HOUSTON — Mental health issues can loom large in the treatment of diabetes in adolescents, especially when barriers to compliance arise, Scot G. McAfee, M.D., said at the annual meeting of the American Society for Adolescent Psychiatry.
It's especially important to stay alert to signs of depression—which is three times more likely to strike diabetics as nondiabetics, said Dr. McAfee, who has lived with diabetes since his youth.
Diabetes is considered to be one of the most demanding of all chronic illnesses, mostly because 95% of diabetes management is conducted by the patient. Some children with diabetes as young as 7 or 8 years old understand how to manage the disease effectively. But when children with diabetes reach puberty or are diagnosed in adolescence, they might develop compliance issues because of feelings of rebellion and desires to be like their peers, said Dr. McAfee, a psychiatrist at St. Vincent's Hospital, New York.
Children and adolescents with diabetes who learn about their condition immediately and learn to monitor themselves have a better chance of avoiding complications.
But some find it too difficult to figure out insulin doses and don't want to stand out at the lunch table. “So they eat whatever everyone else is eating,” Dr. McAfee noted at the meeting, cosponsored by the University of Texas Southwestern Medical Center at Dallas.
In addition to managing their illness, adolescents with diabetes must face the daily traumas of teenage life. For example, anxiety and stress about a test or about a relationship with a friend can increase blood sugar levels. And diabetic adolescents who exercise during a gym class or an after-school sports practice require additional carbohydrates.
Weight maintenance is a difficult issue for diabetic adolescents. A diabetic girl may want to lose weight and eat less, but if she is exercising, she will need to eat more to avoid hypoglycemia. This makes losing weight more of a challenge. “It's important to understand that weight loss must be a gradual process,” he said.
Adolescents require guidance in learning to compromise and achieve a livable balance between the demands of diabetes, the life stresses that all adolescents endure, and a desire for a normal lifestyle.
“If an adolescent with diabetes enters a psychiatric hospital after a suicide attempt with [his or her] diabetes medications, I recommend finding someone with experience in adolescent diabetes to talk with the patient and verify that this was in fact a suicide attempt and not an attempt at overly close diabetes management,” he added.
A diabetic child or adolescent puts stress on the family unit as well. “Adjustments to a diagnosis of diabetes can take 6 months for children and 9 months for parents,” Dr. McAfee said. Family issues include social stigma, possible economic burdens, and marital strife, especially when one parent wants to be more coddling of the diabetic child. Health care providers should reassess the families' knowledge of diabetes and coping strategies every 2 years, he said.
Any health care provider, whether a family physician, psychiatrist, or pediatrician, can remind children and adolescents that the treatment plan for diabetes is an interplay between exercise, diet, and insulin. Physicians can help children and adolescents set specific goals, whether it is testing their insulin three times each day, or eating a vegetable as part of their lunch. “Goals should be specific and measurable—and don't make them too complicated,” Dr. McAfee said.
Peer support groups show children and teens with diabetes that they are not alone, and adolescents in particular are often more receptive to learning from their peers. Online chat rooms and summer camps provide opportunities to learn from and be inspired by other children and adolescents. Those outlets also offer hints for managing diabetes during transitions, such as starting high school or college.
Dr. McAfee is a consultant to Janssen and Otsuka, and is a member of the speakers' bureau of AstraZeneca.