Families and Diabetes and Providers

1
Families and Diabetes(and Providers)

• Donna Follansbee, PhD
• Rita Temple-Trujillo, LCSW, CDE
• Barbara Davis Center - UCHSC

2
peter comes with instructions(continued)
3
Current push to achieve better glycemic control
through the use of more technology MDI,
Pump, CGMS.

• Some families will do great
• Some families will not do so well
• Technology alone will not help us reach goals.
  Careful assessment of family is needed.

4
Newer Technologies

• MDI
• Pumps
• Continuous Glucose Monitoring

5
Promise of better control
Has it been achieved?
6
Hvidoere Study Group on IDDM

• 21 centers worldwide
• 1998 to 2005
• Despite advances in treatment (insulin analogues,
  basal-bolus regimens, CSII) only 2 centers
  significantly improved mean A1c levels
• These centers intensified patient-center contact
  considerably they did not alter insulin regimens
• Hvidoere Study Group on Childhood Diabetes,
  Continuing Stability of Center Differences in
  Pediatric Diabetes Care Do Advances in Diabetes
  Treatment Improve Outcome? Diabetes Care 2007

7
The Patient is the System

• Provider patient relationships are critical to
  healthy outcomes
• The patient is not just the child or teen it
  is the whole family

8
Family Styles

• Enmeshed and/or Organized
• Close
• Dependent
• Rule oriented
• Low overt conflict
• Busy

9
(No Transcript)
10
Family Styles, continued

• Disengaged and/or Chaotic
• Distant
• Independent
• Few rules
• High overt conflict
• Busy

11
(No Transcript)
12
Styles cont.

• Psychosomatic
• Enmeshed
• Overprotective
• Rigid
• Conflict avoidant
• Child triangulated

• Just Right
• Connected
• Interdependent
• Flexible
• Conflicts resolved
• Appropriate hierarchy

13
ResponsibilityWho does what in IDDM care?

• Mothers are primary parent
• Task management
• Emotional support
• Child responsibility usually increases with age
• Parent responsibility increases with complexity
  of regimen

14
Hassle Factor

• If conflict is high, moms yield responsibility to
  maintain peace

15
D.A.D.S.

• When dads less involved in care
• Poorer adherence
• Poorer health status
• When dads more involved in care
• Less impact of IDDM on family functioning
• Fewer maternal psychiatric symptoms
• Higher marital satisfaction
• Higher family satisfaction
• Gavin and
  Wysocki 2002,2006

16
(No Transcript)
17
Old wisdom start em young

• Children should assume responsibility for self
  care
• Tasks tied to age12
• Shots
• Diet
• Schedule
• Avoid creating dependence

18
Assuming Responsibility for Diabetes Management
What Age? What Price?

• Knowledge necessary but not sufficient
• Performance errors and forgetting
• Cognitive Complexity level of maturity and
  ability to analyze
• Locus of Control internal vs external
• Family Factors styles
• Perceptions child vs parent
• Follansbee, Donna S. Diabetes Educator 1989

19
Emotional cost of care

• Frequency of parenting stress increases with
• Parents perceived lower self-efficacy for
  diabetes regimen
• Greater parental responsibility for regimen
• Greater parental fear of hypoglycemia
• Use of MDI vs. CSII

20
Emotional cost of care

• Difficulty of parenting stress increases with
• Greater parental responsibility for regimen
• Greater parental fear of hypoglycemia
• Use of MDI instead of CSII
• Streisand et. al. 2005

21
Whos on First?

• Adherence and control worsen when
• Parents report little or no responsibility for
  IDDM care
• Parent/child reports of responsibility are
  incongruous
• Adherence and control improve with
• High levels of parental support (younger
  children)
• Low levels of critical/negative parenting (teens)
• 
  Lewin, et.al. 2006

22
(No Transcript)
23
Balancing Act

• Structure Autonomy
• Control
• Behavioral Monitoring Self Care

24
Putting it all together
child
tools
25
The vicious cycle of miscarried helpingAnderson
BJ, et al. Diabetes Care 1999
26
Providers ? system
27
The vicious cycle of miscarried
helping(providers)
28
How do we avoid this scenerio?

• Provider/Patient relationshps are critical to
  healthy outcomes.
• We have the same goals (safe and healthy), but
  different perspectives
• Acknowledge this is a complex disease
• Team work
• Most families are doing the best that they can
  and need our support to do more.

29
Parents, teens, and diabetes Tim Wysocki, PhD

• Warmth and empathy
• Defining goals
• Complete autonomy is a myth
• Communication and conflict resolution

30
Motivational interviewingWilliam Miller, PhD
Steven Rollnick, PhD

• Motivation to change comes from the patient
• Behavior change means dealing with the
  conflict/ambivalence around change
• Advice rarely works
• Listen
• Provider style is critical collaboration

31
Ask

• Hows life?
• What questions do you have today?
• Are you concerned about your A1c?
• What is the hardest thing about having diabetes?
  (child and parent)
• Tell me what youve tried working on since last
  visit.
• What do you think we need to do

32
Acknowledge

• Changing behavior is hard
• Ambivalence
• Parents Who does what around diabetes care?
• What happens?
• What do we need to change to make this
  easier/better?

33
Review

• People fall into patternswe have good
  intentions, but fall back into old habits
• Keep it simple--1 change What should we work
  on?
• Support
• What do we need to do to keep momentum?

34
Build on Success

• Specific plan
• How will family support?
• Feedback loop
• Focus on behavior (not b.g)
• Support problem solving
• JOB

35
The discovery of insulin was only the beginning,
diabetes was a far more complicated disease than
anyone had realized.quote from The Discovery
of Insulin by Michael Bliss 1982