It’s The Obstacles You Can’t
See That Can Be Dangerous:
Psychological Factors in
Diabetes
Jody Thomas, Ph.D.
Licensed Clinical Psychologist
Children’s Health Council
Stanford, CA
People instinctively move toward
health. Your job is not to “fix”
them. It is your job to remove
the obstacles and give them the
tools to fix themselves.
PSYCHOPATHOLOGY



Rates of pathology do not appear to be much
greater than they are in the general population.
The impact of the pathology, however, can be
much greater and more disruptive to health care.
Higher levels of depression are associated with
higher A1c’s and increased number of
hospitalizations.
Higher levels of parent anxiety are associated
with higher A1c’s, and lower child motivation for
self care.





Depression: lack of motivation,
hopelessness, helplessness, selfinjury/suicidality
Anxiety: can lead to hyper vigilance
and/or avoidance
Eating Disorders: both anorexia and
restricted eating patterns.
PTSD: dissociation, depressed mood,
lack of attachment to the body
ADHD: difficulty with organization
Skills needed for good
diabetes management:








Ability to appreciate future consequences
Impulse control
Delay of gratification
Consistent good judgment
High degree of social skill finesse
Great time management
Sense of personal responsibility
Good sense of self
Skills kids are still
developing and
completely normally
generally don’t have:








Ability to appreciate future consequences
Impulse control
Delay of gratification
Consistent good judgment
High degree of social skill finesse
Great time management
Sense of personal responsibility
Good sense of self
Aspects of normal development that
make management challenging:






Testing limits
Increasing desire for independence
Developing good judgment through trial
and error
Increased desire to fit in with social
groups
Struggles with identity development
Sense on invulnerability
ADJUSTMENT PROCESS



Adjustment is an ongoing process that is
constantly changing: there are different issues
at different points in time for the child and the
parent.
An enormous amount of information and
education is required at initial diagnosis.
Diagnosis typically occurs during crisis, and is
an intense emotional experience, which can
interrupt the learning/adjustment process.
Parent process is very different from
the child process, though they play off
each other.
 Denial, anger, sorrow, and fatigue
often hit at different times for both
child and caregivers.
 Normal child development often
causes problems with disease
management.

ADHERENCE
INFORMATION
MOTIVATION
BEHAVIORAL SKILLS
DESIRED
HEALTH
BEHAVIOR
INFORMATION




Basic knowledge about disease
Personal beliefs and constructs about the
disease
There are often gaps in knowledge,
particularly when the child is diagnosed at
an early age.
Constantly evolving technology makes it
difficult to keep up and use it effectively.
MOTIVATION
Personal motivation:
 Personal worth put on short and
long term consequences
 “Cost” of good self care vs. “cost” of
longer term consequences.
 Social motivation:
 Perceptions of family attitudes
 Perceptions of peers attitudes

BEHAVIORAL SKILLS











Testing blood sugar
Counting carbs
Adjusting insulin doses
Knowing how to manage situations (ketones, etc), and
appropriately problem solving
Carrying necessary equipment
Determining emergent from non-emergent situations
Negotiating and collaborating with parents
Self-advocating and collaborating with the medical team
Navigating social situation and managing peer
interactions
Dealing with disease in the school environment
Recognizing patterns in their blood sugars, and adjusting
their care accordingly
PARENT BEHAVIORAL SKILLS












Basic care skills (similar to kids)
Determining emergent from non emergent situations
Communicating effectively with child
Collaborative problem solving with child
Scaffolding but not controlling care
Controlling judgment behaviors
Giving up control over care at the “right” pace
Collaborating with medical teams
Dealing with schools, including possibly arranging 504
plans
Trusting your child
Allowing for imperfection
Separating your child from their behavior
FAMILY DYNAMICS




Parents attitudes and ideas influence
child’s attitude and management, both
positively and negatively
Differing levels of parental involvement are
common and often cause problems
Over control often fosters resentment
Successful dynamics require change and
adjustment over time







Efficacious communication patterns must
be established
Over dependence on numbers (blood
sugar levels and A1c) leads to difficulties
Shame vs. empowerment
Power struggle vs. collaboration
Guilt is often a major theme
Disease can be distraction from others
issues at play
Sibling issues require attention