This is a presentation authored and developed by my friend and colleague Dr. Barbara Anderson of Baylor College of Medicine. The presentation is a module in the 2014 Advanced Diabetes Seminar, hosted by Texas Lions Camp. In this discussion, Dr. Anderson dives into the topic of “Diabetes Family Teamwork with Teens: What is Success?”

1. Diabetes Family
Teamwork with Teens:
What is Success?
Barbara J. Anderson, PhD
Professor of Pediatrics
Baylor College of Medicine
Houston, TX

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Objectives
I. Why is family teamwork around diabetes (T1D)
management sometimes difficult during teen years?
II. What is Success in raising a teen with Type 1
Diabetes (T1D)? ―Begin with the End in Mind‖ What do
you hope your teenager will be like when s/he is 22
years old?

3. Page 2
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Objectives
III. Lessons from behavioral diabetes research
about families living with teenagers with
T1D.
-parent involvement
-conflict
IV. Preparing for transition to young adulthood.

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I. Why is T1D management at times a magnet
for negativity & conflict during adolescence?
1. Parent-teen conflict increases normally over
adolescence
2. Normal Tasks of teen development (drive for
autonomy; peer bonds) clash with demands of
daily T1D self-care
•

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Why is T1D management at times a magnet for
negativity and conflict during adolescence?
•3. Parent has normal concerns & worries about
health of their teen with T1D
4. Parental Cognitive Biases can increase
parental T1D concerns & focus the family on the
negative & problematic around T1D
management rather than talking about strengths
& what is going well with T1D care.

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Cognitive Biases
•Short-cuts or glitches in thinking that cause us to make
questionable decisions and reach erroneous
conclusions
Gambler’s Fallacy-the tendency to think that
future probabilities are altered by past events when in
reality they are unchanged.
I’ve flipped heads with this coin 5 times in a row, so the
chance of tails coming out on the 6th flip is much greater
than heads.

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Cognitive Biases related to diabetes
management in the family
1. Confirmation Bias – the tendency to search
for, interpret, & remember information in a way
that confirms one’s preconceptions.
Given how much candy Peter he ate over the
holidays, I knew his A1c would be high in clinic
today.

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Cognitive Biases related to diabetes
management in the family
2. Selective Perception Bias– the tendency for
expectations (especially always, & never) to
affect perception.
•My daughter never remembers her meter. She
always leaves her meter in her locker.

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Cognitive Biases related to diabetes
management in the family
•3. Negativity Bias – the tendency to pay more
attention, remember, frequently recall, & get
aroused by negative rather than positive
experiences or other kinds of information.
•He did not check his blood before practice on
Monday and Friday.
•

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II. What is your idea of „success‟
in raising your teen with T1D?
•Look into your family’s & teen’s
future……
•What do you hope your teenager will be
like when s/he is 23 years old?

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What do you hope your teenager will be
like when s/he is 23 years old?
• Happy /Strong Self-Esteem
• Pursuing work/education
• Kind, Sensitive, Empathic
• Good Communication skills
• Supportive friends
• Good Coping Skills/Resilient

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Resilient
•“Being resilient doesn‟t mean going through
life without experiencing stress & pain.
• Feeling grief, sadness & other emotions in
the face of adversity & stress is normal.
•The road to resilience lies in working
through the emotions & effects of stress and
challenges.”

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Factors that contribute to resilience:
1. Close relationships with family & friends
2. Positive view of yourself and confidence in your
strengths & abilities
3. Ability to manage strong feelings & impulses
4. Good problem-solving & communication skills
5. Feeling in control

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Factors that contribute to resilience:
6. Ability to seek help & resources when needed
7. Seeing yourself as resilient (rather than as a victim)
8. Coping with stress in healthy ways (seeking
information & support) & avoiding harmful coping
strategies (avoidance, substance abuse).
9. Helping others
10. Finding positive meaning in your life despite difficult
or traumatic events

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Getting to Resilience in T1D: The 4 R’s
•Realistic goals for BG and Behavior
•Reduce blame & criticism
•Reach for progress –not perfection.
•Recognize diabetes-related strengths --what is going
well?.

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III. Lessons from Research
Family factors that predict optimal adherence, BG, &
psychological health for teens with T1D:
1. Developmentally-appropriate parent involvement in DM
management tasks.
2. Lower levels of parent-teen conflict about DM
management.

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1. Parent Involvement in T1D mgt.
1) The “Old Message” (pre-1990): “The teen with
diabetes must be independent in diabetes
management.”
1990-- research caused a “Paradigm Shift”
2) The “New Message” (post-l990): “The teen with
diabetes must work inter-dependently with
parents, & this teamwork must change with
development.”

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1. The „New Paradigm‟ for Parent
Involvement
Developmentally-appropriate parent-teen
teamwork in managing diabetes predicts
optimal adherence, blood sugar levels, and
health outcomes.
(Anderson et al, 1990; La Greca et al, 1990; Weissberg-Benchell et al,
l995; Wysocki et al 1996; Anderson et al 1997; Anderson et al 1999;
Laffel et al 2003; Anderson et al 2009)

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2. Family Conflict around T1D
In school-aged children &
adolescents, studies consistently document
that lower levels of diabetes family conflict are
related to better adherence & glycemic
control.
(Waller et al, 1986; Hauser et al, 1990; Miller-Johnson et al 1994; Viner et al
1996; Davis et al 2001; Anderson et al 2002; Anderson 2004; Berlin et
al, 2012 )

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Diabetes-related family conflict predicts poor
adherence, diabetes outcomes & coping.

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Family Communication
and Conflict
 How parent thinks about DM...
- ―What does a blood sugar of 400 mean for my child?‖
- ―Why is his/her DM getting worse?‖
 How parent feels about DM…
- ―I’m scared when I see a blood sugar of 400. Why can’t
s/he have stable blood glucose levels?‖
 How parent talks about DM…
- ―That blood sugar is so bad! What did you eat?‖

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Talking about Blood Sugars
That scares
me! A high
blood sugar
like that
could cause
problems!
Dad, my
blood
sugar is
385.
Dad‟s really
mad at me!
He‟d be
happier if my
blood sugar
were 120 or
if I didn‟t
check at all!
385?! Why so
bad? What
did you eat?
1) OCCASIONAL HIGH BLOOD SUGARS DON’T LEAD TO COMPLICATIONS. It is normal
for growing children to have out-of-range blood sugars. An occasional blood sugar of 300
or even 400 or more will not cause complications.
2) THERE IS NO SUCH THING AS A ―BAD‖ BLOOD SUGAR. Any result from blood sugar
monitoring is good because it gives helpful and important information that lets you
make the best choices in insulin, activity, and food.

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III. Applying these lessons in „real life‟
•Goals during Adolescence:
‐Prevent Premature Parent Withdrawal of T1D
Involvement
‐Minimize Family T1D Conflict
•Goals for Older Teen Transitioning to Young
Adulthood:
‐Sustain diabetes self-care
‐Receive regular diabetes health care

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Normal Developmental Tasks:
Young Teens (11-14 yr.)
•Pubertal changes impact self-image
•Privacy is important.
•Power shifts in P-C relationship increase family
conflict.
•Peers are the priority!

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Involvement & Conflict Challenges for parents
of young teens T1D
•Parent has to recognize this is a period of
insecurity & intensity, to have consistent
expectations, set limits with
consequences, negotiate around parent
involvement & support for T1D management.
•Conflicts & frustrations increases normally in
every family at puberty; protect T1D
management from family conflict & stress.

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Normal Developmental Tasks:
Mid-Late Adolescence (15-17 yr)
•Consolidate Identity Development (self-image,
body image, sexuality, future education / training /
employment)
•Begin to plan for life after high school gradual
transfer of many responsibilities
•Bond with Peer Group
•Shows some Cognitive growth (but not complete!)

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Involvement & Conflict Challenges for parents
of older teens T1D
Negotiate consistent expectations, set limits &
consequences for rule violation (must check
BG before driving); maintain supportive
involvement in T1D
•Prevent Diabetes Burnout --ASK teen how
parent can help with T1D?

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“Burn-Out”
•“A common
response to a
chronically difficult
and frustrating job,
where the individual
works harder and
harder each day and
yet has little sense
that these actions
are making a real
difference. “

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Living with Type 1 Diabetes
•Goal of diabetes self-management: Near- normal blood
sugar ranges.
Teen balances on a tightrope between low blood sugar
(can cause behavioral & mood changes, & acute
emergencies) & high blood sugar (can cause behavioral
& mood changes, & if sustained, long-term problems)--
a chronic & impossible task, as the tools to manage
diabetes are not perfect.

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Living with Type 1 Diabetes
•Psychological consequences of ―tightrope
balancing‖:
Feelings of chronic frustration and failure from
striving for near-normal (―perfect‖) blood sugar
numbers, and from criticism from providers,
family members & self.

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Sample Session #6
Diabetes Burnout
•Diabetes burn-out is preventable.
 Watch for the early signs of burnout, and find
ways to help relieve the stress.
 Talk about your negative feelings about
diabetes.
 Set realistic goals with your health care team.
 Think of ways that your family and friends can help ease the
burden of diabetes.
 Make changes in your diabetes care one small step at a time.
 Diabetes is not about ―passing‖ or ―failing.‖
 NO ONE can successfully manage diabetes all alone

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Involvement & Conflict Challenges for
parents of older teens T1D
•AVOID ―Shame & Blame‖ language around BG
checking…Say ―Hi /Low BG vs. Good/Bad BG !
Praise & encourage the behavior of BG
checking
•TRANSFER gradually responsibility for parts of
T1D mgt. for which Teen has little experience—
ordering supplies; understanding insurance
and co-pays; advocating for self.

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Older Teens with T1D Transitioning to
Young Adulthood (18-23 yrs.)
•Changes in family roles/relationships
•Changes in relationships with health care
providers
•At risk for poor diabetes self-care
•At risk for lapses in diabetes health care

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Diabetes Challenges in Young Adulthood
(for your 23 year old with T1D)
1. Changes in support systems for diabetes self-
mgt.
2. Loss to medical follow-up
3. Accessing health insurance & health care
providers

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Changes in T1D Support Systems
1. Family Supports change
2. Peer supports change – changing schools,
jobs, cities
3. Medical Support Systems – often prior risk
factors (ped history) are unknown to new adult
providers; adult medicine is a different culture
from pediatric care

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Loss to Medical Follow-Up
1. Loss of med follow-up strongest predictor of
complications & mortality in British Diabetic Assoc.
Cohort Study in 20-29-year-old group (Laing et al, l999).
2. Critical period for preventive screening of
microvascular complications in Sweden’s Diabetes
Incidence Study, 15 – 34-yr-olds (Svensson et al, 2003;
Henricsson e al, 2003)
3. ―Window of opportunity‖ in later 20’s to establish
better self-care patterns as transitions slow down

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What do you hope your teenager
will be like when s/he is 22 years?
• Young adult who is happy, caring,
independent, has career/educational goals.
•A resilient young adult with T1D motivated for:
‐Self-Management
‐Self-Advocacy
‐Sustaining diabetes health care

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Summary
•Be aware of cognitive biases that add
negatively to family climate
•Foster resilience in your now so they can carry
it into their 20’s
•Watch for teamwork opportunities & for
reducing T1D conflict
•Prepare for transition to young adulthood

43. Page 42
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Getting to Resilience in T1D: The 4 R’s
• Realistic goals for BG and Behavior
• Reduce blame & criticism
• Reach for progress –not perfection.
• Recognize your teen’s strengths in T1D
management –focus on what is going well.

44. Thank you for your
attention!
Comments? Questions?