psychology and diabetes

Diabetes, Psychology Diabetes, Psychology and the Pyschologistand the Pyschologist

Paul Hofman Paul Hofman 20112011

Dear Mother-in-Law Please don't try to tell me how to raise my kids - I'm married to one of yours and believe me there's room for improvement! Sincerely Your Daughter-in-Law

I am not a psychologist!I am not a psychologist!

However I am a believer!However I am a believer!

Psychology and interventions have Psychology and interventions have an important role to play in the an important role to play in the

management of diabetesmanagement of diabetes

Starting PointsStarting Points

All comments I make are about All comments I make are about groups and NOT individuals. Within groups and NOT individuals. Within groups that are at high risk of doing groups that are at high risk of doing badly some will do really well and badly some will do really well and vica versa.vica versa.

So do not take anything said So do not take anything said personally ....please!personally ....please!

ConfessionConfession I am a diabetes doctor and focus on I am a diabetes doctor and focus on

diabetes control.diabetes control. My goal is to achieve the best glucose My goal is to achieve the best glucose

control possible as this is the best predictor control possible as this is the best predictor of good long term outcome – both quality of good long term outcome – both quality of life and physical health.of life and physical health.

BUT how diabetes is approached, how the BUT how diabetes is approached, how the patient feels and the perception of what patient feels and the perception of what defines necessary care are essential to defines necessary care are essential to good control good control

Diabetes is a family problemDiabetes is a family problem Diabetes does not just affect one Diabetes does not just affect one

individualindividual It must be viewed as affecting everyone It must be viewed as affecting everyone

within the familywithin the family Parents and siblings are as important Parents and siblings are as important

with the child/ teenager with diabetes.with the child/ teenager with diabetes. You cannot be an effective parent if you You cannot be an effective parent if you

are not coping with the diabetes or are not coping with the diabetes or other stressorsother stressors

Pyschological adjustmentPyschological adjustment Children with diabetes are at higher risk of Children with diabetes are at higher risk of

adjustment problems during the initial adjustment problems during the initial period following diagnosisperiod following diagnosis

If not treated effectively then there is If not treated effectively then there is growing USA evidence that these problems growing USA evidence that these problems will persistwill persist– Mainly social difficulties and eating disordersMainly social difficulties and eating disorders

Poor metabolic control associated withPoor metabolic control associated with– AnxietyAnxiety– Poor self esteemPoor self esteem

Pyschological adjustmentPyschological adjustment If adjustment problems persist into If adjustment problems persist into

late adolescence there is greater risk late adolescence there is greater risk for poor diabetes management in for poor diabetes management in adulthood.adulthood.

THUS – if possible we should try and THUS – if possible we should try and help resolve adjustment problems help resolve adjustment problems early and actively!early and actively!

Psychological Adjustment Psychological Adjustment involves the whole familyinvolves the whole family

Many parents have problems after the Many parents have problems after the diagnosis diagnosis – Clinical depression in mothers has been Clinical depression in mothers has been

reported in up to one third.reported in up to one third.– 24% of mothers and 22% of fathers met 24% of mothers and 22% of fathers met

criteria for post traumatic stress disorder 6 criteria for post traumatic stress disorder 6 weeks after diagnosis.weeks after diagnosis.

– Chronic sorrow 7-10 years after diagnosis Chronic sorrow 7-10 years after diagnosis persists in motherspersists in mothers

Psychological Adjustment Psychological Adjustment involves the whole familyinvolves the whole family

High risk groups includeHigh risk groups include– Single parent familiesSingle parent families– Ethnic minoritiesEthnic minorities– Lower socioeconomic groupLower socioeconomic group

If the parents aren’t coping the child/ If the parents aren’t coping the child/ teenager also won’t cope. teenager also won’t cope. – Psychological support for parents and Psychological support for parents and

sometimes other siblings is as important sometimes other siblings is as important as for the child with diabetesas for the child with diabetes

Social SupportSocial Support Mainly from parents and siblingsMainly from parents and siblings Essential for diabetic children and Essential for diabetic children and

adolescents adolescents – High levels of support associated with better High levels of support associated with better

adherence to diabetes regime and better adherence to diabetes regime and better control.control.

Peers also important but often about Peers also important but often about perceived rather than actual peer perceived rather than actual peer reactions.reactions.– If they are felt to be negative this can lead to If they are felt to be negative this can lead to

adherence problems and worse glucose controladherence problems and worse glucose control

Stress and CopingStress and Coping

High life stress = worse glucose High life stress = worse glucose controlcontrol

Youth with poor metabolic control Youth with poor metabolic control ofetn use a ‘learned helplessness ofetn use a ‘learned helplessness style’ and engage in avoidance and style’ and engage in avoidance and wishful thinking in response to stress.wishful thinking in response to stress.

Youth with good control have high Youth with good control have high levels of ‘self- efficacy’ and engage in levels of ‘self- efficacy’ and engage in ‘active coping’‘active coping’

Health belief modelHealth belief model Very important with regards to adherence to Very important with regards to adherence to

treatment and dietary guidelines. For instancetreatment and dietary guidelines. For instance– If you believe in the effectiveness of the treatment If you believe in the effectiveness of the treatment

adherence and glucose control betteradherence and glucose control better– If you are concerned about the seriousness of If you are concerned about the seriousness of

diabetes, personal vulnerability to complications diabetes, personal vulnerability to complications and other factors such as cost increased anxiety and other factors such as cost increased anxiety may occur.may occur.

Generally youth underestimate their risk but Generally youth underestimate their risk but acknowledge other diabetes youth at greater acknowledge other diabetes youth at greater riskrisk

Parental involvement is Parental involvement is critical!critical!

Management requires efficient decision Management requires efficient decision making, complicated physical and mental making, complicated physical and mental skills, frequent planning and dedication to a skills, frequent planning and dedication to a daily regimen.daily regimen.

Children with any chronic illness benefit Children with any chronic illness benefit from a cohesive family environment from a cohesive family environment classically with a parenting style of classically with a parenting style of ‘acceptance and firm control that is ‘acceptance and firm control that is flexible’.flexible’.

During adolescence, with growing During adolescence, with growing independence and autonomy, the independence and autonomy, the challenge is maintaining support while challenge is maintaining support while transferring skill transferring skill

Maternal Parenting StylesMaternal Parenting Styles Three dimensions to parenting styleThree dimensions to parenting style

– Psychological control (regulating thoughts and opinions Psychological control (regulating thoughts and opinions through guilt and criticism)through guilt and criticism)

– Firm control (managing behaviour through close Firm control (managing behaviour through close monitoring and setting limits)monitoring and setting limits)

– Acceptance (love and support)Acceptance (love and support)

127 10-15year old T1DM127 10-15year old T1DM maternal control maternal control ↓ adherence in older adolescents↓ adherence in older adolescents– BUT had no effect on adherence in younger subjectsBUT had no effect on adherence in younger subjects– Girls more affected by parenting style – greater Girls more affected by parenting style – greater

maternal control worse adherence to regimen.maternal control worse adherence to regimen.– Maternal non-involvement associated with Maternal non-involvement associated with ↓ adherence↓ adherence

Journal of Pediatric Psychology. 30(2):167-78, 2005 Mar.Journal of Pediatric Psychology. 32(10):1227-37, 2007 Nov-Dec

The children and mothers reported on The children and mothers reported on their own emotional adjustment. Where their own emotional adjustment. Where the mother and child/ adolescent were the mother and child/ adolescent were uninvolved there were greater depressive uninvolved there were greater depressive symptoms and less positive mood. symptoms and less positive mood.

Collaborative involvement in coping Collaborative involvement in coping efforts may be an important therapeutic efforts may be an important therapeutic strategy especially in adolescents (esp strategy especially in adolescents (esp older and girls)older and girls)

Maternal Parenting StylesMaternal Parenting Styles

Journal of Pediatric Psychology. 32(8):995-1005, 2007 SepJournal of Pediatric Psychology. 32(8):995-1005, 2007 Sep

Fathers are important too!Fathers are important too! Under researched area – most studies focus on Under researched area – most studies focus on

mother and child/adolescent with diabetes.mother and child/adolescent with diabetes. Not usually primary caregiver but involvement Not usually primary caregiver but involvement

important to diabetes outcomesimportant to diabetes outcomes Fathers support of mother may be crucial to later Fathers support of mother may be crucial to later

outcomes ‘Such support may protect the mother outcomes ‘Such support may protect the mother from overinvolvement, create an environment of from overinvolvement, create an environment of mutuality and increased marital satisfaction and mutuality and increased marital satisfaction and improve the mother's perceptions of the child’improve the mother's perceptions of the child’

Psychological adjustment of the father predicted Psychological adjustment of the father predicted poor glucose control 5 years after diagnosispoor glucose control 5 years after diagnosis

Fathers are important too!Fathers are important too! In one study of 47 two parent familiesIn one study of 47 two parent families– Fathers' but not mothers‘ reports of higher levels of total Fathers' but not mothers‘ reports of higher levels of total

family resources were associated with better metabolic family resources were associated with better metabolic controlcontrol

– Fathers' but not mothers' reports of increased family Fathers' but not mothers' reports of increased family stress were associated with poorer metabolic controlstress were associated with poorer metabolic control

– Fathers' but not mothers' reports of greater intrafamily Fathers' but not mothers' reports of greater intrafamily resources, specifically in the areas of communication resources, specifically in the areas of communication and collaboration, were associated with better metabolic and collaboration, were associated with better metabolic control control

– Family integration was ranked by both parents as more Family integration was ranked by both parents as more helpful than social support or information.helpful than social support or information.

Health and Social Work, 18, 101−113. 1993

Parent-Adolescent Distribution Parent-Adolescent Distribution of Responsibilityof Responsibility

Worsening control during Worsening control during adolescence in part due to wanting adolescence in part due to wanting more autonomy and placing greater more autonomy and placing greater emphasis on other areas of life.emphasis on other areas of life.

Responsibility for diabetes control Responsibility for diabetes control generally shifts during these years. generally shifts during these years. However does too rapid gain of However does too rapid gain of diabetes autonomy or too slow affect diabetes autonomy or too slow affect diabetes control?diabetes control?

Helgeson et al studied 132 adolescents Helgeson et al studied 132 adolescents with diabetes (70 girls, age 10.73-14.21 with diabetes (70 girls, age 10.73-14.21 yrs, 93% white Amercian, 26% using yrs, 93% white Amercian, 26% using pump in 1pump in 1stst year and 44% in year 2 year and 44% in year 2ndnd))

Follow up annually for 3 years Follow up annually for 3 years Showed that shared responsibility with Showed that shared responsibility with

parents was associated with better parents was associated with better psychological health, good self care psychological health, good self care behaviour, good metabolic control.behaviour, good metabolic control.

Child or parent responsibility alone did Child or parent responsibility alone did not. not.

Generally affected older adolescents Generally affected older adolescents more.more.Journal of Pediatric Psychology 33(5) pp. 497–508, 2008

HbA1c versus shared parent-child responsibility (as HbA1c versus shared parent-child responsibility (as opposed to predominantly parent responsibility) in 3 opposed to predominantly parent responsibility) in 3 groups of adolescents based on age groups of adolescents based on age

Journal of Pediatric Psychology 33(5) pp. 497–508, 2008

Wysocki et al examined the affect of Wysocki et al examined the affect of autonomy versus maturity in an autonomy/ autonomy versus maturity in an autonomy/ maturity ratio (AMR). Higher AMR reflected maturity ratio (AMR). Higher AMR reflected greater autonomy at lower maturity levels.greater autonomy at lower maturity levels.

142 adolescents treated with usual care (UC) 142 adolescents treated with usual care (UC) n=70 and intensive care (IT) n=72n=70 and intensive care (IT) n=72

UC goal HbA1c<8.0%. Tx 2-3 injections/day. UC goal HbA1c<8.0%. Tx 2-3 injections/day. 3-4 blood tests daily. 3 monthly visits with 3-4 blood tests daily. 3 monthly visits with diabetes team.diabetes team.

IT – offered as much multidisciplinary support IT – offered as much multidisciplinary support as needed. Goal HbA1c<6.5%. 3+injections as needed. Goal HbA1c<6.5%. 3+injections daily or pump. 6x daily tests and 3am once daily or pump. 6x daily tests and 3am once per weekper week

IT patients received 6x as much contact as IT patients received 6x as much contact as UC group during the study.UC group during the study.

Studied for 18 months.Studied for 18 months.Journal of Pediatric Psychology 31(10) pp. 1036–1045, 2006

Journal of Pediatric Psychology 31(10) pp. 1036–1045, 2006

Clear diamonds intensive therapy and black squares usual care

What about peers?What about peers? Important especially in adolescenceImportant especially in adolescence Peer conflict but not support has been Peer conflict but not support has been

associated with outcomes, particularly among associated with outcomes, particularly among girls. girls.

Conflict is more strongly related to poor Conflict is more strongly related to poor metabolic control for girls than boys. metabolic control for girls than boys.

Indices of enjoyable interactions are associated Indices of enjoyable interactions are associated with fewer depressive symptoms and better with fewer depressive symptoms and better self-care—especially among girls.self-care—especially among girls.

Generally however adolescent friendships not Generally however adolescent friendships not associated with diabetes controlassociated with diabetes control

Health Psychol. 2009 May ; 28(3): 273–282.

Diabetes Problem Solving Diabetes Problem Solving IndexIndex

DPSI used to gained insight into diabetic DPSI used to gained insight into diabetic problem solving abilities. Questions asked on problem solving abilities. Questions asked on typical situations diabetics are faced with.typical situations diabetics are faced with.

In parents with low DPSI children had high In parents with low DPSI children had high HbA1c. Med –high DPSI in adults – no HbA1c. Med –high DPSI in adults – no difference in diabetes controldifference in diabetes control

In youth high DPSI frequently had high HbA1c In youth high DPSI frequently had high HbA1c – no relationship with HbA1c and DPSI!– no relationship with HbA1c and DPSI!

Even in youth with good diabetes knowledge/ Even in youth with good diabetes knowledge/ skills they lack the ability to use these skills.skills they lack the ability to use these skills.

Strategies are needed - more than just Strategies are needed - more than just education - to find ways to use the skills they education - to find ways to use the skills they possess.possess.

Does Coping Skills Training Does Coping Skills Training Help?Help?

77 adolescents (12–20 years, duration 8.777 adolescents (12–20 years, duration 8.7± ± 3.9yrs)3.9yrs)

Randomly assigned to two groups with or Randomly assigned to two groups with or without coping skills training (CST).without coping skills training (CST).

CST role playing various social situations so a CST role playing various social situations so a trainer could model appropriate behaviours. trainer could model appropriate behaviours. Emphasis on social problem solving skills. Small Emphasis on social problem solving skills. Small groups 2-3/ trainer and lasted 6 weekly - 90 groups 2-3/ trainer and lasted 6 weekly - 90 minute sessions followed by monthly visits for minute sessions followed by monthly visits for 12 months.12 months.

Data collected over 12 monthsData collected over 12 monthsJ Peds 137(1), July 2000, pp 107-113 J Peds 137(1), July 2000, pp 107-113

J Peds 137(1), July 2000, pp 107-113 J Peds 137(1), July 2000, pp 107-113

CST subjects had lower HbA1c, better CST subjects had lower HbA1c, better diabetes and medical self efficacy and diabetes and medical self efficacy and less impact of diabetes on the quality less impact of diabetes on the quality of their lives after 1 year.of their lives after 1 year.

Males had less effect on Males had less effect on hypoglycaemia and weight gain but hypoglycaemia and weight gain but finding otherwise similar between finding otherwise similar between genders.genders.

J Peds 137(1), July 2000, pp 107-113 J Peds 137(1), July 2000, pp 107-113

Family Focused Teamwork Family Focused Teamwork InterventionIntervention

Aim at increasing child parent shared Aim at increasing child parent shared responsibility.responsibility.

100 children (8-17 years age) 100 children (8-17 years age) assigned randomly into teamwork assigned randomly into teamwork (TW) or standard care (SC).(TW) or standard care (SC).

All subjects had diabetes <6yrsAll subjects had diabetes <6yrs

J Pediatr 2003;142:409-16

Teamwork InterventionTeamwork Intervention Focused on importance of parent-child Focused on importance of parent-child

responsibility sharing through responsibility sharing through childhood/ adolescence. 4 modules childhood/ adolescence. 4 modules were regularly covered:were regularly covered:– Communication esp talking about glucuse Communication esp talking about glucuse

results in the familyresults in the family– Meaning of HbA1c and need for teamwork Meaning of HbA1c and need for teamwork

during adolescenceduring adolescence– Response to blood glucoses and avoiding Response to blood glucoses and avoiding

‘blame/ shame cycle’‘blame/ shame cycle’– Sharing the burden of diabetes tasks and Sharing the burden of diabetes tasks and

using log book to problem solve out of using log book to problem solve out of range values.range values.J Pediatr 2003;142:409-16

J Pediatr 2003;142:409-16

Behavioural Family Systems Behavioural Family Systems TherapyTherapy

Focuses on family communication and Focuses on family communication and conflict resolution, improved parent-conflict resolution, improved parent-adolescent relationships, treatment adolescent relationships, treatment adherence and metabolic control.adherence and metabolic control.

104 families with poor glycaemic control 104 families with poor glycaemic control (HbA1c>8.0%) randomised into (HbA1c>8.0%) randomised into – Standard care (SC)Standard care (SC)– 12 sessions of educational support (ES)12 sessions of educational support (ES)– 12 sessions of BFST-Diabetes12 sessions of BFST-Diabetes

Extra therapy over 6 months and follow up Extra therapy over 6 months and follow up up to 18 months.up to 18 months.

Diabetes Care 30:555–560, 2007

Baseline Characteristics

GroupGroup BaselinBaselinee

6 mths6 mths 12 12 mthsmths

18 18 mthsmths

SCSC 9.69.61.1.55

9.19.11.1.88

9.69.61.1.66

9.69.61.1.77

ESES 9.79.71.1.66

8.98.91.1.22

9.39.31.1.44

9.59.51.1.55

BFST-DBFST-D 9.69.61.1.66

8.88.81.1.33

8.9 8.9 1.41.4

8.8 8.8 1.51.5

Effect of treatments on HbA1c

Diabetes Care 30:555–560, 2007

Important factsImportant facts

HbA1c HbA1c 1% per 4 missed boluses/ 1% per 4 missed boluses/ injections/ weekly.injections/ weekly.

Number of blood tests performed Number of blood tests performed strongly correlated with glycaemic strongly correlated with glycaemic controlcontrol

19% and 47% of adolescents with 19% and 47% of adolescents with pumps and injections respectively take pumps and injections respectively take insulin after eating.insulin after eating.

5% and 23% of these adolescents 5% and 23% of these adolescents forget insulin doses regularly.forget insulin doses regularly.

New TechnologyNew Technology

Trying to remind adolescents to do Trying to remind adolescents to do blood tests or injecting using texting or blood tests or injecting using texting or email.email.

Either automatically generated Either automatically generated message or ‘Sweet talk’message or ‘Sweet talk’

Caused transient improvement Caused transient improvement (<3months) but no long term effects (<3months) but no long term effects on either blood testing, insulin injection on either blood testing, insulin injection or control. Adolescents with poor or control. Adolescents with poor control need more than reminding!control need more than reminding!

SummarySummary Parent-child relationships are essential for Parent-child relationships are essential for

good diabetes control at all ages including good diabetes control at all ages including older childhood and adolescence.older childhood and adolescence.

Sharing of responsibility is necessary but Sharing of responsibility is necessary but ongoing parental input is essential ongoing parental input is essential throughout adolescence and early adulthood.throughout adolescence and early adulthood.

More education is not usually effective in More education is not usually effective in improving diabetes control – especially improving diabetes control – especially where diabetes control is suboptimal.where diabetes control is suboptimal.

Behavioural therapy needs to involve the Behavioural therapy needs to involve the whole family.whole family.

We need psychology input at or early after We need psychology input at or early after diagnosis NOT after problems develop. The diagnosis NOT after problems develop. The ambulance at the bottom of the cliff is ambulance at the bottom of the cliff is inefficient especially if the cliff is very high! inefficient especially if the cliff is very high!

ConclusionsConclusions They don’t always but psychological They don’t always but psychological

support and interventions work!support and interventions work! Pyschological interventions can be Pyschological interventions can be

directed by parent, nurse or psychologist.directed by parent, nurse or psychologist. There is NO social stigma attached to There is NO social stigma attached to

seeking support for stress, depression, seeking support for stress, depression, anxiety or simply guidance.anxiety or simply guidance.

Our kids are precious – lets give them all Our kids are precious – lets give them all the skills we can to do well out there! the skills we can to do well out there!

Important tips for parents of Important tips for parents of diabetic childrendiabetic children

When it is time to make a decision When it is time to make a decision about an activity, ask yourself what you about an activity, ask yourself what you would or wouldn't allow your child to do would or wouldn't allow your child to do if they did not have diabetes. If your if they did not have diabetes. If your child is being responsible in his diabetes child is being responsible in his diabetes care, and you would otherwise allow the care, and you would otherwise allow the activity, give him a chance to prove his activity, give him a chance to prove his ability to care for himself.ability to care for himself.


Kids who do well with their care Kids who do well with their care generally have a parent, or sometimes generally have a parent, or sometimes a grandparent, who stays involved in a grandparent, who stays involved in the diabetes care and keeps the kid the diabetes care and keeps the kid accountable. This person is the accountable. This person is the organizer and the person who will check organizer and the person who will check the numbers in the meter memory to the numbers in the meter memory to make sure tests are being done. make sure tests are being done.


Understand that when it comes to doing Understand that when it comes to doing diabetes tasks, there is not a steady diabetes tasks, there is not a steady progression from one stage to the next as progression from one stage to the next as teens mature. They ebb and flow in their teens mature. They ebb and flow in their ability and capability to take care of ability and capability to take care of themselves. Periodically, you may need to themselves. Periodically, you may need to step in and take over a task that your child step in and take over a task that your child had previously been doing. This effort is had previously been doing. This effort is usually temporary, as he regroups and usually temporary, as he regroups and begins to move forward again.begins to move forward again.


Don't assume that your child or teen is Don't assume that your child or teen is following his diabetes program. following his diabetes program. Countless parents are surprised when Countless parents are surprised when meters or pumps are uploaded at the meters or pumps are uploaded at the doctor's office and they find their child doctor's office and they find their child has not been doing what they are has not been doing what they are supposed to be doing. Stay tuned in to supposed to be doing. Stay tuned in to what they are doing.what they are doing.


Kids learn how to cope and behave from Kids learn how to cope and behave from their parents. Therefore, it is important their parents. Therefore, it is important for you as a parent to model the ways for you as a parent to model the ways you would like your children to behave. you would like your children to behave. Set a good example. If you take care of Set a good example. If you take care of yourself, eat well, exercise, and yourself, eat well, exercise, and establish good sleep habits, it is very establish good sleep habits, it is very likely that your children will as well.likely that your children will as well.


Don't hesitate to seek professional Don't hesitate to seek professional counselling for yourself, your child, or counselling for yourself, your child, or your family. It is hard enough to grow up your family. It is hard enough to grow up these days without the additional these days without the additional burden of diabetes.burden of diabetes.

Thank YouThank You

psychology and diabetes

Health & Medicine