It’s The Obstacles You Can’t See That Can Be Dangerous: Psychological Factors in Diabetes

1. It’s The Obstacles You Can’t See That Can Be Dangerous: Psychological Factors in Diabetes Jody Thomas, Ph.D. Licensed Clinical Psychologist Children’s Health Council Stanford, CA

2. People instinctively move toward health. Your job is not to “fix” them. It is your job to remove the obstacles and give them the tools to fix themselves.

3. PSYCHOPATHOLOGY • Rates of pathology do not appear to be much greater than they are in the general population. The impact of the pathology, however, can be much greater and more disruptive to health care. • Higher levels of depression are associated with higher A1c’s and increased number of hospitalizations. • Higher levels of parent anxiety are associated with higher A1c’s, and lower child motivation for self care.

4. Depression: lack of motivation, hopelessness, helplessness, self-injury/suicidality • Anxiety: can lead to hyper vigilance and/or avoidance • Eating Disorders: both anorexia and restricted eating patterns. • PTSD: dissociation, depressed mood, lack of attachment to the body • ADHD: difficulty with organization

5. Skills needed for good diabetes management:

6. Ability to appreciate future consequences • Impulse control • Delay of gratification • Consistent good judgment • High degree of social skill finesse • Great time management • Sense of personal responsibility • Good sense of self

7. Skills kids are still developing and completely normally generally don’t have:

8. Ability to appreciate future consequences • Impulse control • Delay of gratification • Consistent good judgment • High degree of social skill finesse • Great time management • Sense of personal responsibility • Good sense of self

9. Aspects of normal development that make management challenging: • Testing limits • Increasing desire for independence • Developing good judgment through trial and error • Increased desire to fit in with social groups • Struggles with identity development • Sense on invulnerability

10. ADJUSTMENTPROCESS • Adjustment is an ongoing process that is constantly changing: there are different issues at different points in time for the child and the parent. • An enormous amount of information and education is required at initial diagnosis. • Diagnosis typically occurs during crisis, and is an intense emotional experience, which can interrupt the learning/adjustment process.

11. Parent process is very different from the child process, though they play off each other. • Denial, anger, sorrow, and fatigue often hit at different times for both child and caregivers. • Normal child development often causes problems with disease management.

12. ADHERENCE INFORMATION DESIREDHEALTHBEHAVIOR MOTIVATION BEHAVIORAL SKILLS

13. INFORMATION • Basic knowledge about disease • Personal beliefs and constructs about the disease • There are often gaps in knowledge, particularly when the child is diagnosed at an early age. • Constantly evolving technology makes it difficult to keep up and use it effectively.

14. MOTIVATION • Personal motivation: • Personal worth put on short and long term consequences • “Cost” of good self care vs. “cost” of longer term consequences. • Social motivation: • Perceptions of family attitudes • Perceptions of peers attitudes

15. BEHAVIORAL SKILLS • Testing blood sugar • Counting carbs • Adjusting insulin doses • Knowing how to manage situations (ketones, etc), and appropriately problem solving • Carrying necessary equipment • Determining emergent from non-emergent situations • Negotiating and collaborating with parents • Self-advocating and collaborating with the medical team • Navigating social situation and managing peer interactions • Dealing with disease in the school environment • Recognizing patterns in their blood sugars, and adjusting their care accordingly

16. PARENT BEHAVIORAL SKILLS • Basic care skills (similar to kids) • Determining emergent from non emergent situations • Communicating effectively with child • Collaborative problem solving with child • Scaffolding but not controlling care • Controlling judgment behaviors • Giving up control over care at the “right” pace • Collaborating with medical teams • Dealing with schools, including possibly arranging 504 plans • Trusting your child • Allowing for imperfection • Separating your child from their behavior

17. FAMILY DYNAMICS • Parents attitudes and ideas influence child’s attitude and management, both positively and negatively • Differing levels of parental involvement are common and often cause problems • Over control often fosters resentment • Successful dynamics require change and adjustment over time

18. Efficacious communication patterns must be established • Over dependence on numbers (blood sugar levels and A1c) leads to difficulties • Shame vs. empowerment • Power struggle vs. collaboration • Guilt is often a major theme • Disease can be distraction from others issues at play • Sibling issues require attention