosage using the sliding scale, deciding how to correct high blood glucose levels, completing urine ketone tests, and using her meal plan in restaurants and the school cafeteria. Her mother, on the other hand, regarded each of these skills as totally her daughters responsibility. She stated that, with trying to hold down a job and raise four young children, it just is not possible for her to keep track of her daughters diabetes as carefully as she once did.
Recent research on family sharing of diabetes responsibilities1-2 suggests that children with excessive self-care autonomy relative to their psychological maturity may be at high risk for poor treatment adherence, inadequate diabetes control, and more frequent hospitalizations compared with other children who have type 1 diabetes. Other research indicates that unclear accountability for diabetes responsibilities also may be problematic.3 This childs case is an excellent illustration of these points.
It is understandable that a single mother raising four children might be prone to withdraw from supervision and monitoring of her oldest childs diabetes self-care activities. After referral for a psychological consultation, this mother and the maternal grandmother worked out an arrangement that shifted more responsibility for the care of the younger siblings to the grandmother, so that the mother could more actively monitor her daughters diabetes care.
The counselor also helped the family more clearly and regularly delineate who was responsible for each aspect of the childs diabetes regimen. Specifically, the management tasks that were more complex cognitively (such as insulin adjustments) were assumed exclusively by the mother, and the preparation of insulin injections was done only in the presence of an adult.
Case #2: A Boy With School Problems
J.S. is a 12-year-old boy who was diagnosed with type 1 diabetes at the age of 4 years. He lives with both of his natural parents and a 15-year-old sister.
He was retained in the second grade and has struggled academically throughout his school years due to poor completion of class work and inattentiveness. He has also been suspended several times for obstinate and aggressive behavior in school. His parents confirm that he displays similar problems at home, but they express little concern about these problems, dismissing them as evidence that he is "just being a boy."
At the time J.S. was first diagnosed with diabetes, he presented in very severe diabetic ketoacidosis and diabetic coma. He had lost ~20% of his body weight in the previous 6 weeks. During his first year of diabetes, he had multiple episodes of severe hypoglycemia, two of which required emergency medical involvement.
Coping with diabetes has always been difficult for J.S. and his family. From the onset of his diabetes, he has been very resistant to his injections and blood glucose tests. As he has gotten older, he has become increasingly rebellious and dishonest about his diabetes responsibilities. By the time of this referral, he was testing his blood glucose only about five times per week, eating whatever and whenever he pleased, and deciding how much insulin to take based loosely on how he happened to feel at the time. He admitted to occasionally "forgetting" to take his morning insulin. His most recent HbA1c was 11.9%.
Recently, his school performance and classroom adjustment has taken a turn for the worse. He was referred to an educational psychologist for a psychoeducational evaluation. He is noted to display very poor completion of class work, frequent refusal to complete written assignments, inconsistent instruction-following, and very poor study habits and organizational skills.
There is substantial evidence that children who are diagnosed with diabetes during the preschool years are at increased risk of disorders of learning and attention.4-5 The precise mechanism of this association has not yet been determined conclusively, but J.S.s history included episodes of severe hypoglycemia, diabetic ketoacidosis, and chronic hyperglycemia, any or all of which may have been involved.
He was referred for a complete psychoeducational evaluation, including administration of tests of general intelligence, other specific cognitive functions, and academic achievement. The evaluation also included the collection of behavioral checklists from parents and teachers, as well as direct observation in the classroom.
The assessment indicated that he displayed evidence of learning disabilities in reading (dyslexia) and written language (dysgraphia) based on his average general intelligence, specific weakness in temporal-sequential processing abilities, and academic achievement in reading and written language, which was well below levels that would be expected based on his intellectual potential. In addition, he was diagnosed as suffering from Attention Deficit Hyperactivity Disorder (ADHD) based on test results indicating a deficit in sustained and selective attention and both questionnaire and observational evidence of significant problems with inattention, impulsivity, and hyperactivity.
His primary care pediatrician started him on methylphenidate. He was also enrolled in a special-education program for children with learning disabilities, and he has been seen twice monthly with his parents for behavior modification counseling and individual psychotherapy. This multimodal intervention has resulted in substantial improvement in his behavior and performance in school, as well as somewhat less family conflict surrounding his diabetes management.
Case #3: An Adolescent With Changes in Mood and Behavior
S.L. is 17-year-old boy who has had diabetes for 8 years. He lives with his natural parents and has two grown sisters who have left home. His father owns a construction company, and his mother is a secretary. He is a senior in high school, but he has been arguing recently with his parents about his desire to drop out of school.
His diabetes control has been poor throughout his adolescence, with the most recent HbA1c levels ranging between 11 and 14%. An ophthalmology examination recently revealed retinal changes suggestive of an early stage of diabetic retinopathy.
At a recent clinic visit, his mother reported that he has been increasingly irresponsible about his diabetes self-care within the past few months, including failing to take his diabetes equipment and supplies with him on an overnight trip, drinking an entire half-gallon container of orange juice in a 2-day period, failing to awaken to take his morning insulin injection, and failing to eat promptly when his pre-meal blood glucose level was <65 mg/dl. She related that he frequently stays awake all night and that, during these times, he eats constantly. She reported that S.L. has many angry outbursts surrounding diabetes and its treatment and that these have become increasingly frequent and intense.
His mother also noted that he has been irresponsible about his school work, even though he is in the last semester of high school, and that he was recently fired from a part-time job at a restaurant because of repeated absences from work. He has also broken off several friendships recently and had lost interest in golfing.
His physician referred him to a child psychiatrist to evaluate these symptoms and to determine an appropriate treatment approach.
One carefully conducted study has shown that the prevalence of depression in the pediatric age-group during the first 10 years of diabetes may be as high as 28%.6 Individuals who suffer an episode of depression during the first year following the diagnosis of type 1 diabetes may be more likely to experience recurrent episodes in later years.7 There is additional evidence that depressed adults with diabetes are more prone to poor diabetes control and long-term complications of the disease.8 Consequently, it is important that depression be recognized and treated promptly and that special care be taken to monitor those with a strong personal or family history of depression.
This young man was referred for a psychiatric consultation during a hospitalization for medical reasons. He demonstrated most of the classic symptoms of depression, including dysphoric mood, diminished initiative, sleep and appetite disturbances, possible psychosomatic complaints, impaired concentration and memory, and loss of interest in previously enjoyable activities. His profiles on several symptom checklists confirmed clinically significant depression.
He was started on an antidepressant medication and seen in individual psychotherapy. He initially resisted taking the medication but ultimately recognized that it was helpful. He continues to struggle with occasional episodes of depression, but he has been more successful in managing his diabetes and in getting along with his family since his depression was treated.
Only a minority of children and adolescents with diabetes exhibit psychological or behavioral symptoms that warrant psychological assessment or intervention. However, for those who do, prompt recognition and treatment may help to prevent a spiral of unnecessary suffering, excessive use of health-care resources, and increased risks of the long-term complications of diabetes.
1Wysocki T, Taylor A, Hough BS, Linscheid TR, Yeates KO, Naglieri JA: Deviation from developmentally appropriate self care autonomy: association with diabetes outcomes. Diabetes Care, 19:119-25, 1996.
2Allen DA, Tennen H, McGrade BJ, Affleck G, Ratzan S: Parent and child perceptions of the management of juvenile diabetes. J Pediatr Psychol 8:129-41, 1983.
3Anderson BJ, Auslander WF, Jung KC, Miller JP, Santiago JV: Assessing family sharing of diabetes responsibilities. J Pediatr Psychol 15:477-92, 1990.
4Rovet J, Ehrlich RM, Hoppe M: Specific intellectual deficits in children with early onset diabetes mellitus. Child Devel 59:226-34, 1988.
5Ryan C, Vega A, Longstreet C, Drash A: Cognitive deficits in adolescents who developed diabetes early in life. Pediatrics 75:921-27, 1985.
6Kovacs M, Goldston D, Obrosky DS, Bonar LK: Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care 20:36-44, 1997.
7Kovacs M, Obrosky DS, Goldston D, Drash A: Major depressive disorder in youths with IDDM: a controlled prospective study of course and outcome. Diabetes Care 20:45-54, 1997.
8Lustman PJ, Griffith LS, Clouse RE: Depression in adults with diabetes: results of a five year follow-up study. Diabetes Care 11:605-12, 1988.
Tim Wysocki, PhD, is chief psychologist at the Nemours Childrens Clinic in Jacksonville, Fla.
Copyright © 1997 American Diabetes Association
Last updated: 12/97