Type 1 Diabetes Among Adolescents

Transcription

1 465 Type 1 Diabetes Among Adolescents Reduced Diabetes Self-Care Caused by Social Fear and Fear of Hypoglycemia Purpose The aim of this study was to examine the association between social anxiety and adherence to diabetes self-care and quality of life and to determine the effects of fear of hypoglycemia on these associations in adolescents with type 1 diabetes. It is hypothesized that (1) social anxiety will be negatively associated with adherence and quality of life and (2) that fear of hypoglycemia will mediate this relationship. It is also hypothesized that (3) girls will have higher social anxiety than boys. Methods Adolescents with type 1 diabetes were recruited during clinic visits at 2 international centers. Participants answered a survey containing questionnaires on social anxiety, behavioral adherence to the diabetes self-care regimen, quality of life, fear of hypoglycemia, and last hemoglobin A1C results. Results Seventy-six adolescents (33 boys, 43 girls), mean age 15.9 (1.44) years, participated. Social anxiety levels are not statistically different between genders. In boys, social anxiety is associated with worse diet and insulin injection adherence; no associations are found in girls. Social anxiety is positively correlated with poor quality of life in both genders. Fear of hypoglycemia mediates the Ashley M. Di Battista, MA Trevor A. Hart, PhD Laurie Greco, PhD Jan Gloizer, RN From University of Melbourne, Department of Psychology, Melborne, Australia (Ms Di Battista); Ryerson University, Toronto, Ontario, Canada (Dr Hart), University of Missouri Saint Louis, Department of Psychology, Saint Louis, Missouri (Dr Greco); and North York General Hospital, Diabetes Education Centre, Branson Site, Toronto, Ontario, Canada (Ms Gloizer). Correspondence to Ashley M. Di Battista, MA, Department of Psychology, School of Behavioural Science, 12th Floor, Redmond Barry Building. The University of Melbourne, Victoria 3010, Australia ( ashleydibattista@gmail.com). DOI: / The Author(s)

2 The Diabetes EDUCATOR 466 relationship between social anxiety and insulin adherence in boys. Conclusions Findings suggest that social anxiety, which is common in general populations of adolescents, may interfere with behavioral adherence and quality of life among adolescents with type 1 diabetes. Screening and treatment of social anxiety may result in better adherence and increased quality of life. Despite the necessity for adherence to medical self-care regimens among patients with type 1 diabetes, adherence to the multifaceted self-care regimen is estimated to be only 45% during the adolescent years. 1 Low adherence levels and habits in adolescence often continue into young adulthood, 2 suggesting the potential for benefit in promoting adherence earlier in adolescents with type 1 diabetes. Many elements contribute to the poor adherence rates in adolescents, including but not limited to pubertal hormonal changes, emotional distress, increasing need for autonomy, and, in some cases, onset of eating disorders and insulin omission aimed at weight control. 3-6 In addition to these adherence limiting factors, the social implications of diabetes (both its medical management and symptoms) may affect adherence. Social concerns are of particular relevance in this age group given the emphasis on fitting in with same-aged peers during adolescence. 7 Recent literature suggests that perceptions of peer reactions are important in predicting child and adolescent adherence to type 1 diabetes regimens Specifically, perceptions of disapproval from peers in social situations may be important in predicting problems with self-care regimen adherence among adolescents with type 1 diabetes Many adolescents with diabetes worry about negative peer reactions to glucose-testing and diet limitations, including avoidance of forbidden foods that contain high concentrations of sugar. 11 Low adherence rates have also been linked to fear of hypoglycemic episodes. 14 Fear of hypoglycemia (FoH) involves both fear of the negative acute health consequences of an episode (ie, loss of consciousness, nausea, shaking) and fear of social reprisal for behavioral, motor, and cognitive changes that occur during an episode. 14 FoH has been reported in patients with frequent hypoglycemia, with linkages to anxiety and phobia about future hypoglycemic events. 14,15 FoH has important implications for adherence, because patients may engage in preventive attempts to control hypoglycemia that include maintaining hyperglycemia or engaging in excessive overtreatment of low blood glucose. 16 The social concerns that can limit adherence, because of general fear of negative peer reactions to adherence itself or specifically to the negative effects of a hypoglycemic episode, are consistent with components of a psychological state called social anxiety. 17,18 Social anxiety involves a fear and avoidance of social situations as well as self-critical evaluations while in the presence of others Not surprisingly, social anxiety is prevalent during adolescence, a period marked by social pressures and the desire to belong to a social group. 7 Social anxiety has been documented in otherwise healthy children and adolescents 17,18,22,23 as well as in those with health conditions, including those diagnosed with epilepsy, attention deficit hyperactivity disorder, anorexia nervosa, bulimia nervosa, and endocrine disorders Social concerns have been reported in youth with type 1 diabetes To date, no studies have examined the potential for social anxiety to negatively affect adherence to the self-care regimen in adolescents with diabetes despite the fact that self-care regimens require engaging in observably different-than-normal behavior (eg, glucose testing, dietary restrictions, insulin injection). The potential for social anxiety to influence adherence in adolescents with type 1 diabetes is high, given that they are still subject to social pressures to conform to peer norms but are required to engage in observably different behaviors to adhere to their self-care regimen. The effect of social anxiety on adherence therefore warrants proper investigation in this group, as it has been associated with reduced quality of life and impaired social development among adolescents in normative samples. 29 Given previous findings regarding social concerns about being negatively evaluated in this population, this study hypothesizes that a relationship exists between social anxiety and adherence in adolescents with type 1 diabetes. Specifically, it is hypothesized (1) that social anxiety would be negatively associated with diabetes adherence behaviors and quality of life and (2) that fear of hypoglycemia would mediate the relationship between Volume 35, Number 3, May/June 2009

3 467 social anxiety and diabetes adherence behaviors. Given that girls experience higher social anxiety than boys in normative samples of adolescents, 17,30,31 a secondary hypothesis was (3) that girls would have higher social anxiety than boys. Methods Participants Participant recruitment was ongoing from May 2004 to April Participants were recruited from 2 pediatric outpatient diabetes clinics, the Vanderbilt University Medical Center s Pediatric Diabetes Clinic in Nashville, Tennessee, and the North York General Hospital Diabetes Education Centre in Toronto, Ontario, Canada. Research was approved by the Human Participants Research Committee at York University, the Research Ethics Board at the North York General Hospital, and the Institutional Research Board at Vanderbilt University. Eligibility criteria required that participants were between 13 and 18 years of age, competent in English, and diagnosed with type 1 diabetes more than 6 months from the date of participation. Participants received $10 in US or Canadian dollars, depending on the study site, as an incentive for involvement in this study. Informed consent was required from all participants aged 16 and over, and informed assent was required from participants younger than 16 in addition to parental/legal consent. Procedure Adolescents and their parents were approached in person at both institutions by trained research staff, who followed the same verbal script and emphasized anonymity of responses. Interested participants signed letters of consent (participants <16 years of age required additional parental consent to participate in this study). Following consent and assent, adolescents were escorted to an interview room where they were given the questionnaire packet. Trained research staff was readily available to answer questions. Measures Social Anxiety. Social anxiety was assessed using the Social Anxiety Scale for Adolescents. 32 The SAS-A is a self-report measure that assesses adolescents social anxiety in the context of their peer relations. 32 The SAS-A is an 18-item self-report scale using a 5-point Likert-type scale. The SAS-A contains 3 subscales and 1 total score: Fear of Negative Evaluation (FNE), which assesses fear of negative peer evaluation; General Social Avoidance and Distress (SAD-G), which assesses the amount of social avoidance and distress experienced in the company of peers in general situations; Social Avoidance and Distress in New Situations (SAD-N), which assesses the amount of social avoidance and distress specific to new situations or unfamiliar peers; and the Total Social Anxiety Score (SAS-TOT), which sums the responses to each of the subscales to provide an overall index of social anxiety. Total scores >50 are indicative of clinically significant social anxiety in adolescents. Total scores 36 or lower represent low social anxiety. The SAS-A was developed for use in adolescents and has been used in both clinical (cancer, anxiety disorders, neurofibromatosis) and nonclinical samples. 17,30,33-37 The SAS-A subscales demonstrate acceptable to good internal consistency (range of α = ) 32 and adequate test retest reliability at 2 months ( ) and at 6 months ( ). 32 Diabetes Quality of Life. The Diabetes Quality of Life Measure (DQoL) 38 was specifically designed for use in diabetes populations to assess feelings about diabetes care and its treatment from the patient s perspective. The measure includes 4 subscales, which assess satisfaction with treatment (Satisfaction subscale), the impact of diabetes treatment on one s life (Impact subscale), worry about future complications and effects of diabetes (Diabetes Worry subscale), and worry about how diabetes impacts social situations (Social Worry subscale). Adolescence specific questions are available and were added to the assessment, resulting in 60 self-report questions. The DQoL has been validated for use in adults and adolescents with type 1 diabetes. 39,40 All of the items are rated along a 5-point Likert scale. Items are reverse scored, so that higher scores indicate worse quality of life. Internal consistency ranges from Cronbach s α =.66 to.92 on the subscales and total score. 41 Test retest reliability after 1 week ranges from 0.88 to 0.92 across subscales and total quality of life. 41 Construct validity ranges from r = 0.36 to 0.81 (total score of the DQoL) with other established measures of quality of life in adolescents with diabetes, including the Symptom Checklist 90-R, the Bradburn Affect Balance Scale, and the Psychosocial Adjustment to Illness Scale. 41,42

4 The Diabetes EDUCATOR 468 Adherence to the Diabetes Self-Care Regimen. Adherence to the diabetes self-care regimen was assessed by the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire. 43 The SDSCA is a 12-item selfreport scale using a 4-point Likert-type response set. The SDSCA was specifically designed to assess frequency of engaging in diabetes self-care regimen requirements, including adherence to diet, exercise, glucose testing, and insulin injection. Raw scores for each question within a regimen domain (ie, insulin administration) are converted into standard scores (mean = 0 and standard deviation = 1), and then standardized scores are averaged to generate a composite score for each regimen behavior (thus all scales have equal weighting). Higher scores for each aspect of diabetes self-care reflect greater performance in engaging in those diabetes self-care behaviors. The SDSCA demonstrates reasonable test retest reliability at 6 months, with results ranging between 0.43 and The internal consistency of the measure is a = 0.47, which was assessed by average interitem correlations. 44 The SDSCA has been used in adolescent samples. 45 Fear of Hypoglycemia. The Hypoglycemia Fear Survey 46 is a 23-item self-report scale that was specifically designed for use in diabetic samples to assess individual fear of having a hypoglycemic episode among people with diabetes. The HFS contains 2 subscales that assess worry and fear about having hypoglycemic episodes (Worry/Fear subscale) and the behavioral (maladaptive and adaptive) management of hypoglycemia (Behavior/Avoidance subscale). The 2 subscales are summed in order to determine an overall index of fear of hypoglycemia (HFS total score). Each of the 23-items is rated on a 5-point Likert-type scale. The HFS demonstrates high internal consistency (α =.87) and moderate to high test retest reliability for the Behavior subscale (range, ) and 0.64 to 0.76 for the Worry subscale. 47 The HFS has been used with adolescents 48 and has demonstrated validity as a measure of change instrument via assessment of change in fear of hypoglycemia following hypoglycemia fear and event reductions. 49 A systematic review of the measure 14 also supports the psychometric properties of the HFS and its usefulness in studies on fear of hypoglycemia. Demographics and Medical Variables. Demographics and most recent hemoglobin A1C result were assessed by self-report. Participants were asked to indicate age, sex, ethnicity, parental income, school/work status, country of birth, duration of diabetes, and last hemoglobin A1C result. Data Analysis All data analysis was conducted using SPSS statistical software Sample characteristics and medical variables were examined according to means, standard deviations, and percentage of total. Results are stratified by sex given data suggesting different patterns of correlation between social anxiety 19 and self-care behaviors in girls versus boys. 50 Pearson correlations were computed to test the hypothesis that social anxiety would result in decreased adherence and diabetes related quality of life. Multiple regressions were performed to examine the relationship between social anxiety and self-care adherence and diabetes related quality of life. To test the hypothesis that fear of hypoglycemia would mediate the relationship between social anxiety and adherence behaviors, a multiple regression was performed with social anxiety on step 1 and fear of hypoglycemia on step 2 of the regression. To determine whether girls exhibited more social anxiety than boys, a 2-tailed t test was computed using SAS-A scores. Results Participants A total of 101 participants consented to partake in the study (n = 91 from the Vanderbilt University Medical Centre, n = 10 from the Diabetes North York General Hospital Diabetes Education Centre in Toronto). Data from 82 participants (45 female, 37 male) met the inclusion criteria and were eligible for analysis. The majority of participants were recruited from the Vanderbilt University Medical Center s Pediatric Diabetes Clinic in Nashville, Tennessee (n = 72 versus n = 10 from Toronto, Canada). Six participants were missing a significant amount of responses to their surveys (answered <85% of questionnaire and/or omitted 1 or more responses to the behavioral adherence questions) and were therefore excluded from further analysis. Thus, only 76 participants were examined in the final analyses: 43 female and 33 male, mean age 15.9 (1.44) years, age range 13 to 18 years. Ninety-one percent of the subjects were full-time students, whereas the remaining 9% were in part-time Volume 35, Number 3, May/June 2009

5 469 Table 1 Sample Characteristics Variable Girls, n = 43 (56.6%) Boys, n = 33 (43.4%) Total, N = 76 Age, y, mean (SD) (1.42) (1.45) (1.44) Ethnicity, % African American/African Canadian White Other Country of birth, % Canada USA Other Duration of diabetes, y, mean (SD) 6.34 (3.70) 6.52 (3.60) 6.42 (3.63) A1C, %, mean (SD) 8.88 (1.74) a 8.93 (2.04) a 8.90 (1.86) a Social anxiety total score, mean (SD) (11.43) (11.88) (11.70) a A1C: girls n = 42, boys n = 32, total N = 74. schooling with either part-time or full-time jobs. The average and median household income was $ to $ The mean income bracket represented 27.5% of the sample; 24.6% of the sample were below the $ bracket, 18.8% were in the $ to $ bracket, and 28.9% were in the $ bracket. In both the Canadian and American samples, A1C assays were taken the same day the questionnaire was completed. Of the 76 participants in the final study sample, A1C results were available for analysis for 74 participants (1 missing each from the male and female groups). A summary of demographic information is provided in Table 1. Correlations between social anxiety and other variables can be found in Table 2 for boys and Table 3 for girls. The average social anxiety scores for boys and girls were not clinically significant for social anxiety (SAS-Total not >50). However, girls were on average above the cutoff for low social anxiety (SAS-Total mean = 39.37, SD = 11.43). Boys average SAS-Total score were in the low socially anxious range (SAS-Total mean = 35.59, SD = 11.88). No statistically significant differences were found between boys and girls for social anxiety (t 74 = 1.41, P =.16) or adherence variables (insulin injection, t 74 = 0.94, P =.35; diet, t 74 = 1.64, P =.10; exercise, t 74 = 0.30, P =.77; glucose testing, t 74 = 0.74, P =.46). Social anxiety was not correlated with duration of diabetes or A1C results in boys or girls. Bivariate Associations Between Social Anxiety, Adherence, and Quality of Life Variables Social anxiety was associated with adherence behaviors in boys but not girls. Specifically, social anxiety was found to be negatively correlated with insulin (r = 0.39, P <.05) and dietary adherence (r = 0.50, P <.01) among boys. Social anxiety was positively correlated with poorer quality of life among both boys and girls (Tables 3 and 4). Boys did not have significant associations between social anxiety and Satisfaction or Diabetes Worry subscales, whereas girls social anxiety was positively correlated with all aspects of diabetes quality of life (satisfaction, r = 0.35, P <.05; impact, r = 0.51, P <.01; social worry, r = 0.57, P <. 01; diabetes worry, r = 0.30, P <.05; overall quality of life, r = 0.53, P <.01). Social

6 The Diabetes EDUCATOR 470 Table 2 Summary of Behavioral Adherence Variables The Summary of Diabetes Self-Care Activities Adherence Type Assessed Insulin injection Diet Glucose testing Exercise Question How many of your recommended insulin injections did you take in the last 7 days that you were supposed to? How often did you follow your recommended diet over the last 7 days? What percentage of the time did you successfully limit your calories as recommended for healthy eating for diabetes control? During the past week, what percentage of your meals included high-fiber foods, such as fresh fruits, fresh vegetables, whole grain breads, dried beans and peas, bran? Over the past week, what percentage of meals contained high-fat foods, such as butter, ice cream, oil, nuts and seeds, mayonnaise, avocado, deep-fried foods, salad dressing, bacon, other meat with fat or skin? Over the past week, what percentage of meals included sweets and desserts, such as pie, cake, jelly, soft drinks (regular, not diet), cookies? On how many of the last 7 days did you test your glucose? Over the last 7 days (that you were not sick) what percentage of the glucose tests recommended by your doctor did you actually perform? On how many of the past 7 days did you participate in at least 20 minutes of physical exercise? What percentage of the time did you exercise the amount suggested by your doctor? On how many of the last 7 days did you participate in a specific exercise session other than what you do around the house or as part of your work? anxiety was also positively correlated with the fear of hypoglycemia Worry/Fear subscale and total fear of hypoglycemia among both boys (worry/fear, r = 0.52, P <.01; total fear of hypoglycemia, r = 0.45, P <.01) and girls (worry/fear, r = 0.32, P <.05; total fear of hypoglycemia, r = 0.30, P <.05). Fear of Hypoglycemia as the Mechanism Explaining the Relation Between Social Anxiety and Adherence Given that among boys social anxiety was positively associated with fear of hypoglycemia and negatively associated with insulin administration adherence and that fear of hypoglycemia was negatively associated with insulin adherence, a mediation analysis was run to explore the potential for fear of hypoglycemia to mediate the relationship between social anxiety and adherence (see Figure 1). Among boys, a multiple regression was performed with social anxiety on step 1 and fear of hypoglycemia on step 2, with insulin administration adherence as the dependent variable. Step 1 was significant, F 1,26 = 9.97, P =.004, adjusted R² = Step 2 was also significant, F 1,25 = 4.41, P =.046, adjusted R² = The full model was significant, F 2,25 = 7.85, P =.002. In the final model, fear of hypoglycemia was an independent correlate of lower insulin adherence (semipartial r = 0.39, P =.046), but social anxiety was not (semipartial r = 0.32, P =.11). Discussion This study is the first to assess the role of social anxiety on behavioral adherence among adolescents with Volume 35, Number 3, May/June 2009

7 471 Table 3 Correlations Among Social Anxiety and Adherence, Quality of Life, and Fear of Hypoglycemia in Boys (n = 33) Social Anxiety Insulin Injection Glucose Testing Exercise Diet Social Anxiety * ** Satisfaction (QoL) a * Impact (QoL) b 0.54** 0.38* * Social Worry (QoL) 0.64** Diabetes Worry (QoL) c Overall QoL d 0.53** 0.44* Behavior (HFS) Worry/Fear (HFS) 0.52** 0.50** Total HFS 0.45** 0.38* Abbreviations: QoL, Diabetes Quality of Life Questionnaire; HFS, Hypoglycemia Fear Survey. Quality of Life Scores are reverse coded; therefore, higher scores reflect lower quality of life. a n = 30. b n = 31. c n = 32. d n = 28. *P <.05. **P <.01. Table 4 Correlations Among Social Anxiety and Adherence, Quality of Life, and Fear of Hypoglycemia in Girls, n = 43 Social Anxiety Insulin Injection Glucose Testing Exercise Diet Social Anxiety Satisfaction (QoL) 0.35* Impact (QoL) a 0.51** ** Social Worry b (QoL) 0.57** Diabetes Worry (QoL) 0.30* Overall QoL c 0.53** Behavior (HFS) Worry/Fear (HFS) 0.32* Total HFS 0.30* Abbreviations: QoL, Diabetes Quality of Life Questionnaire; HFS, Hypoglycemia Fear Survey. Quality of Life Scores are reverse coded; therefore, higher scores reflect lower quality of life. a n = 40. b n = 42. c n = 39. *P <.05.**P <.01.

8 The Diabetes EDUCATOR 472 (r =.45, p <.01) Fear of (r =.38, p <.05) Hypoglycemia Increased Social Anxiety (r =.39, p <.05) Decreased Insulin Adherence Figure 1. Administration adherence in adolescent boys with type 1 diabetes. Fear of hypoglycemia mediates the relationship between social anxiety and insulin. Step 1: social anxiety, F 1,26 = 9.97, P =.004, adjusted R ² = Step 2: fear of hypoglycemia, F 1,25 = 4.41, P =.046, adjusted R ² = Full model, F 2,25 = 7.85, P =.002. Fear of hypoglycemia was an independent correlate of lower insulin adherence (semipartial r = 0.39, P =.046), but social anxiety was not (semipartial r = 0.32, P =.11). Note: Bivariate correlations shown on figure. type 1 diabetes. Results partially support study hypotheses regarding social anxiety and behavioral adherence, given that social anxiety was associated with worse behavioral adherence to diet and insulin injection in adolescent boys but not girls with type 1 diabetes. Findings also suggested a mediating effect of fear of hypoglycemia on behavioral adherence among boys; specifically, fear of hypoglycemia was found to mediate the relationship between social anxiety and insulin adherence. Social anxiety was also found to significantly lower diabetes-related quality of life in both sexes. The impact of social anxiety on quality of life should not be underestimated, as data elsewhere support a link between reduced quality of life and depression. 51 Depression in persons with type 1 diabetes has been associated with poor glycemic control and hyperglycemia. 52,53 It is possible that there is a link between each of these factors (social anxiety, reduced quality of life, and depression) that can further impede the medical management and health of adolescents with type 1 diabetes. Limitations of the present study include the use of self-report measures for social anxiety, adherence, and A1C. Although self-report measures are often used in psychological and adherence research, it is possible that self-report does not accurately reflect real management strategies. However, other methods of assessment (observation of adherence) are invasive and more likely to result in socially desirable behavior (eg, performing more adherent behaviors than one usually would because one is being watched). Self-identifying information was not included on the questionnaire (did not retain names of participants) and participants were told that none of the information they provided would be revealed to their health care team or their parents. Although it is possible that patients exaggerated their adherence, it is unlikely given that adherence was not optimal in the majority of questionnaires. Although the present study has strength in its recruitment across 2 countries and within both a large and a small clinic, the sample size limits the generalizability of the study findings. The majority of participants were Caucasian and from the United States. The American sample was drawn from a large clinic (1600 patients, 80% type 1 diabetics, 24% of whom are 14 years of age or older), where the majority of patients (70%) are Caucasian. The sample is similar to the overall clinic in terms of ethnicity, but it is important to note that 30% of the American clinic s patients are on Medicaid, suggesting a lower socioeconomic status than those of the participants in this study. The Canadian sample (n = 10) was drawn from a small clinic in northern Toronto (22 adolescents between 14 and 18 years with type 1 diabetes at the time of recruitment). It is possible that these results do not generalize to persons of other ethnicities or socioeconomic statuses in North America or to all North American adolescents with type 1 diabetes. The sample size may also have limited the ability to detect gender differences in social anxiety. The study only provides data from adolescents interested in participating and may therefore reflect a bias in the sample. It is possible that the sample data are not generalizable to those adolescents who were uninterested in participating in research. However, this is a common limitation in research involving children and adolescents, and it is not unusual for adolescent samples to lack strong motivation to participate. Importantly, the tendency toward motivation to participate did not appear to bias the sample toward inflated reports of appropriate self-care behaviors, as is seen in the findings indicating low adherence to some self-care behaviors. Investigators may wish to further examine whether social anxiety predicts later adherence using longitudinal data with both self-report and thirdparty report of adherence, such as by diabetes educators, other health care providers, or parents. Researchers may also wish to examine whether social anxiety predicts adherence after controlling for other psychological distress variables assessed in the literature, such as depression. 29,30 This study suggests a benefit in conducting research on attitudes toward adolescents with diabetes among normative Volume 35, Number 3, May/June 2009

9 473 samples, because stigma against engaging in diabetes adherence behaviors may increase social anxiety and nonadherence among adolescents with type 1 diabetes. More studies are needed on the relationship of FoH and social anxiety. It is unknown whether social anxiety may be increased because of previous severe hypoglycemic episodes, especially if the youth had a seizure or glucagon administration was required. FoH and anxiety among the parents of adolescents with diabetes may also influence adolescent social anxiety, adherence-related attitudes, and behaviors. Study findings suggest that social anxiety may be a significant contributor to behavioral adherence and quality of life in adolescents with type 1 diabetes. Discussion concerning social anxiety, as well as its assessment, could easily be worked into clinic visits via use of self-report measures such as the SAS-A. 32 Diabetes educators have an opportunity to engage patients in discussions about their fears regarding diabetes management in social situations, as well as fear of hypoglycemia, and provide problem-solving scenarios for both patients and parents to learn from. Gender-specific areas of concern regarding the effects of adolescent social anxiety can also be addressed, with insulin and diet adherence a special issue for boys and quality of life a special issue for both boys and girls. Implications for Diabetes Education The results of this study suggest that there may be a benefit to discussing and assessing, where necessary, social anxiety among girls and boys as well as perceptions of quality of life during clinic visits. Assessments can be conducted quickly in the clinic using the social anxiety scale for adolescents. 32 Importantly, this study included nonclinical, psychologically normal adolescents with type 1 diabetes. The results indicate that the adolescents with diabetes exhibited similar levels of SA found in nonclinical samples of adolescents. Although these results are preliminary, they suggest that typical adolescents with type 1 diabetes may experience concerns regarding their diabetes care in a social context. Discussing fears regarding social situations and diabetes management could provide useful discourse on how to prevent social unease and encourage proper management in a social setting. Discussions could incorporate problem-solving strategies, such as having the diabetes educator open up a dialogue with the adolescent regarding social concerns suggested by the patient: for example, Let s say you are going to a party and you knew that there would be a lot of cake/treats/candy to eat there. Let s come up with some strategies about how to avoid getting high blood glucose in a way that doesn t direct too much attention to yourself and allows you to enjoy the party. It would also be beneficial to discuss fear of hypoglycemia with patients (and their parents) to provide information on how to keep blood glucose levels under control without fearing a hypoglycemic episode. It is possible that discourse on prevention of hypoglycemia is not always evenly tempered with an appreciation for the consequences of hyperglycemia. Taking the time to discuss how to appropriately manage blood glucose while preventing hypoglycemia and hyperglycemia would prove helpful, especially to ease the fears of the adolescents and perhaps ease the fear of parents who are also transitioning in their care role from primary to auxiliary diabetes care provider. Again, the diabetes educator is well suited to this task and can use similar problem-solving vignettes to help address fears and solutions to hypoglycemic concerns. It may also be beneficial for diabetes educators to discuss overall health and well-being with adolescents in an effort to encourage healthy eating and enjoyable exercise (eg, involvement in team sports, yoga class) to improve dietary adherence as well as a means to indirectly increase quality of life. Developing and encouraging a healthy lifestyle approach may dissuade opinions about diabetic limitations in day-to-day life. Supporting a framework that minimizes limitations and focuses on enjoyable, healthy activities may also enhance quality of life. References 1. Kovacs M, Goldston D, Obrosky DS, Bonar LK. Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care. 1997;20: Iannotti RJ, Bush PJ. Toward a developmental theory of compliance. In: Krsnegor NA, Epstein SB, Johnson SB, Yaffe SJ, eds. Developmental Aspects of Health Compliance Behavior. Hillsdale, NJ: Lawrence Erlbaum; 1993: McConnell EM, Harper R, Campbell M, Nelson JK. Achieving optimal diabetic control in adolescence: the continuing enigma. Diabetes Metab Rev. 2001;17: Worrall-Davies A, Holland P, Berg I, Goodyer I. The effects of adverse life events on glycaemic control in children with insulin dependent diabetes mellitus. Eur Child Adolesc Psych. 1999;8:11.

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