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Diabetes & Metabolism 35 (2009) 339350

Review

Psychosocial problems in adolescents with type 1 diabetes mellitus

K. Kakleas , B. Kandyla , C. Karayianni , K. Karavanaki
Diabetic Clinic, 2nd Pediatric Department, University of Athens, P & A Kyriakou Childrens Hospital, Goudi, 11527 Athens, Greece
Received 19 July 2008; received in revised form 11 May 2009; accepted 11 May 2009
Available online 22 August 2009

Abstract
Adolescents with diabetes are at increased risk of developing psychiatric (1020%) or eating disorders (830%), as well as substance abuse
(2550%), leading to non-compliance with treatment and deterioration of diabetic control. At high risk are female adolescents with family problems
and other comorbid disorders. Impaired cognitive function has also been reported among children with diabetes, mainly in boys, and especially in
those with early diabetes diagnosis (< 5 years), or with episodes of severe hypoglycaemia or prolonged hyperglycaemia. Type 1 diabetes mellitus
contributes to the development of problems in parentchild relationships and employment difficulties, and negatively affects the quality of life.
However, insulin pumps appear to improve patients metabolic control and lifestyle. The contributions of family and friends to the quality of
metabolic control and emotional support are also crucial. In addition, the role of the primary-care provider is important in identifying patients
at high risk of developing psychosocial disorders and referring them on to health specialists. At high risk are patients in mid-adolescence with
comorbid disorders, low socioeconomic status or parental health problems. Multisystem therapy, involving the medical team, school personnel,
family and peer group, is also essential. The present review focuses on the prevalence of nutritional and psychosocial problems among adolescents
with diabetes, and the risk factors for its development, and emphasizes specific goals in their management and prevention.
2009 Elsevier Masson SAS. All rights reserved.
Keywords: Type 1 diabetes mellitus; Children; Adolescents; Psychiatric disorders; Eating disorders; School performance; Contraception; Family/friend relationships;
Review

Rsum
Problmes psychosociaux des adolescents atteints de diabte de type 1 (DT1).
Les adolescents atteints de diabte ont une augmentation du risque de dvelopper des troubles psychiques (1020 %) ou alimentaires (830 %),
qui conduisent la non-adhsion au traitement et la dtrioration de lquilibre glycmique. Les risques sont accrus pour les adolescentes avec
des problmes familiaux et dautres troubles. Par ailleurs, des troubles dapprentissage ont t mentionns chez des enfants atteints de diabte de
type 1 (DM1), surtout chez les garcons et chez les enfants chez qui le diabte a t diagnostiqu tt (infrieur cinq ans) ou chez les enfants qui
ont prsent des pisodes dhypoglycmie svres ou dhyperglycmie prolonge. La prsence du DT1 contribue au dveloppement de problmes
dans la relation parentenfant, de mauvais rsultats scolaires, des problmes demploi et une moins bonne qualit de vie. Les pompes insuline
semblent amliorer lquilibre glycmique des patients ainsi que leur mode de vie. Nanmoins, la contribution de la famille et des amis la qualit
de lquilibre glycmique, grce leur support motionnel, sont dune importance cruciale. Entre autres, le personnel soignant a un rle important
dans lidentification des adolescents atteints de TD1 susceptibles de dvelopper des troubles psychosociaux et leur orientation vers le spcialiste.
Ces malades haut risque sont des jeunes en milieu de leur adolescence avec des troubles associs, un milieu socioconomique modeste ou des
problmes familiaux. Il est ncessaire dassocier dans ce cas les quipes mdicales avec le personnel scolaire, la famille et les amis pour faire face
la situation. La prsente revue se focalise sur la prdominance des problmes psychosociaux parmi les adolescents diabtiques, sur les facteurs
de risque de dveloppement de ces problmes, sur leurs complications, et met laccent sur les objectifs spcifiques de leur prise en charge aussi
bien que sur leur prvention.
2009 Elsevier Masson SAS. Tous droits rservs.
Mots cls : Diabte de type 1 ; Adolescents ; Enfants ; Troubles psychiatriques ; Troubles alimentaires ; Performances scolaires ; Contraception ; Relations familiales
et amicales ; Revue gnrale

Corresponding author.
E-mail address: kkarav@yahoo.gr (K. Karavanaki).

1262-3636/$ see front matter 2009 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.diabet.2009.05.002

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K. Kakleas et al. / Diabetes & Metabolism 35 (2009) 339350

1. Introduction
Type 1 diabetes mellitus (T1DM) is a lifelong metabolic disorder that is treated with a complex regimen of insulin injections,
diet and exercise, and can greatly affect the lives of the adolescent
patient and his family.
Adolescence is a period of major physiological and psychological changes, and is also characterized by an effort in
young people to establish their identity and gain independence. Teenagers with T1DM have the additional burden of
diabetes management. Glycaemic control usually deteriorates
during adolescence [1]. Although this deterioration is partly
related to hormonal changes of puberty, and to psychosocial
and behavioural problems, non-compliance with the treatment
regimen is of equal importance, as is knowledge of the illness
and its treatment [2].
In addition, as teenagers become increasingly independent,
they may resent parental supervision of their diabetes care [2].
As diabetes control is considered a family enterprise, such
parental involvement in the adolescents life is associated with
the development of problems in the parentchild relationship
[3].
Psychiatric and eating disorders are reported to be more
frequent among adolescents with diabetes than among their
non-diabetic peers [4]. Because of their frequent psychosocial
problems and their increased need for peer acceptance, adolescents with diabetes are also at high risk of substance abuse [5].
In addition, the presence of diabetes may be associated with
poor school performance and employment difficulties. Health
care providers also need to advise adolescent girls with diabetes
on the prevention of unplanned pregnancy and its dangers.
The present review focuses on the prevalence, risk factors and
consequences of nutritional, psychosocial and gynaecological
problems among adolescents with T1DM, and their effects on
glycaemic control and quality of life (QoL). This report also
emphasizes on the need for standards and specific targets in the
management of this age group as outpatients, the identification
of high-risk adolescents with T1DM, and the need to establish
preventative and early interventional strategies.
2. Eating disorders
Disturbed eating behaviours are a particular concern among
patients with T1DM; these mainly include bulimia nervosa
(BN) and binge-eating disorder (BED), whereas anorexia nervosa (AN) is rare. Sometimes, these behaviours are associated
with inappropriate compensatory habits to prevent weight gain
(purging behaviours) such as excessive exercise to lose weight,
self-induced vomiting, the use of laxatives and insulin omission
[6].
The prevalence of eating disorders among adolescents with
T1DM ranges from 8% to 30%, which is significantly higher
than among their non-diabetic peers (14%), and is more frequently seen in girls (37.9%) than in boys (15.9%) [7]. Colton
et al. [8], reported, in a group of adolescent girls with diabetes
(mean age: 11.8 years), a 50.8% prevalence of eating disorders
that persisted 5 years later (49%). Among preadolescent girls

with diabetes (aged 913 years), a lower frequency (17%) of

eating disorders has been observed [9]:

16% reported dieting for weight control;

2% were binge-eating;
3% indulged in excessive exercise
1% used insulin manipulation for weight control.

No cases of anorexia or bulimia were observed [9].

BN is characterized by an excessive consumption of food
(> 500 calories per episode) that is not part of the scheduled
meals, with no consideration of its nutritional value [10]. The
main difference between BN and binge-eating is that the former
is characterized by purging behaviours with a frequency of more
than twice a week [6].
Insulin omission refers to the skipping or reduction of the prescribed insulin to prevent weight gain [6], and has been reported
in 1540% of adolescents with T1DM [11]. Mainly observed in
BN, it is also seen in AN as a means of preventing hypoglycaemia
[6].
Rodin and Daneman [12] have suggested the following potential pathway from T1DM diagnosis to unhealthy weight-control
behaviours. Before the diagnosis of diabetes, there is often
weight loss in the adolescent, which may be desirable in the
case of young girls. But once insulin therapy begins, weight
gain usually occurs, which can lead to or increase body dissatisfaction. Weight gain and body dissatisfaction can, in turn, lead
to the use of unhealthy weight-control behaviours, especially
insulin restriction as a way to lose weight [13].
AN is a rare eating disorder in adolescents with T1DM
[14,15], and is even more unusual in childhood; for this reason, there is only one study in children with diabetes, starting at
the age of 8 years [16]. The cause of the condition is considered
to be the result of the dietary restrictions applied to children with
diabetes. Food may then become a major enemy to the child or
the main reason for conflicts with parents [17]. The increased
insulin requirements and recurrence of hyperglycaemia may also
trigger an eating disorder in a subject so prone [17].
Several studies have identified the potential risk factors for
the development of disordered eating attitudes and behaviours
in diabetic adolescents, including:
female gender;
age 1314 years for girls and above 16 years for boys, when
adolescents struggle to adapt to the hormonal and psychoemotional changes associated with puberty [17,18];
increased body weight (partially attributed to insulin therapy), leading to denial and rejection of the body image (body
dissatisfaction) [8];
constant food preoccupation because of diabetes [8,15];
presence of eating disorders in parents (especially the mother)
[9];
presence of other psychiatric disorders (such as depression,
anxiety or substance abuse) [11];
problems with family relationships (lack of trust in the parents
regarding diabetes control, or parental conflicts) [7].

K. Kakleas et al. / Diabetes & Metabolism 35 (2009) 339350

An important complication of BN and BED is poor glycaemic

control and frequent episodes of diabetic ketoacidosis (DKA)
[19]. Poor glycaemic control is also a complication of AN (due
to insulin dose reduction), but a more serious hazard is the frequent hypoglycaemic episodes due to skipping meals, which
may even be fatal [17]. Eating disorders are also responsible for
the increased prevalence of long-term diabetic complications,
such as retinopathy, neuropathy and nephropathy [17], because
of poor metabolic control. Rydall et al. [20] reported that the
prevalence of retinopathy, among adolescents with diabetes and
a 5-year history of eating disorders, was 86%, in comparison
with a prevalence of 24% in adolescents with T1DM of a similar
disease duration, but no eating disorders [20].
Taking into consideration the severity of eating disorders,
early diagnosis with screening programmes during the prepubertal ages is important. Special attention should also be given
to girls who are not satisfied with their body image, who present
with insulin omission or excessive exercising, or who have
recurrent hospitalizations because of poor glycaemic control or
episodes of DKA, as well as children with body weight increases
and disturbed family relationships [7].
3. Psychiatric and behavioural disorders
Psychiatric and behavioural disorders in adolescents with
T1DM are commonly seen [21,22], and are categorized as either
internalizing (such as depression and anxiety) or externalizing (such as impulsivity, hyperactivity, aggression) disorders
[23,24].
In the initial period after diabetes diagnosis, children show
difficulties in coping with the disease, often presenting with feelings of sadness, withdrawal and anxiety; 30% develop clinical
adjustment disorder in the 3-month period following diagnosis
[21,25]. Such difficulties often resolve within the first year, but
poor adaptation at this initial phase places children at risk for
later psychological difficulties [21,22]. In longitudinal studies,
the 10-year timepoint and lifetime prevalence rates of psychiatric
disorders in youngsters with T1DM were 47% [22] and 37%
[21], respectively. These disorder rates are two to three times
higher than those found in the general community [26,27]. In
general, over one third of children with diabetes develop a psychiatric disorder within the first decade of disease onset [28],
with depression, anxiety and behavioural disorders being the
most common diagnoses [4,29].
Different studies have observed depression in 1026% of
adolescents with diabetes [30,31], while high rates of anxiety
(919%) and disruptive behavioural disorders (1220%) have
also been reported [21,22,24,32]. Comorbidity is commonly
seen, with up to 60% of those with a psychiatric diagnosis
meeting the criteria for more than one disorder [21].
Predisposing factors contributing to depression or anxiety
disorders are demographic (female gender), diabetes-specific
(poor glycaemic control) and family-functioning variables
(diabetes-specific burden reported by the parents) [22,31].
Indeed, female patients are more likely to have depression, anxiety or low self-esteem [31,33]. Less frequent blood glucose
monitoringan indicator of suboptimal complianceand poor

341

metabolic control have also been associated with higher levels

of depressive symptoms [31]. In addition, there may be an association with familial patterns of depressionmost frequently,
maternal depressionand the presence of diabetes-specific family conflicts can cause stress to parents or caregivers, which may
reduce the psychoemotional support given to young patients
[31]. Furthermore, adolescents with T1DM are at increased risk
for depression compared with their peers due to increased peer
pressure, the attempt to gain independence from their parents
and the effort to discover their self-identity [31,34,35].
Depression and other emotional disorders are associated with
poor glycaemic control in both adolescents [36,37] and adults
[38], resulting in frequent hospital admissions due to episodes
of DKA or severe hypoglycaemia [39]. Poor glycaemic control
in adolescents with diabetes and depression may be attributed to
a lack of compliance with diet, exercise and medications [37].
In addition, there is an increased incidence of coexisting eating
disorders in adolescents with diabetes and psychiatric disorders,
which is associated with intentional insulin omission and, thus,
impaired metabolic control [30,40]. Furthermore, apathy and
lack of self-care, which are frequently seen in patients with
depression or anxiety disorders, can lead to eating or exercise
habits that cause diabetic control to deteriorate [41].
The combination of diabetes and depression in children and
adolescents has been associated with a tenfold increase in suicide
and suicidal ideation [42]. In children and especially adolescents
with T1DM, the recurrence and course of depression may be
more intense (some studies suggest that the depression tends
to be more severe, more difficult to resolve and more likely to
recur) than in youngsters without diabetes [31,43].
It has also been reported that suicidal ideation in adolescents with T1DM is higher than expected, but comparable to
that of the general population [30,44]. Although many young
adolescents with diabetes admit to suicidal ideation, only a few
have attempted suicide [41], commonly using diabetes-related
methods such as insulin misuse [41,45,46] or overdose.
The risk for suicidal ideation is higher among children
with longer duration of diabetes, non-compliance with therapy, coexistent psychiatric disorders and single-parent families
[30]. Among adolescents with T1DM who were admitted to
hospital for recurrent coma due to secret self-administration of
insulin, there was a large predominance of girls who had either
familial difficulties or major fears of diabetes complications
[45].
Thus, routine psychological screening of adolescents with
diabetes and their specific follow-up is of great importance
[47] for the early detection of psychiatric disorders and the
prevention of suicidal attempts. Adolescents suspected to have
psychiatric disorders are those with frequent hospital admissions because of DKA, or those with severe diabetes-related
family problems, and also those who have severe conflicts with
their parents. Youngsters with internalizing disorders (depression and anxiety) may be less noticeable to their parents and
teachers than those with externalizing symptoms, such as anger
and aggressive outbursts. For this reason, the clinician should
question their younger patients with T1DM about specific
symptoms of depression. Adolescents suspected to have

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K. Kakleas et al. / Diabetes & Metabolism 35 (2009) 339350

psychiatric disorders need closer follow-up in terms of diabetes

control and psychological interventions.
4. Self-management of diabetes, compliance and
glycaemic control
Optimal glycaemic control is important for delaying progression to long-term complications of T1DM [48]. Studies by the
Hvidore group and others [4952] have demonstrated that glycaemic control between 11 and 18 years of age remains poor.
This is mostly attributed to the normal physiological changes
of puberty, as increased levels of growth hormone are responsible for overnight insulin resistancealso known as the dawn
phenomenon [53].
However, other factors such as psychosocial and behavioural
problems, and non-compliance with treatment, also play important roles in the development of metabolic dysregulation in
adolescence. As teenagers become increasingly independent,
they resent parental supervision of their diabetes care and rebel
against the restrictive nature of diabetes treatment regimens.
Reluctance to do more than the minimum number of blood glucose tests, erratic meals and missed insulin doses are frequently
seen [54,55]. In addition, as previously mentioned, the incidence
of depression, eating disorders and insulin omission is increased
in adolescence, which, in turn, increases the risk of deterioration of glycaemic control. Moreover, many adolescents cannot
understand the long-term consequences of T1DM, tend not to
believe that they are vulnerable to them and hold the view that
they will never happen to them [56].
Another factor associated with poor glycaemic control is noncompliance with treatment. During the first years of diabetes
diagnosis [57,58], the lack of adequate knowledge of diabetes
can affect compliance in children and adolescents [59]. After
this initial phase, though, compliance depends on the avoidance
of unhealthy self-care behaviours, and the degree of parental
support given to diabetes management [60,61]. In fact, the relationship between compliance behaviours and glycaemic control
is highly complex and probably bidirectional, as poor compliance is often preceded by an initial worsening of glycaemic
control [2]. Indeed, it is likely that the deteriorating metabolic
control during early adolescence because of hormonal factors,
despite stable compliance and continued self-care, can seriously
discourage adolescents subsequent self-care efforts and, thus,
contribute to the decline seen in older adolescents self-care
behaviours [2].
Other factors that predispose to young patients noncompliance are the presence of other health problems, and
learning, emotional and behavioural disorders. Also, family factors such as a single-parent home, chronic mental or physical
health problems of the parents, low socioeconomic status and
particular cultural or religious beliefs may all contribute to poor
compliance with therapy [62].
The hormonal and psychological changes of puberty are complicated by the demands of the intensified treatment regimens
used in adolescence, which can result in poor glycaemic control
[63]. Intensified treatment is necessary to ensure normal physical growth [64] and secondary sexual development, and also

to prevent or retard the development of long-term microvascular complications. Adverse effects of intensified glycaemic
control are the inconvenience of frequent blood tests, weight
gain and more frequent bouts of severe hypoglycaemia due to
hypoglycaemia unawareness [65].
Nevertheless, it is difficult to achieve near-normoglycaemia
during adolescence. Indeed, several studies in the US and Europe
[31,48,62] have documented that mean HbA1c levels in adolescence are generally greater than 8.0%. Reducing these levels
increases the risk of severe hypoglycaemia. For this reason,
the American Diabetes Association [62] has concluded that,
although an ideal target HbA1c identical to that for adults (< 7%)
might be recommended for adolescents, it is recognized that this
target is not easily achieved in most young patients. Thus, bearing in mind the risk of hypoglycaemia and the possibility of
creating feelings of failure in the patient, an HbA1c level of less
than 7.5% is recommended for this age group [62].
5. Diabetes-pump therapy
Continuous subcutaneous insulin infusion (CSII) is becoming increasingly popular as a means of delivering insulin, being
used by nearly 8% of adults and 6% of children with T1DM
around the world [66].
Compared with the multiple daily injection (MDI) regimen, the use of insulin pumps is associated with lower HbA1c
levels, fewer episodes of severe hypoglycaemia (especially in
patients under 5 years of age), low risk of ketoacidosis and
greater reduction of glucose fluctuations [67,68]. Also, longterm improvements in metabolic control over a 5-year period
have been observed [68]. In addition, with CSII, the total daily
insulin dose may be significantly decreased [67], while there
are mixed reports of an increase in body mass index (BMI)
associated with pump use [69,70].
As for the impact on patients lifestyle, most studies report
that CSII provided patients with greater flexibility, freedom and
ease with meals, and reduced feelings of physical restriction
[71]. However, there is conflicting evidence regarding the QoL
of patients treated with the insulin pump compared with MDI
[7274]. Nevertheless, most studies of adolescent and adult
pump-users have shown a decrease in depressive symptoms,
with no differences in anxiety, self-esteem and locus of control
[75,76].
However, the disadvantages of the pump include the continual
reliance on an external device, and the need for intensive blood
glucose monitoring and high patient motivation [77]. Also, their
proper use requires a good understanding of how diabetes, food
and insulin all interact, and their cost is considerable [74].
Among the necessary factors for CSII treatment success, it is
important to identify those patients who have unrealistic expectations with using the pump, a disturbed body image and a lack
of social support [71]. Women using CSII show higher levels of
self-consciousness and body dissatisfaction [71,78], while adolescents report feeling different and less acceptable, and consider
pumps to be fashion inconveniences [71].
Thus, insulin-pump therapy is a suitable alternative to insulin
injections in some adolescents, as it appears to improve patients

K. Kakleas et al. / Diabetes & Metabolism 35 (2009) 339350

metabolic control and lifestyle while placing fewer diseaserelated limitations on the family. However, its application
demands active participation in self-care and realistic expectations [79].
6. Family relationships
Type 1 diabetes is a demanding chronic illness that influences patients everyday life, and has particular implications on
adolescents and their families. Given that diabetes management
must be integrated into the familys lifestyle, it is likely to affect
every family member. Parents often become involved in aspects
of their teenagers lives that they would otherwise ignore [80].
The increased responsibility and demands of diabetic treatment
can lead to parentchild conflicts. Furthermore, parental involvement may be in conflict with the adolescents developing sense
of autonomy [81].
The growing autonomy and creation of a personal identity are
important developmental tasks of adolescence [82]. These tasks
may be more complicated for adolescents with T1DM because,
at this time in their lives, both metabolic control and treatment
compliance are likely to deteriorate [61,81]. It has been found
that less parental involvement in diabetes care is associated with
poorer diabetes outcomes [83]. In contrast, adolescents whose
parents remain involved in their self-care activities have better compliance and more effective glycaemic control. However,
increased parental involvement in diabetes management is also
reported to create diabetes-related family conflicts [84]. Indeed,
high levels of family conflict, and low levels of family cohesion
and support, are associated with poorer metabolic control and
poorer compliance with treatment among adolescents [85].
Another effect of diabetes on parental behaviour is the high
burden of stress that parents carry for the wellbeing of the
affected child. Parents often express excessive worry over diabetes and its treatment, especially concerning high and low blood
sugar levels and long-term diabetes complications, in addition to
the usual adolescent activities such as driving. This worry is often
expressed by intrusive behaviours such as nagging, scolding,
asking too many questions and giving orders [86]. Sometimes,
parents will question their adolescents management decisions,
resulting in disrupted communication and resentment.
Another reason for childparent conflict is the lack of
understanding in the parents, leading to intrusive and blaming
behaviours. Thus, although these parents are attempting to help,
they are, in fact, suggesting that their child or adolescent is incapable of managing the diabetes rather than truly helping their
child to learn how to manage the illness [87].
Adolescents, on the other hand, consider their parents
behaviour as annoying and, at times, accuse them of losing
sight of them as people and of seeing them solely as having
diabetes [86]. They may also feel frustration and guilt over the
effect of diabetes on their parents, and the stress it can cause to
the family [84].
Nevertheless, many families are able to raise their adolescents
with T1DM without excessive trouble. These families approach
problems with warmth and empathy, rather than hostility and
anger, and have clearly defined goals and expectations. By antic-

343

ipating imperfection in self-management, they encourage the

appropriate level of autonomy, using social support systems
and effective communication to solve the problems together
[88].
Several family-related factors are associated with diabetic
adolescents behaviours and non-compliance, including having
a single-parent family, lower socioeconomic status, high levels of family conflict, poor family communication and poor
problem-solving skills [89]. If a child or family is identified as being at high risk of non-compliance with treatment
and having problems in their relationships, they need to be
scheduled for outpatients follow-up by a specialized psychologist.
7. Relationships with friends and the opposite sex
In middle childhood, as children spend increasing amounts
of time outside of the family, they become affiliated with peer
groups, spending more time with them and deriving significant
support from such friendships [90]. The support of friends for
an adolescent with diabetes is mostly orientated towards companionship (such as during exercise) and emotional support,
and less frequently towards helping with insulin injections and
blood glucose testing [90]. Also, girls have more support than
boys for diabetes control and emotional problems, which may be
attributed to the more intimate nature of female compared with
male friendships [90,91]. There is some indication that friends
support for blood glucose testing is predictive of compliance
in diabetes [92], and may be related to the adolescents disease
adaptation and QoL [90].
Nevertheless, peers may sometimes lack sufficient knowledge of diabetes and of the importance of daily care
management, so they may not support the diabetic friends in a
regular and consistent manner, and may even have an influence
that is either neutral or detrimental to the daily care regimen
[91,93].
7.1. Romantic relationships
Adolescents with diabetes are no different from their nondiabetic peers as regards dating attitudes, as they have similar
psychosocial maturity [94]. However, they tend not to focus as
much on intimacy in their relationships as their non-diabetic
peers, and look for romantic partners who can offer them security, support and assistance in a stable relationship [95]. In
addition, adolescents with T1DM are reported to experience
less trust and less of a sense of intimate friendship in their love
relationships than their non-diabetic peers [96], which suggests
specific feelings of lower self-worth and self-esteem in social
relationships [97].
As regards marital status, both men and women with diabetes
are less likely to be married compared with their age-matched
controls. Several factors other than diabetes complications,
including job discrimination, high medical costs and psychological pressures, are thought to be responsible for this disparity
[98].

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K. Kakleas et al. / Diabetes & Metabolism 35 (2009) 339350

8. Cognitive function and professional success

Type 1 diabetes appears to be associated with an increased
risk of mild neuropsychological dysfunction, although there is
controversy over its precise cause and extent [99]. A recent study
from Sweden reveals that children who developed diabetes during 19772000 had poor school performances compared with
their non-diabetic peers [100].
Some studies have shown that impaired cognitive and learning abilities are more common among boys, and in children
diagnosed with diabetes during infancy and their preschool years
(< 5 years of age) [101103]. Some abilities are more vulnerable to early disease onset, such as attention and processing
speed, and have been associated with mild central brain atrophy [104]. In addition, hypoglycaemia has been associated with
impaired intellectual abilities such as verbal and full-scale intelligence scores [105,106], while another study [107] reported that
only children who had severe hypoglycaemic episodes leading
to seizures appeared to score lower on tests of memory, attention,
perception and motor skills. In fact, electroencephalography
(EEG) abnormalities have been frequently observed in children
and adolescents who have frequent episodes of severe hypoglycaemia [108].
Prolonged hyperglycaemia has also been associated with cognitive dysfunction [109]. Behavioural disturbances (overactivity,
lack of concentration, negative mood swings) have been reported
in children with elevated blood glucose levels of long duration,
an effect that has also been observed in adults [110,111].
Indeed, most reports show that children and adolescents with
T1DM may have mild cognitive and academic difficulties, which
are probably due to the intercorrelation of several factors such as
the frequencies of severe hypoglycaemia and DKA, cumulative
glycaemic exposures and duration of diabetes [101]. However,
maintaining good glycaemic control, especially in children diagnosed at an early age, may protect against cognitive impairment.
Adolescents and young adults with diabetes frequently experience health-related problems that affect their job employment
[112]. Among these problems, 19% reported losing their job
because of diabetes, 28% were unable to do the job they
preferred and 41% had shift-work problems [113]. A minority of patients admit to withholding information about their
condition from their employees [114] while, in some cases,
work difficulties are associated with their lower self-esteem
[112].
9. Quality of life (QoL)
Concerning this important aspect in the care of patients with
diabetes, most studies demonstrate a negative effect of diabetes on QoL [115117], while a few studies have reported no
effects [118,119]. The most important determinants of QoL are
the absence of psychosocial dysfunction and family conflicts
[36,120]. It has been found that the presence of a supportive and
emotionally warm parental environment, good family communication, reinforcement strategies by health practitioners and
adequate social supports are critical for the improvement of QoL
in patients with T1DM [3].

Among the factors affecting QoL in adolescence are

increasing age, female gender [121], an increased prevalence of psychiatric and behavioural disorders [122,123], and
socioeconomic factors. This means that adolescents from singleparent families and ethnic minority groups have markedly poorer
QoL [74,122], which may be attributable to communication
problems, and differences in culture and diet.
Some studies suggest a link between QoL and metabolic control, as poor metabolic control has been associated with a greater
family burden [121]. However, other studies could find no such
association [3,120].
As for the impact of the insulin regimen on adolescents QoL,
no significant adverse effects with MDI treatments have been
reported [121]. With CSII, some studies suggest that it may
improve important aspects of health-related QoL by improving
metabolic control and lifestyle [69,74].
For these reasons, it has been suggested [121] that specific
attention should be paid by primary-care providers (PCPs) to
the management of adolescent girls and patients belonging to
single-parent families and ethnic minorities. Moreover, PCPs
are advised to keep on the lookout for diabetic adolescents with
psychosocial problems and to refer them on for psychological
or psychiatric evaluation.

10. Smoking, alcohol and drugs

Smoking is an independent risk factor for the development
of late diabetic complications [116,124], whereas alcohol consumption has been associated with the presence of delayed
hypoglycaemia [125] and an impaired ability to detect hypoglycaemic symptoms [126].
The frequency of smoking among adolescents and young
adults with diabetes aged 1729 years is reported to be 24%
[127] whereas, in the younger age group (1120 years), there is a
wide variation in smoking rates across different studies (ranging
from 9 to 34%) [2,128].
The overall frequency of alcohol use among adolescents with
diabetes (1220 years) was 4050% [128,129], indicating that
almost half of adolescents with T1DM drink dangerously while,
in another study, approximately 50% reported having tried alcohol [130]. The presence of a family history of alcohol use was
more frequent among those adolescents who consume alcohol
[131].
Studies of substance abuse among adolescents with diabetes
are extremely limited and vary from one country to another. The
frequency of drug use in adolescents (aged 1020 years) with
diabetes in the US is reported to be 10% [128]. A study from
the UK [129] reported that, of 158 adolescents and young adults
(aged 1630 years) with T1DM who attended a diabetes clinic
and filled out an anonymous questionnaire, 29% admitted using
street drugs. Among these drug-users, 68% used them more than
once a month and 72% were unaware of the adverse effects on
diabetes. These studies concluded that (self-reported) drug use
is common among young adults with T1DM, and may contribute
to poor glycaemic control and the more serious complications
of diabetes [128,131].

K. Kakleas et al. / Diabetes & Metabolism 35 (2009) 339350

Similar factors have been found to contribute to the initiation of smoking and alcohol consumption in adolescents
with diabetes, namely: the presence of psychological disorders
(depression and anxiety) [132] and the use of smoking or drinking as a way of coping with treatment difficulties [133] and
improving self-image [134]. Also, the frequency of alcohol,
tobacco and solvent consumption is reported to be higher in
adolescents from the higher social classes compared with those
from lower ones [135].
One study found that young people aged 1020 years with
diabetes perceived themselves to be less at risk of adverse health
effects associated with risky behaviours, such as smoking, than
their peers [128]. This observation highlights the importance of
educating adolescents on the deleterious effects of tobacco and
alcohol consumption, and of offering alternatives to those who
wish to become accepted by their peers.

345

T1DM who smoke is the condom [143]. Nevertheless, even

if adolescents use oral contraception as their chosen method,
the use of condoms is necessary to prevent sexually transmitted
diseases.
Thus, PCPs need to inform young women and adolescents
with T1DM of both the appropriate contraceptive methods and
the importance of maintaining tight glycaemic control before
conception.
12. Therapeutic interventions in psychosocial disorders
Young people with diabetes and their families are often
referred by PCPs to psychiatrists and psychologists for
behavioural management services. The problems are usually
associated with treatment compliance and diabetic control,
social and coping skills, and diabetes-related anxiety and stress
management.

11. Contraception
13. Detecting high-risk adolescents
It has been reported that 50% of all teenagers aged 1519
years are sexually active. However, the prevalence of unplanned
pregnancy among adolescents with diabetes is no different from
that of their non-diabetic peers (4.6% vs 4.2%, respectively),
and 3.5% have sexually transmitted diseases (Chlamydia or
Trichomonas) [136]. This suggests that adolescent girls with
or without diabetes are engaged in less than optimally protected sexual activities, thereby increasing their risk of having
an unplanned pregnancy and sexually transmitted infectious disease.
However, pregnant adolescent girls with T1DM are at greater
risk of early miscarriage, preeclampsia, fetal distress [137,138]
and congenital malformations in their offspring, with a frequency of 69% [139,140], which is three to four times higher
than that seen in the general neonatal population (2%) [138].
However, intensive diabetes management during pregnancy has
been reported to reduce the birth anomaly rate from 10.9 to
1.2% [138]. Thus, for all young women with T1DM who wish to
become pregnant, intensified glycaemic control is suggested during the 4 months prior to conception and throughout pregnancy
[138]. Also, safe and effective contraceptive methods are essential for those women who wish to have a planned pregnancy
under optimal conditions [141].
Another problem lies in the choice of an optimal contraceptive method for young women with T1DM, as oral contraceptives
are associated with adverse metabolic effects such as changes in
blood pressure, carbohydrate metabolism and lipid metabolism
[142]. However, previous studies suggest that synthetic oestrogens (mestranol and ethinyloestradiol) have few adverse effects,
whereas 19-norprogestogens adversely affect metabolism [142].
Thus, oral contraceptives containing less than 50 g of oestrogen or a weak progestin, such as low-dose norethindrone, are
preferable [142].
So, although gynaecologists have limited experience of
contraception in young women with T1DM, oral hormonal contraceptives appear to be the first choice for contraception in
adolescents and women with or without diabetes [142144],
while the preferred contraceptive method for young women with

The first step towards successful intervention in patients who

are non-compliant with treatment is to identify the responsible
risk factors. These are either demographic or behavioural, and
may be related to either the child or the family.
Child-related risk factors include [61,145]:

older age (mid-adolescence);

presence of other health problems (asthma, eating disorders);
poor school attendance;
learning disabilities;
emotional and behavioural disorders, such as risk-taking
behaviours;
depression and/or anxiety;
unsatisfactory responsibility for treatment tasks.
Family-related risk factors include [62,146]:
single-parent family;
chronic physical or mental health problems (substance abuse
in parents or other close family member);
recent major life change for parent (job loss, death in the
family);
lack of adequate health insurance;
complex child-care arrangements;
health or cultural or religious beliefs that make it difficult to
follow the treatment plan;
a parent with diabetes who might have an outdated or inappropriate concept of care for a child with diabetes, and/or anxiety
or depression related to personal diabetes care affecting the
ability to learn and apply the recommended care for the child;
high levels of family conflicts;
poor family communication and problem-solving skills.
14. Prevention and early interventional strategies
If a child or family is identified as being at high risk of
non-compliance with treatment, they should be scheduled for

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K. Kakleas et al. / Diabetes & Metabolism 35 (2009) 339350

an outpatients follow-up with a psychiatrist or psychologist.

A number of interventions have been developed that offer support for improving treatment compliance. Behavioural contracts
involve negotiation between parents and teenagers with the
aim of reaching an agreement that will provide positive reinforcement for achieving treatment goals [147]. Self-monitoring
behaviours, learning problem-solving skills, and a multisystem
therapy that involves the individual, family, peers, school and
medical team all appear to increase compliance with therapy
and to improve metabolic control [148].
Important behavioural interventional plans should always
include the family of the patient with T1DM. The Joslin group
has conducted a series of interventional studies [149151] using
psychoemotional education and increased supportive contact
to enhance parental involvement in diabetes care, encourage
regular clinic attendance and reduce diabetes-related family conflicts. Although these studies reported success in achieving these
goals, they nevertheless had a variable impact on metabolic
control and no significant effect on the patients QoL [150].
As effective disease-specific social and coping skills are crucial for treatment compliance, these have been investigated in
a number of studies. Their findings show that interventions
improved patients treatment compliance and self-monitoring,
with subsequent improvements in glycaemic control [147,152]
and a decreased negative impact of the disease on QoL [153].
Other interventions have targeted anxiety and stress in children
with diabetes [154]. Some studies used biofeedback-assisted
relaxation [155] or progressive muscle relaxation [156] to lower
blood glucose levels. These interventions reduced stress in the
participants, but failed to improve metabolic control or treatment
compliance.
The above-mentioned studies reveal that stress-management
treatments are useful only in combination with other interventions that more directly target behavioural problems [154,157].
Multisystem therapy involves, in addition to the patient and
his family, the patients school, peers and medical team. School
personnel need to be aware and supportive of the childs potential
medical and psychosocial needs, and should be properly educated in how to identify and treat hypoglycaemia. Also, school
staff members should keep on the lookout for signs of depression, anxiety [158] and risk-taking behaviours (use of tobacco,
drugs, alcohol and sex) [99].
Attempts have been made to involve patients peers in diabetes management during adolescence. In one study [159], a
significant improvement in knowledge of diabetes in both peers
and adolescent patients with diabetes was observed, as well as
a decline in diabetes-related family conflicts.
Regarding the role of PCPs, five important contributions have
been suggested by Wysocki et al. [3]:
PCPs can promote family cooperation in diabetes management by encouraging family members to set realistic goals for
diabetes control and to maintain parental support throughout
adolescence;
periodic screening of adolescents for depression, anxiety, eating disorders and learning disabilities is essential;

PCPs should regularly assess the need for psychiatric or psychological services in patients and their families, and refer
patients to providers who are familiar with the psychological
aspects of paediatric medical conditions;
PCPs should advocate health promotion on a community level
for obesity prevention, and opportunities for exercise and
sports. They should facilitate the in-school management of
diabetes and also help in the transition from paediatric to
adult care;
PCPs should counsel patients and their families on the latest
advances in medical care, and also seek continuing education
on the psychological aspects of diabetes.
15. Conclusion
Adolescents with diabetes have an increased risk of developing eating disorders, depression and substance abuse, leading to
deterioration of diabetic control. Those at particularly increased
risk are female adolescents with family problems and coexistent psychiatric disorders. In addition, the presence of T1DM
contributes to family conflicts and problems with parentchild
relationships, poor school performance, employment difficulties and poor QoL. However, the contribution of friends and
family to improvement of metabolic control and to emotional
support is crucial. Insulin pump therapy appears to improve
patients metabolic control and lifestyle. However, PCPs play
an important role in identifying those adolescents with diabetes
who have an increased risk of psychosocial problems, and in
closely following them up in terms of glycaemic control and
referral to specialist support. PCPs should also cooperate with
the patients family and school personnel for identification of
risk-taking behaviours, and the proper management of the medical and psychological needs of adolescents with diabetes.
16. Conicts of interests
There are no conflicts of interests related to the above study.
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