Can teaching coping skills to adolescents with diabetes improve their blood sugar control and quality of life?

A nurse-led behavioral intervention to teach coping skills for stresses associated with intensive diabetes management helped adolescents achieve better blood sugar control and improvement in quality of life as compared with a similar group of youth engaged in intensive diabetes management only.

Why is this important?

Each year, about 13,000 children and adolescents are diagnosed with type 1 diabetes, in which the body does not produce insulin necessary to digest sugar and other food (LaPorte et al. 1995). The Diabetes Complications and Control Trial demonstrated a 50 percent lower risk of developing eye disease after seven years among adolescents who reduced their average hemoglobin A1c level to about 8 percent (DCCT Research Group 1994).

The physical, emotional, and social demands of intensive diabetes self-management—which requires monitoring blood sugar, regulating diet and exercise, and making multiple insulin injections daily—are challenging for adolescents given developmental changes and stresses (Grey et al. 1999). As a result, adolescents with diabetes are at risk for poor disease control leading to hospitalizations and long-term complications, such as eye, kidney, and nerve damage (Silverstein et al. 2005).

Interventions

This study included 77 adolescents (ages 12 to 20 years) attending the Yale Children's Diabetes Clinic who were receiving intensive diabetes team management, including monthly visits at a specialty clinic and telephone follow-up.

One-half of the teens were randomly selected to receive coping skills training during four to eight weekly small group sessions, followed by monthly booster sessions, to increase their "sense of competence and mastery by retraining inappropriate or non-constructive coping styles and forming more positive styles and patterns of behavior" (Grey et al. 2000).

A nurse practitioner with experience in pediatric psychiatry and diabetes led teens in role-playing to model and give feedback on appropriate behavior in various social situations identified as problematic by youth, such as managing food choices with friends, decision-making about drugs and alcohol, and handling conflicts (Grey et al. 1999).

Findings

Hemoglobin A1c test results (which give a two- to three-month average reading of blood sugar control) were nearly identical at the start of the study among youth selected to receive coping skills training (intervention group) and those who did not (control group). One year after the start of the intervention:

• Average glycemic (blood sugar) control improved more in the intervention group than the control group (1.6 vs. 0.7 percentage point reduction in hemoglobin A1c level). A one percentage point reduction in this test is associated with a 15 to 30 percent reduction in risk of developing long-term diabetes complications (Stratton et al. 2000).
• Average quality of life impact score improved in the intervention group (13 percent lower perceived impact of diabetes) but worsened in the control group (9 percent higher impact), such that the average score was 14 percent better for teens who received coping skills training than for the control group after one year (Grey et al. 1999).

Implications

An individual's ability to cope with a chronic disease influences the success of treatment (Lazarus and Fokman 1984). Adding a behavioral intervention to intensive diabetes management improves disease control and quality of life for adolescents.

Improvement Ideas and Resources

Additional resources on diabetes management for teens are available from the American Diabetes Association and the National Diabetes Education Program.

Measure:

Adolescent patients (ages 12 to 20 years) attending a university-affiliated diabetes clinic were invited to participate in this randomized controlled trial if they had no other health problems except for treated hypothyroidism, had been taking insulin for at least one year, had recent hemoglobin A1c between 7 percent and 14 percent, had no severe hypoglycemic events in the past six months, and were in school grade appropriate to their age within one year. Between November 1, 1995, and December 1, 1997, 77 of 105 invited patients agreed to participate and were randomly assigned to control or intervention groups; there were no significant differences between participants and non-participants or between control and intervention groups on measured variables at baseline. Diabetes care providers and data collectors were blinded to study group assignment. Analysis of variance for repeated measures and simple post hoc contrast tests found that average hemoglobin A1c levels and quality-of-life scores (measured using the Diabetes Quality of Life: Youth instrument) improved significantly more over time and were significantly different at six months and 12 months for the intervention group compared with the control group (Grey et al. 2000).

Limitations:

The study involved a small number of patients in an academic setting and may not be generalizable to other settings; further demonstrations are needed in routine practice.

Source:

Clinical data and youth self-reports from the ABCs of Diabetes Study (Adolescents Benefit from Control of Diabetes), conducted by researchers at the Yale University School of Nursing and School of Medicine and the Children's Clinical Research Center, New Haven, Conn. (Grey et al. 2000; Grey et al. 1999; personal communication with Margaret Grey 2003).

References:

* Indicates source of data used in the chart(s).DCCT Research Group (Diabetes Control and Complications Trial Research Group). 1994. Effect of Intensive Diabetes Treatment on the Development and Progression of Long-Term Complications in Adolescents with Insulin-Dependent Diabetes Mellitus. The Journal of Pediatrics 125(2): 177–88.

Grey, M., E. A. Boland, M. Davidson et al. 2000. Coping Skills Training for Youth with Diabetes Mellitus has Long-Lasting Effects on Metabolic Control and Quality of Life. The Journal of Pediatrics 137 (1): 107–13.

* Grey, M., E. A. Boland, M. Davidson et al. 1999. Coping Skills Training for Youths with Diabetes on Intensive Therapy. Applied Nursing Research 12 (1): 3–12.

LaPorte, R. E., M. Matsushima, and Y.-F. Chang. 1995. Prevalence and Incidence of Insulin-Dependent Diabetes. In Diabetes in America, ed. National Diabetes Data Group, 37–46. Bethesda, Md.: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.

Lazarus, R. S., and S. Fokman. 1984. Coping and Adaptation. In The Handbook of Behavioral Medicine, ed. Gentry, W. D., 282–325. New York, N.Y.: Guilford.

Silverstein, J., G. Klingensmith, K. Copeland et al. 2005. Care of Children and Adolescents with Type 1 Diabetes: A Statement of the American Diabetes Association. Diabetes Care 28 (1): 186–212.

Stratton, I. M., A. I. Adler, H. A. Neil et al. 2000. Association of Glycaemia with Macrovascular and Microvascular Complications of Type 2 Diabetes (UKPDS 35): Prospective Observational Study. BMJ 321 (7258): 405–12.