Diabetes Treatments

Health Plan of the Redwoods is partnering with the California Diabetes Control. Program to launch peer-to-peer diabetes education and counseling in Sonoma, …

PSYCHOSOCIAL ASPECTS OF TYPE 1 DIABETES MELLITUS
Mala Dharmalingam, KM Prasanna Kumar ABSTRACT Psychological factors play a crucial role in the management of children with type 1 diabetes mellitus They are important for the child as well as the family and are related to the reactions at the time of diagnosis and when complications occur, cognitive consequences and psychological factors that influence the management of diabetes Children may face psychological problems such as temporary adjustment disorder with somatic complaints, social withdrawal, anxiety or depression Mild impairment of cognition such as visuospatial or verbal defects may also occur Factors in the family, such as cohesiveness and conflicts in the family, influence the psychological and self-care behavior of the child In conclusion, it is important to treat the child rather than just the blood glucose values and give the child a sense of complete well being KEY WORDS: Childhood diabetes; Diagnosis; Family cohesion; Withdrawal; Depression; Compliance INTRODUCTION Type 1 diabetes mellitus is a chronic condition affecting nearly 300,000 children and adults in the United States each year 1 In India, the prevalence
varies from about 101 per hundred thousand 2 to 16 per hundred thousand 3 THE CHALLENGES OF GROWING UP WITH DIABETES The gradual attainment of independence from adults and an increasing sense of body integrity and identity characterize childhood and adolescence Additionally other factors such as adjustment to and acceptance of the emotional and physical changes of puberty, the development of intimate and personal relationships, the establishment of personal values and the choice of future educational and vocational directions also come into play 4 These developmental changes required for normal growth and maturation may be negatively affected by diabetes because of the regimen required for diabetes care, the feeling of being different from ones peers, and parental supervision of the self-care treatment plan A childs sense of independence, body image, identity, sexuality, relationships and selfesteem may thus be adversely affected by the development and treatment needs of type 1 diabetes Diabetes and psychology have long been linked There are many points of interaction between diabetes and psychology Psychological reactions to the development of diabetes and its complications The
neuropsychological consequences of diabetes or cognitive

Psychological factors that influence or are influenced by the management of diabetes THE PSYCHOLOGICAL IMPACT OF DIABETES Diabetes requires the patient to take responsibility of managing their health with daily injections, careful monitoring of diet, exercise and blood glucose levels for the rest of their lives Chronic illness marks the children as different from their peers It also burdens the family with demanding health care responsibilities that they may be unwilling to meet It is therefore not surprising that many children with diabetes have many problems both emotional and behavioral Table 1 Psychological Stress Shortly after Diagnosis Kovac studied 95 children aged 8-13 years and followed them up for 6-10 years 4 14 of the children had psychiatric disorder at diagnosis, with anxiety disorder being the most common 8 Within three months of diagnosis, 36 of the children had psychological disorders Most of them had an adjustment disorder that can be defined as a transient reaction that exceeds the normal and expectable response to a specific stress which develops within three months of the onset of the stress and lasts no
more than six months 5 This occurrence signals that the child is beginning to come to terms with the diagnosis of diabetes 6It has been stated that major depression is common in diabetic children However only 4 met the criteria for major depression shortly after diagnosis 7 Children show low rates of psychological disorder that were comparable to nondiabetic children from the community or children with

MS Ramaiah Medical College, Bangalore email: kmprasanna@vsnlcom 60 INT J DIAB DEV COUNTRIES 2001, VOL 21

Table1: Psychological problems in children Diabetic group Children and adolescents at onset of diabetes little known about adults with recent-onset diabetes Psychological problem Temporary adjustment disorder, somatic complaints, social withdrawal, sleeping disorder, anxiety, depression Higher frequency of depression comparable to other chronic illness Depression, poor quality of life, psychological distress Mild impairment of cognitive functioning visuospatial /verbal defects Verbal IQ and academic achievement lowered

Psychological Reactions to Chronic Diabetic Complications Diabetic complications disrupt the individuals life style and interfere with self care activities They
remind the person that even with the best of effort, they have failed to manage their diabetes adequately Patients with proliferative diabetic retinopathy are particularly more prone for the development of psychopathology They have higher rates of depression and poorer quality of life Both the duration of visual problems and level of visual activity appear to affect mental health Wulsen et al 13 followed such patients and found that greater impairment in visual activity was associated with increased psychological distress and poorer coping efforts Duration of diabetes, quality of metabolic control and overall time of depressive disorder could predict the severity of diabetic retinopathy Depression may therefore be a factor not only for the development of psychological problems but also of future complications Quality of Life Quality of life includes an understanding of how health related variables affect physical, social and mental functioning, as well as the individuals overall feeling of well being and general satisfaction with life Healthy, type 1 diabetic children report being satisfied overall with their life and indicate that diabetes has little impact on their lives 14 The
quality of life tends to decline as the number and severity of complications increase 15,16 A study has found that marital satisfaction is more in children who were diagnosed as diabetics before the age of nine years and that they were more likely to have children, than the children diagnosed after that age 17 THE NEUROPSYCHOLOGICAL IMPACT OF DIABETES Diabetes does not invariably cause neuropsychological dysfunction Nevertheless, a subset of individuals manifest mild impairments that are not intellectually disabling, but render them less efficient mentally than would have been expected had they not developed diabetes The psychosocial risk factors vary at different stages of life Hypoglycemia has a particularly deleterious effect in children Early Onset Diabetes, Cognitive Dysfunction and Hypoglycemia The cognitive dysfunction can be attributed to two different risk factors as shown in Table 2
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Older children with established diabetes, when hospitalized Patients with proliferative retinopathy

Children with repeated hypoglycemia

Later onset diabetes in children/adolescents

recent acute medical illness 8,9 Younger preschool children show a similar psychological reaction to
diabetes Within two years of diagnosis, children under five years of age had high rates of internalizing behavior like somatic complaints, social withdrawal, sleep disturbances, symptoms of depression and anxiety, but not externalizing symptoms like destructive aggressiveness Like school age children, their degree of true psychopathology was low and not considered clinically significant Psychological Reactions Emerging in the Course of Diabetes in Children and Adolescents Most cross sectional surveys and all prospective studies have found no evidence of severe behavioral or psychological problems in diabetic children and adolescents In a three-year follow up study, Ahnsjo studied diabetic children and demonstrated normal patterns of physical and ego development with only mild tendencies toward anxiety and depression that do not meet the diagnostic criteria for psychological distress 8 The level of psychological distress shortly after the onset of diabetes was the best predictor of symptomatology six years later Glycosylated hemoglobin had no predictive value in most studies 10-12

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Table 2: Cognitive Dysfunction in Diabetes Mild to moderate
hypoglycemia affects the developing nervous system Psychosocial and educational disruption associated with management of diabetes The child who develops diabetes in the first four or five years of life is particularly vulnerable to the effects of repeated hypoglycemia The specific pattern of impairment depends on the age at the time of assessment Younger children with early onset of diabetes are more likely to show performance decrements that are largely limited to visuospatial tasks 18 By adolescence, impairments may be evident on a wider range of measures, both verbal and visuospatial, with girls and boys being equally affected on tests of learning, memory, problem solving, intelligence and eye hand coordination 19 This impairment may be largely due to inability to concentrate effectively and use optimal learning strategies to organize and encode information 20 As many as 24 of children with an early onset of diabetes showed neuropsychological deficits, compared with only 6 of later onset diabetic children and 6 of non diabetic comparison group 19 Indirect evidence suggests that hypoglycemia may be the cause of neuropsychological deficit in children with early onset diabetes
Children and adolescents who develop diabetes below the age of five years, have a significantly more rate of hypoglycemia than children who develop diabetes after that age Repeated hypoglycemia early in life may lead to relatively subtle neuropsychological dysfunction with visuospatial skills being most affected Higher rates of hypoglycemia in children may occur because the counter regulatory mechanisms are less well developed in young children 21,22 Sufficiently, severe hypoglycemia can produce severe brain damage at any age 23 In young children the brain appears to be particularly vulnerable to traumatic or neurotoxic insult 24,25 The frequency of hypoglycemia can be reduced in young children if monitored carefully and frequently by their parents 26 Later Onset Diabetes in Childhood and Adolescence Role of psychosocial risk factors There is a marked difference in children and adolescents who developed diabetes after the age of four or five years Children with later onset diabetes perform well as their non-diabetic colleagues but on closer evaluation they have minor deficits in

psychomotor efficiency, general intelligence and academic achievement 26,27 Later onset diabetics tend
to perform more slowly but no less accurately on psychomotor tests that require eye-hand coordination or rapid translation of numbers into symbols according to a prearranged code 26 Performance based on measures of verbal intelligence and academic achievements with later onset diabetic adolescents earning verbal IQ scores may be lower on average by 10 points than their nondiabetic peers Children and adolescents followed during the first five years of life showed significant performance decrements with girls showed the decline in verbal intelligence and boys showed drop in school grades 28 Verbal intelligence is a measure of knowledge base acquired in the classroom and may be poorer in children who have missed class 29 Diabetes affects intellectual and academic performance because it interferes with education This may be mediated in part by the psychosocial problems that often develop within the families of diabetic children and perhaps by transient episodes of asymptomatic hypoglycemia Cognitive Dysfunction and Poor Metabolic Control in Adults with Type 1 Diabetes Hyperglycemia, rather than hypoglycemia may be a more potent risk factor Tasks requiring psychomotor speed and / or
spatial information processing are most likely to be disrupted but other cognitive functions including attention, learning and memory are often affected in the poorly controlled adult The mechanism for this is poorly understood It may be a mechanism which affects the neuronal metabolism of the brain, affecting the Na /K ATP activity and polyol metabolism This is supported by the demonstration that adults with diabetes of long duration show slower brain transmission times during electrophysiological recordings of brain stem auditory evoked potentials 30-32 Repeated Episodes of Severe Hypoglycemia and Cognitive Dysfunction Mild to moderate hypoglycemia induces significant cognitive impairment in children whose brain is still developing 32 Longitudinal studies 33,34 have not found any connection between repeated hypoglycemia and brain damage, while cross sectional studies have consistently supported a link 35-38 DIABETES MANAGEMENT AND PSYCHOLOGICAL PROCESSES Certain traits of coping styles that are intrinsic to the individuals psychological make up may determine
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the ability to deal with various barriers like adherence, including missed
meals or tests, peer pressure, disruptive interpersonal conflicts and the normal stresses of everyday life There is no simple direct relationship between any single psychological variable and metabolic control 39 Figure 1 shows one such model Fig 1: A system Model of the Relationship Between Psychological and Metabolic Variables Psychological traits are relatively enduring
Psychological traits Adherence or self care behavior Metabolic control Psychological states

metabolic control Temperament predicts glycosylated haemoglobin in diabetic children 39 Good metabolic control is more common in children with normal activity and display milder responses to external stimuli 40 Personality characteristics also predict metabolic control Individuals having a strong need for achievement and a high level of responsibility enjoy better metabolic control 41 Control tends to be poorer with patients with dramatic, dependent personality 42 Locus of control is another psychological trait that may affect glycemic control Individuals who have an internal locus of control believe that they are responsible for their health whereas, those who have an external locus believe that they are at the mercy of
chance Individuals who have an internal locus are more likely to have a better control and a better adherence to treatment 43, 44 Psychological States Poor glycemic control is associated with higher levels of stress in both adolescents and adults Stress may affect metabolic control indirectly by disrupting the individuals ability to manage diabetes effectively Stress could directly affect metabolic control by stimulating the autonomic nervous system to induce hyperglycemia 45, 46 Depression and anxiety are usually but not invariably associated with poor metabolic control 47-53 Family Characteristics Diabetes can disrupt the entire family Shortly after a childs diagnosis the mother may manifest a mild increase in overall psychological distress but this usually resolves within 6-12 months 53 Children, especially younger ones, enjoy better control when their parents take an active role in managing their diabetes 54 Adolescents have better control when parents share management responsibilities with them 55 Within the family, low level of conflict 56, better communication 57 and a stronger family orientation towards achievement, are all associated with better control 58 The relationship
between family characteristics and glycemic control may be mediated either via an affective route or a purely behavioral route 59,60 Adherence and Self Care Self-care behavior may be a good indicator of diabetic management 61 However, not all self-care activities are equally predictive of glycemic control for children 62 Younger diabetic children tend to show better adherence Mood state is also a predictor

Psychological characteristics

Family functioning

characteristics that include temperament or personality and coping style These may have a direct impact on self- care behavior adherence and on emotional state Psychological states are more transitory and reflect emotions or feeling at a given point of time Both family interactions and self-care behavior may affect and be affected by the individuals mood Theoretically at least, certain emotional states especially stress, may influence metabolic control directly via the autonomic nervous system or indirectly by interfering with the patients ability to manage his or her diabetes This psychological link may be reciprocal ie changes in the mood may occur as a psychological reaction to an inability to maintain reasonable diabetic
control Family functioning, including conflicts and degree of family cohesiveness, can affect psychological state and influence self care behavior Psychological Trait These encompass psychological concepts that include temperament, personality, coping style, locus of control, self efficacy, type A behavior and health beliefs Each of these variables predicts
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of adherence Lernmark et al 63, examined whether affective reactions and the adolescent belonged to a minority or an immigrant group While the overall satisfaction was not different, the impact of diabetes was greater and diabetes control was worse in the ethnic minority adolescents Quality of life was positively related to social status Adolescents in two-parent household tended to have better quality of life and blood glucose control than in a house where only one parent worked The psychological factors identified during the first year following the onset of diabetes could predict psychological adjustment and metabolic control five years later In a longitudinal study on 67 children, early affective reactions, locus of control and adjustment to diabetes were shown to predict
psychological adjustment to diabetes five years later Attempts should be made to therefore evaluate early adaptation to diabetes in order to identify and treat children at risk for future problems with psychological adjustment to the condition For most children with diabetes, achieving blood glucose control involves adherence to a complex system of self-care behaviors They have to pay close attention to diet, insulin administration, frequent monitoring of blood glucose levels, regular exercise and routine medical care Through repeated education programs, children learn how to use information from blood glucose monitoring to determine insulin needs, balance food intake, and obtain regular exercise However, the family ultimately shares some of the responsibility for the management For many individuals, effective selfmanagement behaviors are difficult to achieve and maintain 62, 63 Poor personal decisions about the need for lifestyle changes and inadequate confrontation of the emotional and psychological issues that accompany the diagnosis of diabetes, are barriers to effective therapy Feelings of anger, guilt, resentment and fear often interfere with the individuals ability or desire
for successful self-care The very nature of diabetes, its chronicity, the constant attention demanded by the disease and treatmen t program, the strong commitment necessary for adherence to the self-directed treatment plan and the consequences of long-term self-care, constantly pose as a challenge to the individual Frequent problems encountered are lack of family support, excessive stress, lack of insurance reimbursement and frustration with the results of treatment These are looked upon as barriers to effective self-management

Physicians have traditionally focused on the medical aspects of diabetes care However, a psychosocial approach is necessary to overcome potential barriers to self-care, so that effective selfmanagement is successful Towards this aim, emotions need to be explored, expressed, experienced and ultimately accepted by the individual with diabetes as well as by his healthcare team 64 Strategies for identifying and overcoming potential barriers need to be explored Personal choices need to be clarified, targeted changes in lifestyle and behavior appropriately implemented Dr Van der Ven and colleagues 65, evaluated the efficacy of cognitive group training in 24
individuals with poorly controlled type 1 diabetes Self-care behavior, diabetes-related distress, emotional well being, and glycemic control were evaluated prospectively at baseline, three months and six months after completion of the educational program Glycosylated hemoglobin levels decreased from 96 at baseline to 88 at three months and to 85 at six months Diabetes-related distress decreased and positive well-being increased following cognitive behavioral therapy Patients were more likely to perform blood glucose monitoring and increase their compliance with diet after the fourweek course, although the number of omitted insulin doses remained unchanged Although cognitive therapy had little effect on emotional distress, most subjects appreciated the increased attention they received from the staff The most important effect of the four-week course was that subjects sensed that someone was genuinely interested in the outcome of their treatment Fear of self-monitoring of blood glucose values and self-injecting of insulin is frequently a barrier to the self-management of diabetes Mollema et al [66] evaluated potential psychosocial co-morbidities in insulin treated subjects with
diabetes The individuals identified as fearful of self-testing and self-injecting were noted to have a greater incidence of depression and fear of blood, when compared with other children who were not fearful These indicate that psychological co-morbidities are frequent in patients who are fearful of self-testing and self-injecting insulin The co-morbidities may explain in part, this fearful behavior and may need to be adequately treated if this fear is to be overcome In an attempt to identify potential factors that may determine the quality of life of patients with type 1 diabetes, Sengül et al 67, evaluated overall quality of life and its relationship to sociodemographic, diabetes-related control parameters and presence
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of diabetes complications Approximately 300 subjects including 156 men with type 1 diabetes mellitus of 126 48 years duration and an average age of 244 96 years were recruited Four sub scales: satisfaction, impact, social/vocational worry and diabetes worry were evaluated Diabetes quality of life scores averaged approximately 73 in both male and female subjects Higher educational level, greater exercise frequency, and
improved overall compliance with diabetes treatment positively affected scores They were negatively affected by diabetes duration, greater number of hypoglycemic reactions, higher HbA1c levels, and greater incidence of complications Of interest, there were no differences between adolescents and adults with the condition Behaviors related to enhanced self-management are thus associated with better diabetes control and improved quality of life It is tempting to speculate that greater compliance with diabetes treatment is associated with a increased awareness of oneself, higher sense of self-control and improved feelings of self-worth, all of which have a positive effect on the quality of lifeE ETHNIC MINORITIES AND DIABETES : QUALITY OF LIFE Dr Danne and coworkers 68, examined the association between metabolic control and quality of life with social status and origin of ethnic minorities in adolescents with type 1 diabetes They evaluated 2077 adolescents from 17 countries including Japan, Europe and the North American countries Social status was determined by whether one or two parents were at home and whether one or both were employed The health professional responsible for the
adolescents care study, concluded that ethnic minority adolescents have a poorer quality of life and have poorer blood glucose control than their native counterparts CONCLUSION Diabetes in children is a serious condition, which has to be managed by both medical professionals and the social support system The social support system could be organizations of nonmedical personnel or patients themselves who organize themselves into groups to discuss their problems These children also need family support both emotional and financial The psychology of the child has to be understood and each child managed individually The adolescent period is by itself a turbulent one and when diabetes intervenes it could be very tumultuous Medical and para medical personnel should rise and be care givers than just
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pill providers It is indeed important to treat the person rather than just his blood glucose and complications and give the patient a sense of complete well being
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diabetes Program and abstracts of the 35th Annual Meeting of the European Association for the Study of Diabetes; September 28-October 2, 1999; Brussels, Belgium Abstract 140 Anderson RM, Funnell MM, Barr PA, Dedrick RF, Davis WK Learning to empower patients Results of professional education program for diabetes educators Diabetes Care 1991; 147: 584-590 Eakin EG, Glasgow RE Physicians
role in diabetes selfmanagement: helping patients to help themselves The Endocrinologist 1996; 6: 109 Van der Ven NCW et al Cognitive behavioural group training for type 1 patients in poor control: Effects on glycemic control and well-being Program and abstracts of the 35th Annual Meeting of the European Association for the Study of Diabetes; September 28-October 2, 1999; Brussels, Belgium Abstract 137 Mollema ED et al Psychological comorbidity in diabetic patients fearful of self-injecting and/or self-testing Program and abstracts of the 35th Annual Meeting of the European Association for the Study of Diabetes; September 28-October 2, 1999; Brussels, Belgium Abstract 138 Sengül AM et al Determinants of the quality of life of patients with type 1 diabetes in Turkey Program and abstracts of the 35th Annual Meeting of the European Association for the Study of Diabetes; September 28October 2, 1999; Brussels, Belgium Abstract 134 Danne T et al The association of metabolic control and quality of life with social status and ethnic minority origin for adolescents with diabetes Program and abstracts of the 35th Annual Meeting of the European Association for the Study of Diabetes; September
28-October 2, 1999; Brussels, Belgium Abstract 139

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