Facilitating Adherence in Adolescent Diabetes: Focus on Mental Health Amy Lynn Meadows, MD, MHS Assistant Professor of Psychiatry and Pediatrics University of Kentucky College of Medicine

Introduction

• I have no financial disclosures

• The project described was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR001998. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Disclosures

• Upon completion of the learning activity, participants will be able to:

• Discuss the impact of mental health comorbidities on diabetes management

Learning Objectives

Adolescents and Adherence

• 75% of all cases of type 1 diabetes (DM1) are diagnosed in those <18 years

• About 18,000 new cases/yr of DM1 diagnosed in <20 years

Diabetes in Youth

Silverstein J et al (2005) “Care of Children and Adolescents with Type 1 Diabetes: A Statement of the American Diabetes Association” Diabetes Care, 28 (1): 186. CDC (2017) “National Diabetes Statistics Report”

Pediatric Nonadherence

• Averages about 50% across chronic health conditions.

• Inadequate coping or maladjustment to illness is associated with nonadherence in multiple medical conditions (e.g., DM, CF, transplantation)

Smith BA & Wood BL (2007) “Psychological factors affecting disease activity in children and adolescents with cystic fibrosis: medical adherence as a mediator.” Curr Opin Pediatr, 19: 553-58.

Diabetes Control by Age

0%

10%

20%

30%

40%

50%

60%

70%

Meets HgbA1c Goal

Meets ADA Targets by age

under 6y 6-12y 13-19y

Wood et al (2013) “Most youth with type 1 diabetes in the T1D Exchange Clinic Registry do not meet American Diabetes or International Society for Pediatric and Adolescent Diabetes Clinical guidelines.” Diabetes Care, 36 (7): 2035-2037.

• Cardiovascular (stroke, myocardial infarction) • Renal (kidney disease, end stage renal disease): • Limb (amputations)

Morbidity

• Acute metabolic complications is the most common cause of death in people with IDDM under age 30

• Complications from Diabetes is the 7th leading cause of death in the US

Mortality

Skrivarhaug T et al (2006) “Long term mortality in a nationwide cohort of childhood-onset type 1 diabetic patients in Norway.” Diabetologia, 49: 298-305.

• Hormones (make everything worse) • Body Image • Experimentation (and high risk behaviors) • Problem solving/reasoning/cognitive bias • Family conflict • Parent monitoring versus independence/autonomy • Peer relationships

Bio-Psycho-Social Adolescent Development

Influences on Adherence

• Improved adherence with: • Increased self esteem • Perceived competence • Improved social functioning • Internal locus of control • Good adjustment

Jacobson AM et al (1987) “Psychologic predictors of compliance in children with recent onset of diabetes mellitus.” J Ped; 110: 805-11.

Mental Health and Diabetes

Risk factors for emotional disruption

• Premorbid psychopathology • Inadequate preparation for admission or invasive procedures • Inadequate comprehension of illness • Poor parent-child relationship • Psychiatric disorder in either parent • Debilitating reaction by parents • Severe or ambiguous medical diagnosis • Chronic illness with multiple admissions • Multi-system/CNS involvement Lewis, M. & Vitulano, L. A. (2003) “Biopsychosocial issues and risk factors in the family

when the child has a chronic illness.”Child and Adol Psych Clin of N America, 12: 389-399.

• Psychiatric disorders increase in longitudinal assessments from childhood to young adulthood from 16% to 28%

• Psychiatric disorders in adolescence predict both later psychiatric disorders and risk for diabetic ketoacidosis (DKA)

Risk for Psychiatric Disorders

Bryden KS et al (2003) “Poor prognosis of young adults with type 1 diabetes: a longitudinal study.” Diabetes care, 26(4): 1052-1057.

• Negative affect is associated with negative perception of competence

• Poor coping is related to poor metabolic control • Depression and diabetes-related distress predict episodes of

diabetic ketoacidosis

Glycemic control and mental health

Helgeson (2010); Dweck (1999); Kovacs et al (1992)

• T1DM is a risk factor for development of depression in adolescents and young adults:

• Rates range from 20-30% • Generally 2-3x greater risk than age-matched comparisons

Diabetes and Depression

Buchberger B et al (2016) “Symptoms of depression and anxiety in youth with type 1 diabetes: A systematic review and meta-analysis.” Psychoneuroendocrinology, 70: 70-84. Grey M et al (2002) “Depression in type 1 diabetes in children: natural history and correlates.” J Psychosom Res, 53 (4): 907-11.

• May involve binge eating, caloric restriction, insulin omission • Range in adolescents with DM1 8-30% (other adolescents 1-

4%)

Disordered Eating

Newmark-Sztainer D, Mellin A, Utter J, Sockalosky J. (2002) “Weight control practices and disordered eating behaviors among adolescent females and males with type 1 diabetes.” Diabetes Care 25:1289–96.

• ~40% of adolescents with DM1 have used illicit substances

• Risk for blood glucose lability (highs and lows)

• Risk for poor compliance

Substance Use

Ng (2004) “Street drug use among young patients with type 1 diabetes in the UK” Diabet Med, 21: 295-296.

• Life stressors in the past year affects glycemic control • Diabetes-specific stress has a bigger impact on adherence

behaviors than general stress

Trauma and Stress

Baucom, K. (2015) “Depressive symptoms, daily stress, and adherence in late adolescents with Type 1 Diabetes,” Health Psychol, 34 (5): 522-530. Commissariat et al (2017) “Associations between major life events and adherence, glycemic control, and psychosocial characteristics in teens with type 1 diabetes.” Pediatric Diabetes: 1-7.

• Diabetes-related family conflict PREDICTS poor adherence, glycemic control, and coping

• Shared responsibility leads to better self-care

Family Conflict

Helgeson V et al (2007) “Comparison of adolescents with and without Diabetes on Indices of Psychosocial Functioning for Three Years.” J Ped Psychology 32(7): 794-806.

Quality of Life

• Presence of psychiatric conditions increases risk for poor functioning

• In the relationship between chronic illness and quality of life, depressive symptoms and contextual variables explain a significant proportion of the variance

Edwards TC et al (2003) “Quality of Life of Adolescents with Perceived Disabilities” J Ped Psychology, 28 (4): 233-241

Addressing mental health is addressing adherence

Building Resilience

Why think about resilience?

• Stress influences the severity of physical symptoms, disability, adherence, and quality of life associated with medical illness.

• Resilience is a strength-based framework that focuses on supporting positive coping

• Coping successfully requires mobilization of support, role flexibility, emotional expression, and problem solving in patients and families.

“…Highly resilient people are flexible, adapt to new circumstances quickly, and thrive in constant change. Most important, they expect to bounce back and feel confident that they will. They have a knack for creating good luck out of circumstances that many others see as bad luck.” - Al Seibert The Resiliency Advantage

Resilient Adolescents and Young Adults

Promoting Resilience

• Active Coping Style: Problem-solving and managing emotions that accompany stress

• Positive Outlook: Enhancing optimism; embracing humor • Cognitive Flexibility: Finding the good in adverse situations • Moral Compass: Developing and living by meaningful

principles • Social Support: Developing and nurturing relationships • Physical Exercise: Engaging in activity to improve mood and

health

Haglund, M. et. Al. (2007) “6 Keys to Resilience for PTSD and everyday stress.” Curr Psychiatry, 6 (4): 23-29.

“Active Coping Style”

• Practical and emphasize immediate obstacles that must be conquered, before visualizing a remote resolution

• Select from a wide range of potential strategies and are resourceful

• Heed various possible outcomes and are aware of consequences

• Generally flexible and open to suggestions, but they do not give up the final say in decisions

Schlozman SC et al (2010) “Coping with illness and psychotherapy of the medically ill” In Stern et. al. eds. The MGH Handbook of General Hospital Psychiatry, p. 425-32.

• Adolescents who have high levels of self-efficacy (e.g., “I can do it!”) have better glycemic control

“Positive Outlook”

Grossman HY et al (1987) “Self-efficacy in adolescent girls and boys with insulin-dependent diabetes mellitus.” Diabetes Care 10 : 324-329.

Feelings are not the enemy

Mind-Body Techniques: • Mindfulness: goal to

cultivate present moment awareness without judgment.

• Separates bodily sensations from accompanying thoughts and emotions

“Diabetes is Taking Over My Life!” • When do you test (4x/d)?:

• Go to the meter (if you know where your meter is)

• Calibrate strip (30 seconds) • Lancet out of the package • Wipe skin with alcohol prep • Stick self with lancet • Put drop of blood on strip • Put strip in meter • Press button and wait 5 seconds for

results • Total = 1 minute, 4x day

• When do you give insulin (4x/d)? – Syringe out of package – Wipe insulin bottle with alcohol – Draw up insulin AND recheck

(assume 2 minutes) – Wipe skin with alcohol – Inject insulin – Toss sharps in water jug – Total = 2 minutes, 30 seconds

x 4

“Wow! That’s only 14 minutes! Maybe it’s taking over your life because you’re thinking about it the other 23 hours?”

“Cognitive Flexibility”

• Peer group support: focus on stress management, coping, and problem-solving

• Improves glycemic control • Improves quality of life

Peer support

Anderson BJ et a. (1989) “Effects of peer-group intervention on metabolic control of adolescents with IDDM: randomized outpatient study.” Diabetes Care 12:179– 183.

Resilient Families

• Goal for adolescence is INTERDEPENDENCE not independence in diabetes management

• Clear and consistent expectations

• Set limits with consequences • Negotiate involvement and

support • Gradual transfer of

responsibility

Families: Teamwork!

Jaser, SS (2010) “Psychological Problems in Adolescents with Diabetes” Adol Med State Art Rev, 21(1): 138-xi.

Stress among Caregivers

• High levels of parental distress can be associated with higher depression and anxiety in chronically ill children

• High parental stress is also associated with poor disease management

Whittemore R et al (2012) “Psychological experience of parents of children with type 1 diabetes: a systematic mixed-studies review.” Diabetes Educ. 38 (4): 562-79.

Building Resilient Families

• Child Illness Resilience Project (Australia): • Positive Parenting • Open Parent-Child Communications • Inclusion of siblings in information sharing • Parental support for older children to manage their illness/symptoms • Parental encouragement of children to engage in relaxation activities

Hamall et al. (2014) “The Child Illness and Resilience Program (CHiRP): a study protocol of a stepped care intervention to improve the resilience and wellbeing of families living with childhood chronic illness.” BMC Psychology, 2 (5).

Caregiver Self-Care

• Encouraging parents to care for their physical and emotional needs

• Encouraging support and community connection

Avoiding Avoidance

• Parents who use problem solving have less anxiety than parents who avoid facing children’s illness

Norberg AL et al (2005) “Coping Strategies in parents of children with cancer.” Social Science & Medicine, 60 (5): 965-975.

Resilient Health Care Systems

Providing Education

• Gauging understanding • Developmentally appropriate • Ongoing • Implications for participation

in classes and activities • Special attention to transitions

Perrin et. Al. (2012) “Psychological aspects of chronic health conditions,” Peds in Rev, 33: 99-109.

Innovative Educational Methods

• Use of the internet or video games is an emerging method to deliver education

• “Experience journaling” • Text message reminders • Artificial intelligence and

automated systems

Barlow JH and Ellard DR (2004) “Psycho-educational interventions for children with chronic disease, parents and siblings: an overview of the research evidence base.” Child: Care, Health & Development, 30 (6): 637-645.

• Very critical period • Loss to follow up is a predictor of complications and mortality

Transition to Adult Care

Laing et al (1999)

• “Health-care providers can play an important role as their professional skills are founded on attitudes, commitment, optimism, and realism.”

Health Care Providers

Sinnema G (1991) “Resilience among children with special health-care needs and among their families.” Pediatr Annals; 20 (9): 483-486.

Broader Considerations

• Finances • Cultural issues • Religious/spiritual

concerns • Travel • Access to mental

health care

Questions?

Contact: Amy.Lynn.Meadows@uky.edu