**Type I Diabetes in Children and Adolescents**

Laura Nabors1, Phillip Neal Ritchey2, Bevin Van Wassenhove3 and Jennifer Bartz3 *1School of Human Services, College of Education, Criminal Justice, and Human Services, University of Cincinnati, 2Department of Sociology, College of Arts and Sciences, University of Cincinnati, 3Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, Ohio USA* 

#### **1. Introduction**

Type I Diabetes is characterized by pancreatic failure. Daily exogenous insulin replacement is necessary for the child's survival. Insulin typically is administered by injections before lunch and dinner. Type I diabetes affects approximately 1 in every 400 to 600 children (Centers for Disease Control and Prevention, 2003). Rates of Type I diabetes are increasing (Chisholm et al., 2007). This is concerning as this disease has long-term health care consequences including problems with circulation, vision, and cardiovascular issues (Frey et al., 2006). The care of children with Type I diabetes involves complex procedures including daily blood glucose testing, dietary monitoring, intensive insulin therapy, and increased physical activity to maintain metabolic control (Anderson et al., 2007). Several studies have shown that children as well as adolescents have difficulty adhering to diet, exercise, blood glucose testing, and insulin regimens (e.g., Chang et al., 2007; Frey et al., 2006). Patterns of diabetes care are established early in the disease course, and therefore understanding factors related to child adherence is a mechanism for generating strategies to improve diabetes management for children. This, in turn, may positively influence health outcomes in adolescence and adulthood (Bui et al., 2005).

Children's management of their diabetes is often measured by assessment of blood glucose or HbA1c levels (i.e., measure of diabetic control). Monitoring blood glucose levels has become an increasingly important self-management task for children who have diabetes (Bui et al., 2005). Psychosocial factors, such as attitudes about one's diabetes, support from others, and stress, have been related to HbA1c levels or other factors serving as proxy variables for diabetes management (Chisholm et al., 2007; Nabors et al., 2010). This chapter reviews the relationship between psychosocial factors, chiefly children's attitudes, support from others, stress, and diabetes management. This chapter will provide suggestions for improving children's attitudes and reducing their stress to improve their diabetes management. The next section of this chapter reviews ways in which children's attitudes, namely health locus of control and stress, influence children's diabetes management.

Type I Diabetes in Children and Adolescents 87

Children may experience stress related to feeling different from peers due to having Type I Diabetes. They also may have difficulty talking to teachers about how to manage their disease at school (Nabors et al., 2003). Coaching for these children, in addition to written care plans may assist them in communicating important information to teachers and other professionals in the school setting. But, not all children and adolescents with diabetes may face significant diabetes-related stressors. For example, Hema et al. (2009) discovered that children and adolescents with diabetes reported daily stressors similar to youth without chronic illnesses; interestingly, they did not report significant diabetes-related stressors as being hassles. Consequently, health care professionals need to consider the social and emotional needs of children with diabetes to determine whether recommendations for stress

Children with diabetes also can experience stress related to negative school experiences. Storch et al. (2006) found a link between bullying of children with diabetes and selfmanagement behaviors. If children with diabetes experienced teasing or negative reactions from peers for testing their blood glucose or other self-management behaviors, they were less likely to engage in self-care. In addition, these researchers proposed that children who are depressed because of having diabetes may be less likely to monitor their glucose levels. They concluded that assessment of bullying experiences by peers is an important component of clinical interviews with school-age children, because bullying can be an

In another study, Peters et al. (2008) assessed the relationship between experiences of teachers being unsupportive and adherence and self-management in one hundred and sixtyseven children, between the ages of eight to seventeen years, with Type 1 Diabetes. Their findings indicated that perceptions of teachers as being unsupportive of the child's selfmanagement were related to poorer adherence behaviors for younger children, between the ages of eight and eleven years, but not for older children (ages twelve through seventeen). Thus, a poor teacher-student relationship, often characterized by teachers misunderstanding the importance of adherence to the medical regimen, may be detrimental to diabetes management for elementary or primary school-age youth, who depend on teacher support

Diabetes management can be very difficult and children may not be able to independently manage their treatment regimen (Allen et al., 1983). Additionally, children have reported that they benefit from support from teachers, peers, and nurses in school settings (Nabors et al., 2003). A key factor influencing diabetes management is support from friends and family. LaGreca et al. (1995) reported that support from parents and friends were protective factors for adolescents with diabetes. Greco and her colleagues (2001) found that support from a best friend was perceived as beneficial for diabetes management by adolescents. Skinner and Hampson (1998) also discovered that family support is a critical component of diabetes

Arguably, the most important support for diabetes management may come from children's parents. Hanna and Guthrie (2001) reported that when parents acted as supervisors, providing guidance to assist their child in diabetes management, both

management or referral for counseling is appropriate (Chisholm et al., 2007).

and guidance to facilitate their efforts at managing their diabetes at school.

indicator of poor self-management and higher HbA1c levels.

**3. Systems-level factors and diabetes management** 

**3.1 Support from others** 

management for adolescents.
