**8.3 Communication skills training**

This kind of training aims to help individuals express themselves in ways that are clear, appropriate, and constructive. Two main skills are identified under communication skills training: social skills training and assertiveness training. Models for social skills training include those by Carteledge & Milburn (Carteledge & Milburn, 1980) and Goldstein *et al.*  (Goldstein et al, 1980). These models strive to teach individuals how to work with others in a way that will result in positive outcomes for all. Assertiveness training permits one to communicate in ways that are direct, honest, and appropriate. Working groups allow

Inadequate Coping Attitudes, Disordered Eating

management can be sustained over 1 year (Grey et al, 2000).

anxiety, anger expression, or diabetes stress, compared with baseline.

**8.7 Coping skills training with parents and children or adolescents** 

adherence (Wysocki et al, 2000; Wysocki et al, 2001).

Behaviours and Eating Disorders in Type 1 Diabetic Patients 105

psychosocial outcomes in adolescents with type 1 diabetes mellitus implementing intensive diabetes management. They showed that, at 3 months, adolescents who received coping skills training had lower hemoglobin A1c levels and less distress about coping with their diabetes than adolescents receiving intensive management alone. Furthermore, adolescents who received coping skills training found it easier to cope with their diabetes and experienced less negative impact from diabetes on their quality of life than those who did not receive the training. The authors also demonstrated that the effects on glycaemia control and quality of life associated with coping skills training combined with intensive diabetes

Hains et al*,* (Hains et al, 2001) examined the impact of a cognitive behavioral intervention for distressed adolescents with type 1 diabetes mellitus. They studied six youths who had increased levels of anxiety, diabetes stress, or anger who received eight individual sessions using cognitive restructuring with problem solving through a conceptualization phase, skill acquisition phase, and application phase. Four patients demonstrated improvement on

The results of the aforementioned studies suggest that in children and adolescents with type 1 diabetes, coping skills training increases the repertoire of skills that youth have to selfmanage diabetes. Thus, they can improve their metabolic control and their quality of life.

Family environment has been found to play an important role in the adaptation of children with type 1 diabetes (McDougal, 2002). It has been shown that family interventions decrease parent-child conflicts about diabetes and improve metabolic control (Grey et al, 2003; Wysocki et al, 2000; Wysocki et al, 2001). One study that includes 119 families of adolescents with type 1 diabetes mellitus, assessed the effectiveness of an experimental group receiving Behavioral-Family Systems Therapy compared to both education and support groups in reducing parent-adolescent conflict in diabetes management. The Behavioral-Family Systems Therapy intervention targeted parent-adolescent conflict by focusing on family problem solving, communication skills training, cognitive restructuring, and aspects of functional and structural family therapy over 10 sessions. The results revealed that the experimental group showed significant improvement in parent-adolescent relationships, decreased diabetes-specific family conflicts, and increased treatment adherence when compared with education and support groups. At 6-month follow-up, parent-adolescent relationships remained significantly improved for the experimental group as compared to the control group. At 12 months, diabetes-specific family conflict was significantly improved compared to the control group. The experimental group showed improved treatment adherence compared with the control and education groups that both showed deteriorated

When parental involvement decreases, which is frequent in early adolescence, the metabolic control tends to deteriorate. Anderson et al. (Anderson et al, 1995) studied an office-based intervention to maintain parent adolescent teamwork in diabetes management. The study variables included parental involvement in diabetes care, family conflict, and subsequent metabolic control. Eighty-five patients aged 10 to 15 years were randomly assigned to one of three groups, which included teamwork, attention control, or standard control for 24 months. The teamwork families reported less conflict at 12 months. More adolescents in the teamwork group when compared to the comparison groups improved their HbA1c levels

members to observe the behavior of others as well as practice and obtain feedback on how effectively they communicate with the other members of the group.

#### **8.4 Coping skills training**

Coping skills training has been utilized by Grey and Barry (Grey & Berry, 2004) in individuals with diabetes, particularly, in the area of problem solving. The framework is derived from Bandura's conceptualization of self-efficacy, where the individuals act as the catalyst for positive changes in their lives (Bandura, 1986). When a person can practice and rehearse a new behavior, such as learning how to cope successfully with a problem situation, self-efficacy or self-concept can be enhanced. Further, by enhancing self-efficacy, problems with psychosocial well-being may be decreased. When an individual cannot cope effectively with a problem situation, confidence is decreased for dealing with the next problem, and less successful coping patterns are employed (Marlatt & Gordon, 1985).

This kind of training was originally developed for work with youth to prevent drug and alcohol use, training in the use of coping skills can teach personal and social behaviors that can assist individuals in dealing with potential stressors they encounter in their daily lives and the stress reactions that may result from these situations (Forman et al, 1993). In children and youth, such interventions have been demonstrated to reduce substance abuse (Forman et al, 1993), improve social adjustment (Bierman & Furman, 1984), prevent smoking (DelGreco et al, 1986) and reduce responses to stressors (Elias et al, 1986). In adults, coping skills training has been used to address drug and alcohol use and weight reduction.

#### **8.5 Cognitive-behavioural modification**

The cognitive-behavioural modification process comprises three steps. The first is working with the individual to reflect on how they think and then respond to situations. The individual's thoughts are then examined to consider if the thoughts are based on fact or assumption. Once the thoughts are examined the next step is to solve the social problem. The last step consists in teaching the individual to use his or her thoughts to help follow through on the decision made in the previous step. The group members can list their negative thoughts and then the member and the group can formulate alternate positive thoughts to counter the negative thoughts.

#### **8.6 Coping skills training with children and adolescents**

The use of coping skills training for youth with diabetes was based on the hypothesis that improving coping skills would improve the ability of youth to cope with the problems faced on a day-to-day basis in managing diabetes. Initially, a number of studies were conducted in five to 10 years old school-children and preadolescents using coping skills training (Gross et al, 1982; Gross et al, 1983; Johnson et al, 1982). The results of these studies suggested that coping skills training increased appropriate verbal assertiveness and performance in social situation, but not glycaemia control. An experimental pilot study by Boardway et al (Boardway et al, 1993) also supported the potential of this intervention to assist adolescents to manage diabetes, the authors observed that diabetes-specific stress was found to decrease significantly after stress management training, but glycaemia control, coping styles, selfefficacy, and adherence to regimen remained unchanged.

Some controlled studies *(*Davidson et al, 1997; Grey et al, 1998; Grey et al, 2000) were conducted to determine whether coping skills training would improve glycaemia and

members to observe the behavior of others as well as practice and obtain feedback on how

Coping skills training has been utilized by Grey and Barry (Grey & Berry, 2004) in individuals with diabetes, particularly, in the area of problem solving. The framework is derived from Bandura's conceptualization of self-efficacy, where the individuals act as the catalyst for positive changes in their lives (Bandura, 1986). When a person can practice and rehearse a new behavior, such as learning how to cope successfully with a problem situation, self-efficacy or self-concept can be enhanced. Further, by enhancing self-efficacy, problems with psychosocial well-being may be decreased. When an individual cannot cope effectively with a problem situation, confidence is decreased for dealing with the next problem, and less successful coping patterns are employed (Marlatt & Gordon, 1985). This kind of training was originally developed for work with youth to prevent drug and alcohol use, training in the use of coping skills can teach personal and social behaviors that can assist individuals in dealing with potential stressors they encounter in their daily lives and the stress reactions that may result from these situations (Forman et al, 1993). In children and youth, such interventions have been demonstrated to reduce substance abuse (Forman et al, 1993), improve social adjustment (Bierman & Furman, 1984), prevent smoking (DelGreco et al, 1986) and reduce responses to stressors (Elias et al, 1986). In adults, coping

skills training has been used to address drug and alcohol use and weight reduction.

The cognitive-behavioural modification process comprises three steps. The first is working with the individual to reflect on how they think and then respond to situations. The individual's thoughts are then examined to consider if the thoughts are based on fact or assumption. Once the thoughts are examined the next step is to solve the social problem. The last step consists in teaching the individual to use his or her thoughts to help follow through on the decision made in the previous step. The group members can list their negative thoughts and then the member and the group can formulate alternate positive

The use of coping skills training for youth with diabetes was based on the hypothesis that improving coping skills would improve the ability of youth to cope with the problems faced on a day-to-day basis in managing diabetes. Initially, a number of studies were conducted in five to 10 years old school-children and preadolescents using coping skills training (Gross et al, 1982; Gross et al, 1983; Johnson et al, 1982). The results of these studies suggested that coping skills training increased appropriate verbal assertiveness and performance in social situation, but not glycaemia control. An experimental pilot study by Boardway et al (Boardway et al, 1993) also supported the potential of this intervention to assist adolescents to manage diabetes, the authors observed that diabetes-specific stress was found to decrease significantly after stress management training, but glycaemia control, coping styles, self-

Some controlled studies *(*Davidson et al, 1997; Grey et al, 1998; Grey et al, 2000) were conducted to determine whether coping skills training would improve glycaemia and

effectively they communicate with the other members of the group.

**8.4 Coping skills training** 

**8.5 Cognitive-behavioural modification** 

thoughts to counter the negative thoughts.

**8.6 Coping skills training with children and adolescents** 

efficacy, and adherence to regimen remained unchanged.

psychosocial outcomes in adolescents with type 1 diabetes mellitus implementing intensive diabetes management. They showed that, at 3 months, adolescents who received coping skills training had lower hemoglobin A1c levels and less distress about coping with their diabetes than adolescents receiving intensive management alone. Furthermore, adolescents who received coping skills training found it easier to cope with their diabetes and experienced less negative impact from diabetes on their quality of life than those who did not receive the training. The authors also demonstrated that the effects on glycaemia control and quality of life associated with coping skills training combined with intensive diabetes management can be sustained over 1 year (Grey et al, 2000).

Hains et al*,* (Hains et al, 2001) examined the impact of a cognitive behavioral intervention for distressed adolescents with type 1 diabetes mellitus. They studied six youths who had increased levels of anxiety, diabetes stress, or anger who received eight individual sessions using cognitive restructuring with problem solving through a conceptualization phase, skill acquisition phase, and application phase. Four patients demonstrated improvement on anxiety, anger expression, or diabetes stress, compared with baseline.

The results of the aforementioned studies suggest that in children and adolescents with type 1 diabetes, coping skills training increases the repertoire of skills that youth have to selfmanage diabetes. Thus, they can improve their metabolic control and their quality of life.
