The psychosocial impact of diabetes in adolescents and children ...

The psychosocial impact of diabetes in adolescents and children

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The psychosocial impact of diabetes in adolescents and children

The psychosocial impact of diabetes in childhood is ubiquitous and involves the entire family, as well as schools and society as a whole. Diabetes in infants, toddlers, older children, and adolescents poses serious physical, mental, and emotional challenges. Striking a balance among hypoglycemia/hyperglycemia, growth/development, and other life factors is not easy for health care providers, patients, or families. In addition, personal, family, or environmental conditions present before the onset of diabetes may compound the delicate balance needed to maintain good glycemic control.

Therefore, there is a great need, especially at the time of initial diagnosis, to assess the developmental, behavioral,and psychosocial history of children with diabetes and their families.

Psychosocial Impact

Any potentially life-threatening condition has some psychological impact, and that of diabetes is profound. If the care regimen is complex, the impact is greater in terms of financial cost, misunderstandings, external influences (e.g., patients may be accepted or rejected by the community), and the needs imposed by the disease itself. Family members often experience the classic stages of grief, progressing from anger and denial to bargaining, depression, and finally resolution or acceptance Adjustment to a diagnosis of diabetes takes 6?9 months for children and 9?12 months for parents. The stressors of everyday life can greatly affect both family functioning and blood glucose control. Stressors such as divorce, family arguments, violence, or abuse can lead to elevated blood glucose levels and increase the need for intervention by a supportive health care team.
Families play the key role in the adjustment of children to diabetes, to their level of care, and to their specific management regimens. The impact of diabetes depends on children?s and families? perceptions and knowledge of self-care and self-management, as well as on the background, structure, and functioning of families as a whole. For some, and especially low-income families, limited access to health providers and high costs of health care also affect diabetes control and family stability. A history of diabetes complications among patients? relatives can significantly affect the outlook (optimistic or pessimistic) of both diabetic children and their families.

Schoolchildren

School-aged children and adolescents with diabetes must contend with a range of issues and feelings that vary with developmental stage. Feeling different from their peers is the most common issue they must face. these concerns fell into five categories: 1) recognizing they had a ?disease,? 2) the degree of discipline that required, 3) their concept of wanting to be normal, 4) things that were considered good or bad (e.g., ?good? or ?bad? blood glucose levels), and 5) degree of support from family and friends, both for daily self-care and for the costs of the disease, such as doctor visits, hospitalizations, and supplies.

Separating from parents when starting or returning to school also causes schoolchildren with diabetes to fear for their safety. Are teachers, school nurses, and other staff educated properly to treat hypoglycemia or to respond appropriately to high blood glucose levels? If meals are offered in school, is the time for eating or the amount of food available a problem? Are too many sweets available? Often, these fears are shared by parents. Teachers and school nurses must be educated about diabetes. Considerations must be given to appropriate teacher-pupil relationships so that children with diabetes do not get singled out as misfits in the classroom.

Without adequate education, participation by students with diabetes in all available academic and social activities is often blocked or questioned. All parents of children with diabetes should, but many do not, visit their child?s school to discuss specific needs with teachers, the principal, and, when available, the school nurse. When there is no school nurse on staff, a health professional could be assigned to visit the school. If no health professional is available, a willing individual should be trained to assess and assist in meeting the child?s needs (from testing blood glucose to treating hypoglycemia) in the school environment so that having diabetes at school will be safer and less fearful for children, parents, and teachers.

Adolescents

families with diabetes tend to be more dysfunctional than families without diabetes. These families are confused about diabetes-related goals. There are more problems for girls caring for their diabetes than for boys (e.g., eating disorders or issues involving the starting of menstrual periods). For families not functioning well, there is more need of support from outside the home, such as from peers, schools, or clinic personnel. Adolescents with chronic illnesses have described their situation as ?hard.? A study revealed that adolescents with diabetes tend to ignore their vulnerability to the potential consequences of their disease in their age-appropriate preoccupation with the present. Only one-fifth of the diabetic adolescent participants felt that they complied fully with what they believed they were expected to do regarding diabetes management.

The desire for more independence was one of the barriers to compliance identified by these adolescents. However, this conflicts with fears young people have reported developing after they experience ?doing something weird? during an insulin reaction. Because adolescents live in the here-and-now, they usually feel invulnerable to long-term complications. Those who do fear such complications sometimes respond by adopting risky or haphazard behaviors while they perceive that they are still able?a response too often observed in older adolescents. Peer support has been found important for adolescents not only in adjusting to diabetes but also in controlling blood glucose. On the other hand, diabetic adolescents can be influenced by peer pressure toward cigarette smoking, alcohol and drug use, and unprotected sex and must be counseled by the diabetes team on the dangers of such activities. The prevalence of eating disorders in adolescents raises questions about the use of rigid dietary restrictions.

Weight gain during the pubescent period can lead to low self-esteem and depression. Long-term contact and supervision by parents, health care providers, educators, and others may be viewed as an annoyance by these young people or may leave them fearful of ?doing something wrong.? On the other hand, such contact may help them learn the necessity of careful guidance and follow-up that will be useful in adapting and coping with their disease. Adolescents require guidance in learning to compromise and to achieve a livable balance among the demands of diabetes, life stressors, and their desire for a carefree lifestyle.

Adolescents who experience multiple hospitalizations as a group are more vulnerable and in need of psychosocial support. Independence issues in adolescents need to be resolved individually, taking into account each child?s level of maturity and emotional affect. It should be considered unsafe for adolescents to take responsibility for their own diabetes care and self-management before reaching an adequate level of maturity. Adolescents need to be followed by a health care provider knowledgeable in these issues and in the changing needs of children with diabetes during the teenage years. Social support also must be provided in the context of adolescents? development stage. It is therefore recommended that children of all ages who are diagnosed with diabetes be referred to a diabetes specialist.

Parents

Parents of children with diabetes must deal with many pressures. The greatest of these is the fear that their child will experience severe hypoglycemia, especially when it is associated with seizures or a loss of consciousness. Parents may also feel guilty for having transmitted the genetic components of diabetes to their child and worried that they have not done enough to manage the disease.

Parents of children with diabetes are extremely concerned about how poor glycemic control has influenced their child?s growth and development. A review found that parents have differing ways of coping with these pressures based on their environment and interpersonal skills. And in spite of their various fears and concerns, parents of adolescents with diabetes also perceive benefits resulting from their child?s adoption of responsibility for self-management. Having a child with diabetes places significant stress on marriages. One parent may blame the other not only in regard to genetics, but also in regard to division of diabetes management responsibilities and how that might influence the overall level of diabetes control. Parents may also be in conflict about being too responsible (overprotective) or not responsible enough (neglectful).

This is most evident when children reach adolescence. Planning the gradual transfer from child-centered diabetes care (performed by parents) to adult-focused care (performed by the adolescent or young adult with diabetes) may prevent the precipitation of poor metabolic control. Newer modes of treatment (e.g., insulin pumps) and medication (e.g., ?designer? insulin analogs) should help to ease this transition by increasing lifestyle flexibility and facilitating more normalized blood glucose levels.

Coping Strategies

Families should be assessed and provided with interventions to help them develop coping skills as soon as possible after diagnosis, and these skills should be reassessed about 2 years after diagnosis. Simple skills such as recognizing and treating hypoglycemia must be taught early.

All such interventions must be designed with age-appropriate developmental capabilities and intellectual capacities in mind. Training in non?emotion-based coping strategies, which have been associated with better metabolic control and self-care practices, are helpful, as are interventions to help families ?re-normalize? after diagnosis. Health care professionals must always be aware that, in the absence of healthy coping strategies for family members and young patients with diabetes, the potential for psychological problems is great, especially in situations in which culture and health care strategies clash.

Dysfunctional families are far less likely to develop healthy coping strategies. Professionals who learn to observe patients? coping strategies and educate those at risk have found the outcome to be an increase of healthy coping choices.

Source: http://pakmed.net/college/forum/?p=60218

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