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

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

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

Inadequate Coping Attitudes, Disordered Eating

**9.1 Diabetes treatment** 

physical and mental health.

Jones & Khan, 2007).

**9.2 Nutritional management** 

Behaviours and Eating Disorders in Type 1 Diabetic Patients 107

The diabetes team has the important responsibility of monitoring insulin regimens and providing education about diabetes management and potential complications to patients and families (Krakoff, 1991). There are no studies looking at treatment of ED/DEB in youth with type 1 diabetes. The traditional approaches to poor blood glucose control involving a stricter and more intensive monitoring of the diabetic management may increase the risk for disordered eating (Colton et al, 1999). For this reason, it is recommended a less rigid approach in the insulin regimen and nutrition therapy to improve DEB. Lowering the amount of time spent on diabetes management during the day may help to lessen stress associated with the diabetes, which may in turn help alleviate DEB. Krokoff (Krokoff, 1991) suggested that self-destructive insulin manipulation within the context of an ED may also be an indirect call for help, signaling the need for more parental/adult intervention in patient's

Trento et al, (Trento et al, 2009) suggest that offering a carbohydrate counting program within a group care management approach may help patients with type 1 diabetes acquire

Technological advances can also be used to address specific treatment issues seen in these patients. For example, the first challenge that most patients face is weight gain associated with insulin restart. Patients need to be taught to indentify insulin edema, which may make them feel fat, bloated and uncomfortable, as temporary water retention that is different from the development of fatty tissue. Special tools designed to measure water-related weight versus lean muscle mass versus fat mass could help patients tolerate the temporary weight gain related to edema (Goebel-Fabbri 2008). Additionally, newer insulin analogs show evidence of improving weight profiles which could be of help (Goebel-Fabbri 2008; Russell-

The dietician must balance the difficult tasks of providing diabetes education, ED education, writing meal plans and defining weight goals for patients and families (Anzai et al, 2002; Krakoff, 1991). The challenge presents when trying to balance the goal of slow weight gain and /or maintenance with diabetes meal planning. As the patient continues to increase calorie intake, insulin doses will need to be adjusted to match the amount of food eaten avoiding hyperglycemia. It is recommend a realistic goal of good blood glucose control instead of optimal blood glucose levels as the body readjusts to refeeding and the patient begins to benefit from psychotherapy. Multiple daily injections regimens that use insulin to carbohydrate ratios provide greater flexibility with meal times and amounts of food but do require increased blood glucose monitoring and insulin injections. Such intense diabetes management may increase the potential for disordered eating as the child or adolescent must think constantly about the effects of food, insulin and exercise on his or her blood glucose levels. This may not be an ideal approach to diabetes meal planning during the treatment and recovery from the ED. As the individual's physical and psychological health improves, the incorporation of more flexible meal-planning strategies may be useful. Care professionals, including nutrition therapists and diabetes educators, should be sensitive to weight-related changes and concerns in youth with type 1 diabetes. It is important for all health care professionals to be aware that weight loss may be related to glycaemia control.

better self-efficacy and restructure their cognitive and lifestyle potential.

from the 12- to 24-month period. The results suggested the value of parent-adolescent partnership in diabetes management.

The results of the mentioned studies of coping skills training and problem-solving interventions in children, and adolescents with diabetes, as well as parents of children with diabetes, have demonstrated that these interventions are effective in assisting people to improve diabetes self management and to achieve better diabetes outcomes (Grey & Berry, 2004).
