1.6.0.0 Psychoso­cial Is­sues

Rapid and dy­nam­ic cog­ni­tive, de­vel­op­men­tal, and emo­tion­al changes occur dur­ing child­hood, ado­les­cence, and emerg­ing adult­hood. Di­a­betes man­age­ment dur­ing child­hood and ado­les­cence places sub­stan­tial bur­dens on the youth and fam­i­ly, ne­ces­si­tat­ing on­go­ing as­sessment of psy­choso­cial sta­tus and di­a­betes dis­tress in the pa­tient and the care­giv­er dur­ing rou­tine di­a­betes vis­its (28-34). Early de­tection of de­pres­sion, anx­i­ety, eat­ing dis­or­ders, and learn­ing disabil­i­ties can fa­cil­i­tate ef­fec­tive treat­ment op­tions and help min­i­mize ad­verse ef­fects on di­a­betes man­age­ment and dis­ease out­comes (33,35). There are val­i­dat­ed tools, such as the Prob­lem Areas in Di­a­betes-‍ Teen (PAID-‍T) and Par­ent (P-PAID-‍Teen) (34), that can be used in as­sessing di­a­betes-‍specific dis­tress in youth start­ing at age 12 years and in their par­ent care­giv­ers. Fur­ther­more, the com­plex­i­ties of di­a­betes man­age­ment re­quire on­go­ing par­ental in­volve­ment in care through­out child­hood with de­vel­op­men­tally ap­pro­pri­ate fam­i­ly team­work be­tween the grow­ing child/‍teen and par­ent in order to main­tain ad­her­ence and to pre­vent de­te­ri­o­ra­tion in glycemic con­trol (36,37). As di­a­betes-‍specific fam­i­ly conflict is re­lat­ed to poor­er ad­her­ence and glycemic con­trol, it is ap­pro­pri­ate to in­quire about such conflict dur­ing vis­its and to ei­ther help to ne­go­ti­ate a plan for res­o­lu­tion or refer to an ap­pro­pri­ate men­tal health spe­cial­ist (38). Mon­i­tor­ing of so­cial ad­just­ment (peer re­la­tionships) and school per­for­mance can fa­cil­i­tate both well-‍being and aca­dem­ic achieve­ment (39). Subop­ti­mal glycemic con­trol is a risk fac­tor for underper­for­mance at school and in­creased ab­sen­teeism (40).

Shared de­ci­sion mak­ing with youth re­gard­ing the adop­tion of reg­i­men com­po­nents and self-‍man­age­ment be­hav­iors can im­prove di­a­betes self-‍efficacy, ad­her­ence, and metabol­ic out­comes (22,41). Al­though cog­ni­tive abil­i­ties vary, the eth­i­cal po­si­tion often adopt­ed is the “ma­ture minor rule,” where­by chil­dren after age 12 or 13 years who ap­pear to be “ma­ture” have the right to con­sent or with­hold con­sent to gen­er­al med­i­cal treat­ment, ex­cept in cases in which re­fusal would significant­ly en­dan­ger health (42).

Be­gin­ning at the onset of pu­ber­ty or at di­ag­no­sis of di­a­betes, all ado­les­cent girls and women with child­bear­ing po­ten­tial should re­ceive ed­u­ca­tion about the risks of malfor­mations as­so­ci­at­ed with poor metabol­ic con­trol and the use of ef­fec­tive con­tra­cep­tion to pre­vent un­planned preg­nan­cy. Pre­con­cep­tion coun­sel­ing using de­vel­op­men­tally ap­pro­pri­ate ed­u­ca­tional tools en­ables ado­les­cent girls to make well-‍in­formed de­ci­sions (43). Pre-‍con­cep­tion coun­sel­ing re­sources tai­lored for ado­les­cents are avail­able at no cost through the ADA (44). Refer to the ADA po­si­tion state­ment “Psychoso­cial Care for Peo­ple With Di­a­betes” for fur­ther de­tails (35).

Youth with type 1 di­a­betes have an in­creased risk of dis­or­dered eat­ing be­hav­ior as well as clin­i­cal eat­ing dis­or­ders with se­ri­ous short-‍term and long-‍term neg­a­tive ef­fects on di­a­betes out­comes and health in gen­er­al. There­fore, it is im­por­tant to screen for eat­ing dis­or­ders in youth with type 1 di­a­betes using tools such as the Di­a­betes Eat­ing Prob­lems Sur­vey-‍Re­vised (DEPS-‍R) to allow for early di­ag­no­sis and in­ter­ven­tion (45-48).

Screen­ing

Screen­ing for psy­choso­cial dis­tress and men­tal health prob­lems is an im­por­tant com­po­nent of on­go­ing care. It is im­por­tant to con­sid­er the im­pact of di­a­betes on qual­i­ty of life as well as the de­vel­op­ment of men­tal health prob­lems re­lat­ed to di­a­betes dis­tress, fear of hy­po­glycemia (and hy­per­glycemia), symp­toms of anx­i­ety, dis­or­dered eat­ing be­hav­iors as well as eat­ing dis­or­ders, and symp­toms of de­pres­sion (49). Con­sid­er as­sessing youth for di­a­betes dis­tress, gen­er­ally start­ing at 7 or 8 years of age (35). Con­sid­er screen­ing for de­pres­sion and dis­or­dered eat­ing be­hav­iors using avail­able screen­ing tools (28,45). With re­spect to dis­or­dered eat­ing, it is im­por­tant to rec­og­nize the unique and dan­ger­ous dis­or­dered eat­ing be­hav­ior of in­sulin omis­sion for weight con­trol in type 1 di­a­betes (50). The pres­ence of a men­tal health pro­fes­sion­al on pe­di­atric mul­ti­dis­ci­plinary teams high­lights the im­por­tance of at­tend­ing to the psy­choso­cial is­sues of di­a­betes. These psy­choso­cial fac­tors are significant­ly re­lat­ed to self-‍man­age­ment difficul­ties, subop­ti­mal glycemic con­trol, re­duced qual­i­ty of life, and high­er rates of acute and chron­ic di­a­betes com­pli­ca­tions.