Child Adjustment to Type 1 Diabetes

A considerable amount of research has been conducted over the past three decades that examines youth adjustment to type 1 diabetes. Collectively, the extant research suggests that many of these children are well adjusted across multiple domains of emotional and behavioral functioning (e.g., Dela-mater 2007; Jacobson et al. 1997; Johnson 1980). At the same time, a consistent subset of youth with type 1 diabetes appears to be at risk for developing significant adjustment difficulties, particularly depression, anxiety, and eating disorders (e.g., Kovacs et al. 1997). However, the relative risk to these individuals for developing a significant mental disorder and the extent to which their disease directly or indirectly contributes to psychiatric symptomatology remain to be determined. Indeed, some of these youth may have experienced premorbid adjustment problems and family dysfunction prior to the diagnosis of type 1 diabetes. Although Kovacs et al. (1997) found relatively high rates of major depression and anxiety disorders over a 10-year period after diagnosis (27% and 12%, respectively), others have found psychiatric rates to be no higher than in healthy controls (Jacobson et al. 1997). Still other researchers have found no differences between youth with type 1 diabetes and healthy controls on various dimensions of psychosocial maturation (Pa-coud et al. 2007). Interestingly, Martínez-Aquayo et al. (2007) found that younger high school students (grades 8-10) with type 1 diabetes used less alcohol, tobacco, and illicit drugs than did healthy controls. By grades 11 and 12, however, their use was comparable to (but not greater than) that of healthy peers. Although tempting to conclude that youth with type 1 diabetes are therefore no more at risk for psychiatric disturbance or drug and alcohol use than their healthy peers, one could also argue that the health risks associated with such psychiatric disorders are substantially higher when one has diabetes and that a more aggressive approach should be taken in terms of prevention and intervention. Furthermore, to the extent that these children do exhibit adjustment problems, the risk of nonadherence, glycemic control problems, and school absenteeism; the need for home health visits; and the rate of hospitalization are increased significantly (e.g., Chisholm 2003; Korbel et al. 2007).

Decades ago, Johnson (1980) argued cogently that perhaps the most fruitful (and clinically relevant) approach to examining adjustment to type 1 diabetes is to identify the multiple interrelated factors that are associated with or predict such difficulties. Since that time, a large number of risk factors for adjustment problems have been documented. Children who exhibit adjustment problems soon after diagnosis are at higher risk for future adjustment problems (e.g., Kovacs et al. 1995). High family conflict and dysfunction not only appear to place youth at risk for psychiatric problems but also predict metabolic control and diabetic ketoacidosis. Girls are more likely than boys to receive a psychiatric diagnosis as well (Northam et al. 2004), although gender bias and cultural issues may well play a role in this diagnostic pattern. Delamater (2007) noted that single-parent status and low income have been implicated in glycemic control problems and, therefore, should also be seen as potential risk factors for adjustment difficulties.

Parenting style has also been identified as a risk factor, with higher levels of maternal control being associated with higher levels of depressed mood in older adolescents with type 1 diabetes (Butler et al. 2007). Higher levels of parental overprotectiveness have been associated with greater depressive symptomatology in younger children with type 1 diabetes, with this relationship being magnified under conditions of greater parenting stress (Mullins et al. 2004). Mothers' and children's appraisals of involvement in coping with the stressors associated with type 1 diabetes have also been linked to adjustment. Berg et al. (2007) found an inverse relationship between a child's perception of his or her mother's supportive involvement and depressive symptoms. They further found that the mother's and child's perceptions of lower involvement with each other's stressors were associated with greater depressive symptoms and less positive mood. Clearly, a large number of personal, familial, cognitive, and environmental factors may place a child at risk.

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