**6. Conclusion**

90 Type 1 Diabetes – Complications, Pathogenesis, and Alternative Treatments

improve their abilities to cope with stress as well as co-occurring symptoms of depression or

Poor parental adjustment and parental stress may be related to becoming overwhelmed with caretaking responsibilities and disease management for a significant period of time, leading to classic symptoms of "burnout. " Parents who are "burned out" may not assist their child with disease management, and feel apathetic about assisting their child in coping with his or her diabetes (Lindstrom et al., 2010). Other variables that may be related to parental stress are uncertainty about the treatment of the child's diabetes and uncertainty about health outcomes related to diabetes (Carpentier et al., 2006). Health care providers should informally assess parental stress and uncertainty associated with their child's illness on a regular, ongoing basis. Counseling should be recommended when parental stress is high, as lowering parental stress can have a positive influence on parents, which leads to improved diabetes management for their child. Parents experiencing high levels of trauma because their child has diabetes may require counseling to avoid symptoms of depression

Parental support may be critical to diabetes management during adolescence, as children begin to take a more active role in managing their diabetes (Silverstein et al., 2005). Adherence is a very important area of study for adolescents with diabetes because managing IDDM involves multiple strategies including, diet, exercise, and glucose monitoring as well as administering medication (Helgeson et al., 2010). The early teenage years are a difficult time to manage insulin levels, because adolescents may have decreased insulin sensitivity and poor self-management skills (Shroff-Pendley et al., 2002). Difficulties in managing diabetes may also occur in late adolescence, especially when adolescents experience stressful life events (e.g., change in a romantic relationship, parental divorce; Helgeson et al., 2010). Self-care may be compromised for a period of time as the child copes with the event, and during this period the adolescent may require counseling or additional support from family or friends to manage his or her diabetes. Previous research (Weissberg-Benchell, 2007) and guidelines of the American Diabetes Association (Silverstein et al., 2005) suggest that parent and child teamwork, or shared responsibility, for diabetes management tasks facilitates diabetes management. Thus, a partnership between the adolescent and his or her parents may be one strategy that doctors can emphasize to promote the development of a relationship that is supportive and allows parents to move between doing more to assist with diabetes management when needed and doing less when the adolescent is doing a

Skinner and Hampson (1998) found that family support, such as high levels of connectedness among family members, is a critical component of diabetes management for teenagers. On the other hand, family conflict and a lack of cohesion in family relationships has been related to with poor metabolic control (higher glycosated hemoglobin levels or HgbA1C levels; Hauser, Jacobson, Lavori, et al., 1990). Strong, constructive family relationships may have a positive influence on adherence (Skinner at al., 2000; Lewin et al., 2006). Family functioning is related to adolescents' adherence, management, and metabolic control (Wysocki et al., 2001). In general, we believe that a positive parent-teenager relationship will lead to family cohesion and will improve diabetes management. For this reason, we recommend that members of the child's medical team encourage a team-based approach to diabetes management and in other aspects of the child's life as a "family-level"

intervention when an adolescent is having difficulty with diabetes management.

anxiety (Streisand et al., 2008).

and anxiety (Horsch et al., 2007; Streisand et al., 2008).

**5. Adolescence: A critical period** 

good job managing on his or her own.

Our review of the literature indicated that child and parent adjustment influence diabetes management. Moreover, the phase of the child's life and phase in the family's own life-cycle impacts disease management and glycemic control (Chisholm et al., 2007; Rolland, 1987). We recommend that health and mental health professionals provide support as needed to children and parents, providing education based on child and parent needs. This type of patient- and family-centered approach may improve child and parent efficacy for disease management. A child- or patient-focused approach to adherence will ensure that health care professionals and school personnel "meet children where they are" and offer patientcentered care that will promote diabetes management and wellness for youth (Bauman, 2000). Counseling for children may improve their ability to cope with difficult psychosocial and developmental issues. Existing studies (e.g., Cohen et al., 2004) indicate that children's emotional and behavioral problems and low family cohesion are related to regimen adherence as well as glycemic control. Interventions which provide education about stress management and increase peer support (i.e., support from close friends) may improve adjustment to diabetes (Boardway et al., 1993; Greco et al., 2001). Health and mental health professionals working with children with diabetes should also work with children and their parents to reduce barriers, such as a lack of support from teachers or friends, to child illness management. Working to strengthen positive attitudes about disease management and illness trajectories and reduce stress also may be related to patient and parent satisfaction with the child's medical care and adherence to the child's medical regimen. More research on ways that group and individual counseling can assist children with diabetes and their parents and other family members will provide more information about the success of these support-based interventions. In conclusion, strengthening child and parent resilience, working with children and parents to develop strategies to facilitate diabetes management, and helping children and parents adjust to diabetes-related stress are elements of successful care that will optimize care and health outcomes for children with diabetes.

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**6** 

*Spain* 

**Inadequate Coping Attitudes, Disordered** 

**Eating Behaviours and Eating Disorders** 

Diabetes mellitus has been found to be the sixth leading cause of death for those living in the United States affecting the young and old at an alarming rate (National Center for Health Statistics, 2011). Type 1 diabetes typically has an early onset in life, but can occur at any age. It primarily develops when the body's own immune system attacks and destroys pancreatic beta cells, which produce the hormone insulin that regulates blood glucose levels. This type of diabetes accounts for 5 to 10 % of all diagnosed cases. Type 2 diabetes affects mainly adult subjects, its prevalence around the world has increased in relationship with the increase of the prevalence of overweight and obesity, attributed to lifestyle changes such as sedentary habits and overeating. Consequently, diabetes is one of the most challenging and burdensome chronic diseases of the 21st century, and it is a growing threat to the world's public health (King et al, 1995; King et al, 1998). Diabetes mellitus, especially type 1 form represent a very hard experience that requires subsequent psychological adaptation. Unfortunately, this often does not occur and it is followed by frustration and the nonacceptance of the disease. Problems with coping are one of the important consequences of

The management of type1 diabetes and its associated health-risk factors are often complex and require considerable patient education and frequent medical monitoring (Koopmanschap, 2002). The participation of the patients is basic in order to obtain a correct degree of metabolic control; however, this carries as a consequence considerable amount of stress. People on insulin must learn how to regulate their blood sugars by monitoring blood glucose levels daily while carefully attending to their food intake and an exercise regimen. Careful blood glucose monitoring is necessary to prevent wide variations in blood sugars that affect both short term and long term health and functioning. Hypoglycaemia reactions are a concern in the short run not only because they are frightening and disruptive, but also because, when severe, they can lead to unconsciousness, coma and death (Cox & Gonder-Frederick, 1992). The constant stress of maintaining tight glycaemia control can result in two types of psychological distress (a) subclinical emotional distress, and (b) diagnosable psychological disorders (Rubin & Payrot, 2001). Additionally, psychiatric conditions can

the disease and the cause of uncountable problems in the future.

**1. Introduction** 

**in Type 1 Diabetic Patients** 

*Eating Disorders Section, Endocrinology, Diabetes,* 

*Nutrition and Metabolism Department,* 

*University Hospital of Vigo* 

Ricardo V. García-Mayor and Alejandra Larrañaga

