Type 1 diabetes mellitus (T1DM) is one of the most common chronic, unremitting medical conditions that develops in childhood or adolescence.1 There is a bimodal age of onset, with the first peak at 4 to 6 years and the second peak in early adolescence.2
Classic T1DM is an autoimmune disease that occurs because of loss of insulin production by the pancreas as a result of destruction of the beta cells. Ideal treatment requires close monitoring of blood glucose levels by finger pricks 5 to 10 times daily and insulin injections with all carbohydrate intake and as often as every 2 hours for corrections of blood glucose levels. Basal insulin injections are also needed once or twice daily. A subcutaneous insulin pump can substitute for multiple injections in some cases.
Children with T1DM are at increased risk for other autoimmune diseases, such as celiac disease, autoimmune thyroid disease, and adrenal insufficiency. First-degree relatives of those with TIDM are at increased risk for this disease. For those afflicted with celiac disease, dietary modifications necessitate a gluten-free diet in addition to the recommended restrictions for simple sugars and the need to avoid grazing. Needless to say, for the child or teen with both T1DM and celiac disease, the dietary modifications can significantly affect the quality of their lives (eg, no pizza with friends, no cake and ice cream at birthday parties, and no on-the-go diet favored by teens).
Poorly controlled T1DM can lead to potentially life-threatening short- and long-term conditions that range from subtle neurocognitive changes to organ-destroying macrovascular and microvascular damage (Table 1).3 The age at onset of the illness has implications for complications that can arise from hypoglycemia (tremor, confusion, seizures) and hyperglycemia (nocturia, ketoacidosis, coma, microvascular changes). Neurocognitive changes from hypoglycemic or hyperglycemic episodes can be both acute and chronic (Table 2).4-6
The preschool-age child is more prone to hypoglycemic episodes that may lead to problems with spatial memory deficits, compromised cognitive function, and lower gray matter volume in the left superior temporal region. Fortunately, treatment for T1DM has advanced greatly over the past 10 years, and medications such as insulin detemir have greatly reduced the risk of severe nocturnal hypoglycemia.7 With the increased risk of hypoglycemic episodes for the preschool-age child with T1DM, the struggle with care and dietary control as the child transitions into school may occur. Determining what is behavioral and what is a short-term complication can be a challenge.
T1DM was diagnosed when Timmy was 3½ years old. He had a severe episode of hypoglycemia when he was 4, and his parents were instructed to “let his sugars run a little high.” As he was getting older, he was able to clearly tell his parents when his sugar was low, and more strict control was instituted. In first grade, with less supervision in the cafeteria, Timmy learned to sneak favorite higher-sugar foods, which resulted in more aggressive behavior, difficulty in sitting still, and acting more “wild.” His parents reported difficulties with adhering to dietary recommendations and with his tendency to “get wild” when he couldn’t get away with unapproved foods or behaviors. Despite this, his glucose monitoring results were in accordance with treatment guidelines. His parents and school worked with a pediatric psychologist to establish a positive behavioral system that resolved Timmy’s behavior problems.
Older children and adolescents are less vulnerable to nocturnal hypoglycemia and to neurocognitive changes. The consequences of longer-term poorly controlled diabetes, as evidenced by elevated hemoglobin A1c levels associated with microvascular changes, such as renal failure, retinopathy, and neuropathies, usually do not present until early adulthood.
The impact of chronic illnesses for children and adolescents and their family functioning has been well described since the 1970s, and studies of psychiatric comorbidity have been reported since the 1980s.
Treatment for type 1 diabetes mellitus (T1DM) has progressed remarkably over the past 10 years with insulin pumps and continuous glucose monitoring, yet challenges remain for affected youths and their families. This article summarizes recent findings on neuropsychological effects of short- and long-term consequences of hypoglycemia and hyperglycemia, use of evidence-based family treatments for families struggling with T1DM, and the impact of psychiatric comorbidity on outcomes for the patient with T1DM and family members.
For the psychiatrist treating a child or family member with T1DM, assessing the functioning of the family and the patient for psychiatric comorbidity is vital. Teasing out behavioral challenges from the disease necessitates close contact with the medical care providers. Evidence-based treatments, such as multisystemic treatment, cognitive-behavioral therapy, psychoeducation, and prudent psychopharmacology, are tools for the psychiatric provider.
Family and developmental issues
The diagnosis of T1DM can be devastating to both the child and family. Family functioning is stressed by the treatment regimen that may be uncomfortable and painful and out of alliance with the normal tasks of development. Because of the potential for immediate life-threatening complications of poorly controlled diabetes, family members must readjust their approach to daily living.
At the time of diagnosis, parents and older children are faced with the daunting task of learning a great deal of information rapidly and the need to shift priorities to include glucose monitoring and insulin administration. Because of dietary restrictions, meal structure and appropriate food choices also become more difficult. Children with T1DM are expected to follow up with the diabetes care team at least every 3 months and sometimes more often if they or family members cannot maintain tight glycemic control.
The impact at the time of diagnosis on the family is often one of shock followed by acceptance. Some parents may experience varying levels of anxiety and depression weeks to months after the diagnosis.8
The impact of family functioning on childhood T1DM was described by Minuchin and colleagues9,10 in the 1970s. They described families with a diabetic child as vulnerable to 4 maladaptive transactional patterns: enmeshment, overprotectiveness, rigidity, and lack of conflict resolution. In addition, Minuchin’s group reported that stressful family interactions could lead to immediate elevations in the patient’s blood glucose levels.
1. SEARCH for Diabetes in Youth Study Group, Liese AD, D’Agostino RB Jr, Hamman RF, et al. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:1510-1518.
2. Felner EI, Klitz W, Ham M, et al. Genetic interaction among three genomic regions creates distinct contributions to early- and late-onset type 1 diabetes mellitus. Pediatr Diabetes. 2005;6:213-220.
3. Fritsch SL, Overton MW, Robbins DR. The interface of child mental health and juvenile diabetes mellitus. Child Adolesc Psychiatr Clin N Am. 2010;19:335-352, ix.
4. Desrocher M, Rovet J. Neurocognitive correlates of type 1 diabetes mellitus in childhood. Child Neuropsychol. 2004;10:36-52.
5. Hershey T, Perantie DC, Warren SL, et al. Frequency and timing of severe hypoglycemia affects spatial memory in children with type 1 diabetes. Diabetes Care. 2005;28:2372-2377.
6. Perantie DC, Lim A, Wu J, et al. Effects of prior hypoglycemia and hyperglycemia on cognition in children with type 1 diabetes mellitus. Pediatr Diabetes. 2008;9:87-95.
7. Braun D, Konrad D, Lang-Muritano M, Schoenle E. Improved glycemic control and lower frequency of severe hypoglycemia with insulin detemir; long-term experience in 105 children and adolescents with type 1 diabetes. Pediatr Diabetes. 2008;9(4, pt 2):382-387.
8. Northam E, Anderson P, Adler R, et al. Psychosocial and family functioning in children with insulin-dependent diabetes at diagnosis and one year later. J Pediatr Psychol. 1996;21:699-717.
9. Minuchin S, Baker L, Rosman BL, et al. A conceptual model of psychosomatic illness in children. Family organization and family therapy. Arch Gen Psychiatry. 1975;32:1031-1038.
10. Minuchin S, Fishman HC. The psychosomatic family in child psychiatry. J Am Acad Child Psychiatry. 1979;18:76-90.
11. Lewandowski A, Drotar D. The relationship between parent-reported social support and adherence to medical treatment in families of adolescents with type 1 diabetes. J Pediatr Psychol. 2007;32:427-436.
12. Anderson BJ, Holmbeck G, Iannotti RJ, et al. Dyadic measures of the parent-child relationship during the transition to adolescence and glycemic control in children with type 1 diabetes. Fam Syst Health. 2009;27:141-152.
13. Cohen DM, Lumley MA, Naar-King S, et al. Child behavior problems and family functioning as predictors of adherence and glycemic control in economically disadvantaged children with type 1 diabetes: a prospective study. J Pediatr Psychol. 2004;29:171-184.
14. Ellis DA, Frey MA, Naar-King S, et al. Use of multisystemic therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control: a randomized controlled trial. Diabetes Care. 2005;28:1604-1610.
15. Ellis DA, Templin T, Naar-King S, et al. Multisystemic therapy for adolescents with poorly controlled type I diabetes: stability of treatment effects in a randomized controlled trial. J Consult Clin Psychol. 2007;75:168-174.
16. Anderson BJ, Brackett J, Ho J, Laffel LM. An office-based intervention to maintain parent-adolescent teamwork in diabetes management. Impact on parent involvement, family conflict, and subsequent glycemic control. Diabetes Care. 1999;22:713-721.
17. Court JM, Cameron FJ, Berg-Kelly K, Swift PG. Diabetes in adolescence. Pediatr Diabetes. 2008;9(3, pt 1):255-262.
18. Northam EA, Matthews LK, Anderson PJ, et al. Psychiatric morbidity and health outcome in Type 1 diabetes—perspectives from a prospective longitudinal study. Diabet Med. 2005;22:152-157.
19. Kovacs M, Goldston D, Obrosky DS, Bonar LK. Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care. 1997;20:36-44.
20. Kovacs M, Feinberg TL, Paulauskas S, et al. Initial coping responses and psychosocial characteristics of children with insulin-dependent diabetes mellitus. J Pediatr. 1985;106:827-834.
21. Kanner S, Hamrin V, Grey M. Depression in adolescents with diabetes. J Child Adolesc Psychiatr Nurs. 2003;16:15-24.
22. Jones JM, Lawson ML, Daneman D, et al. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ. 2000;320:1563-1566.
23. Powers SW. Empirically supported treatments in pediatric psychology: procedure-related pain. J Pediatr Psychol. 1999;24:131-145.
24. Dahan A, McAfee SG. A proposed role for the psychiatrist in the treatment of adolescents with type I diabetes. Psychiatr Q. 2009;80:75-85.
25. Goodnick PJ, Henry JH, Buki VM. Treatment of depression in patients with diabetes mellitus. J Clin Psychiatry. 1995;56:128-136.
26. Duncan GE. Prevalence of diabetes and impaired fasting glucose levels among US adolescents: National Health and Nutrition Examination Survey, 1999-2002. Arch Pediatr Adolesc Med. 2006;160:523-528.
27. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549-1555.
28. McIntyre RS, Jerrell JM. Metabolic and cardiovascular adverse events associated with antipsychotic treatment in children and adolescents. Arch Pediatr Adolesc Med. 2008;162:929-935.
29. Correll CU, Manu P, Olshanskiy V, et al. Cardiometablolic risk of second-generation antipsychotic medications during first-time use in children and adolescents [published correction appears in JAMA. 2009;302:2322].