Teens with Diabetes. Michael A. Harris

to detail to a complex and changing medical regimen, usually multiple times a day. Diabetes management affects and is affected by every aspect of daily life. There is no vacation from the procedures related to diabetes management. Perhaps more than any other chronic disease of childhood, with the possible exception of asthma, diabetes requires continuous attention by the individual and his or her family and caregivers. The complex nature and imperfection of insulin replacement and the diabetes management regimen place substantial burdens on patients and their families. This burden is present at all ages and stages of life with different implications at each stage. However, these burdens are most challenging during adolescence. The nature of adolescence and the struggles prominent during this stage of psychosocial development conflict with the demands and continual immersion required to optimize metabolic control of diabetes. And even when implemented diligently, the results may be less than anticipated. Clearly, there is more to optimal diabetes management than providing the right amount of insulin at the correct times relative to nutrient intake and exercise. Optimal management requires an understanding and appreciation of the stresses and burdens of diabetes superimposed on the underlying social and family structure and characteristics.

      In this book, Drs. Michael Harris, Korey Hood, and Jill Weissberg-Benchell, three child psychologists with considerable personal, clinical, and academic experience with children and teenagers with diabetes, use their collective experience to provide a developmental and psychosocial context for optimizing diabetes management in teens. Further, they highlight real-world examples of the conflicts and challenges that exist in adolescents with diabetes and their families and give practical approaches to facilitate resolution. Each chapter tackles a different aspect of adolescent–parent and adolescent–health care provider interactions and uses examples of approaches to deal with the given situation. Health care providers caring for adolescents with type 1 diabetes need to apply these examples and approaches when approaching teenagers with type 1 diabetes and their families.

      The first chapter addresses the developmental demands of adolescence and the developmental constructs of why teenagers behave as they do. In the second chapter, the authors address adjustment to the diagnosis of a chronic disease such as diabetes and how diabetes affects the lifestyle of the adolescent. These lifestyle changes are considerable, and it is important that parents and health care providers understand this to maintain a supportive and ongoing relationship.

      Chapter 3 addresses the language of diabetes and how what is said and how words are used conveys a message that can be either supportive or obstructive to the interaction and the relationship. Chapter 4 discusses diabetes self-management and the importance of focusing on self-care behaviors and realistic, achievable goals instead of only on unachievable metabolic outcomes. In this context, it is important to note that even with good self-management behaviors, outcomes may not be optimal. Chapter 5 concentrates on the parent-teen relationship and its impact on diabetes. This chapter’s primary focus is to highlight the importance of problem-solving strategies and the appropriate distribution of support and responsibility.

      The remaining chapters address specific topics that are critical to understanding when working with teens with diabetes. Chapter 6 addresses mood and the risk of distress and depression in teenagers with diabetes. The prevalence of depression is high, and unfavorable consequences on outcomes are frequent. Professional psychological intervention is often necessary. Chapter 7 concentrates on the potential use of new and emerging technologies to benefit teens with diabetes. While the impact of these technologies on the health behaviors of adolescents are not fully known yet, they serve as a promising avenue for optimizing outcomes. Chapters 8 and 9 address important concerns related to repeat diabetic ketoacidosis episodes and high-risk behaviors, respectively. The issues discussed in these chapters include disordered eating and insulin omission, alcohol and other substance abuse, sexual activity, and driving.

      Finally, Chapter 10 focuses on the important issue of transition from pediatric to adult health care and Chapter 11 focuses on advocacy—two themes that mark the conclusion of the adolescent period and evolution toward adulthood. These are issues that can fall down on the priority list, since many issues need to be addressed with adolescents; however, they absolutely need to be addressed to set the stage for successful navigation of the adult diabetes world.

      Overall, this book provides, through examples based on the experiences of three knowledgeable and very capable clinical psychologists, an evidence-based practical approach to understanding the turmoil inherent in the triad of adolescent, parents, and health care providers. Understanding the developmental state of adolescents and addressing psychosocial, psychoeducational, and family issues that result are critical to providing the best medical care for teens with diabetes and their families. Our success (or failure) as health care providers for youth with diabetes will best be judged by the future success of our patients in their diabetes management and health care as they make the transition to adulthood. In this book, Drs. Harris, Hood, and Weissberg-Benchell lay a framework for these efforts.

      Neil H. White, MD, CDE

      Professor of Pediatrics

      Washington University School of Medicine

      St. Louis, Missouri

Acknowledgments

      Collectively, we have worked with some of the best diabetes teams across the country, headed up by some of the best endocrinologists. Our work has been heavily influenced by these teams and their physician leaders, including the diabetes teams at St. Louis Children’s Hospital in St. Louis, Missouri (Neil H. White, MD, and the late Julio Santiago, MD), Children’s National Medical Center in Washington, D.C. (Allen Glasgow, MD, and Fran Cogen, MD), Joslin Diabetes Center in Boston, Massachusetts (Lori Laffel, MD, MPH), Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio (Lawrence Dolan, MD), Lurie Children’s Hospital in Chicago, Illinois (Donald Zimmerman, MD), the Harold Schnitzer Diabetes Health Center in Portland, Oregon (Andrew Ahmann, MD, and Bruce Boston, MD), and the Madison Clinic for Pediatric Diabetes in San Francisco, California (Saleh Adi, MD).

      In addition, the success of our work has been made possible only through the support, guidance, and direction of the many expert clinicians and scientists in the field of diabetes, including Cindy L. Hanson, PhD, Tim Wysocki, PhD, Barbara J. Anderson, PhD, Richard R. Rubin, PhD, Mark Peyrot, PhD, David Marrero, PhD, Dennis Drotar, PhD, Pat Lustman, PhD, Alan Delamater, PhD, Marilyn Ritholz, PhD, and Suzanne Bennett Johnson, PhD, and the many members of BRIDGE (Behavioral Research in Diabetes Group Exchange).

      During the writing of this book, a titan in the field, Dr. Richard R. Rubin, passed away. Dr. Rubin was considered one of the founding fathers of behavioral and psychosocial research in diabetes. He was a key player in many of the large multicenter studies examining better ways to treat diabetes, including the Diabetes Control and Complications Trial (DCCT), the Diabetes Prevention Program (DPP), and Diabetes Attitudes, Wishes, and Needs (DAWN), as well as many others. Along with Dr. Barbara J. Anderson, Dr. Rubin coauthored one of the first books for professionals addressing the psychosocial and behavioral challenges of diabetes care, Practical Psychology for Diabetes Clinicians (Anderson and Rubin 1996). Besides being an exemplary researcher and professional, Dr. Rubin was an incredibly grounded and compassionate individual. He was one of the nicest people we have had the pleasure of working with. When speaking about our successes in diabetes, we always think about the expression “standing on the shoulders of giants.” Dr. Rubin is and was one of those giants.

      We