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J. Indian Assoc. Child Adolesc. Ment. Health 2019; 15(1):85-109

Review article

Psychosocial issues in Type 1 Diabetes Mellitus: A review and proposal of a model for

evaluation and management in the Indian context

Sahithya BR, Vijaya Raman

Address for correspondence: Department of Psychiatry, 1st floor, St John’s Medical College

Hospital, Sarjapur Main Road, Koramangala, Bengaluru, 560034. Email id:

sahithyabr@gmail.com

Abstract

Type 1 Diabetes Mellitus (T1DM) is a major public health challenge globally. Children with

diabetes face unique challenges as the impact of the illness reaches far beyond the physical

symptoms of the disease. Emotional distress and psychosocial impact on the quality of life of

these children complicates the effective management of their disease, which can lead to long

term complications. This paper provides an overview of the psychosocial issues in T1DM by

reviewing existing literature and summarizing evidence-based interventions. Based on the

current empirical literature, a model that takes various psychosocial issues into consideration is

proposed in order to provide better care to children with diabetes.

Key words: Type 1 Diabetes Mellitus, psychosocial issues, evaluation, management

Introduction

Type 1 diabetes mellitus (T1DM) also known as insulin-dependent diabetes mellitus is caused by

loss of insulin-secreting capacity due to selective autoimmune destruction of the pancreatic beta

cells [1]. Typically, it first appears in childhood or early adulthood. Diabetes is a growing

problem posing a major public health challenge globally [2]. T1DM has a bimodal presentation

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for age of onset, with the first peak between 4 and 6 years of age; and second peak in early

adolescence [3].

T1DM is the most common form of diabetes in children and adolescents in most part of the

world [4], with approximately 50–60% of children diagnosed before the age of 15 years [5]. The

incidence of T1DM varies with age, gender, family history, and race [6]. Globally, the incidence

of T1DM is increasing at a rate of approximately 3% per year [7], particularly in children under

the age of 5 years [8]. Around 78,000 children under 15 years are estimated to develop T1DM

annually worldwide [9]. India accounts for most of the children with T1DM in South-East Asia,

with 3 new cases of T1DM/100,000 children aged 0–14 years [9]. However, the prevalence of

diabetes in India is variable, and range from 3.2 - 17.93 cases/100,000 children [10]. The

increasing incidence of T1DM is worrisome because it negatively affects the quality and

duration of life, mainly due to morbidity and mortality from its chronic complications.

The treatment goals for T1DM are simple and include maintaining near normal blood glucose

levels and avoiding long-term complications, however, it is a constant juggle between insulin

and maintaining an appropriate lifestyle [10]. While tight blood glucose control is paramount to

reduce the risk of diabetic complications, in practice it is very difficult to achieve. Despite the

considerable progress, glycemic control in children with T1DM remains suboptimal, thus placing

children at risk for developing long-term complications [11]. Short term complications of

diabetes include difficulties associated with hypoglycemia, ranging from tremor, confusion, and

lethargy, to stupor and seizures. Acute hyperglycemia can lead to polyuria, nocturnal enuresis,

weight loss, and risk for diabetic ketoacidosis, which can potentially cause coma and death [6].

In the long term, poorly controlled diabetes may lead to neuropathy and retinopathy, with

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increased risk of heart disease, kidney disease, blindness and lower limb infections leading to

gangrene [12].

Psycho social Factors

It is important to look at psychosocial factors associated with chronic conditions like T1DM

because they affect symptom severity, management as well as treatment adherence. The

prevalence of psychosocial issues in children with T1DM is high, and these children are at risk

of decreased psychological wellbeing [13]. One study found the prevalence for mild, moderate

and severe psychosocial issues in diabetic children to be at 8.33%, 27.38% and 20.24%

respectively [14]. Psychosocial problems can result in nonadherence to medications, decreased

quality of life, lack of interest in managing disease, and poor dietary compliance, resulting in

poor glycemic control and long-term complications [15]. Psychological factors and metabolic

control have a bidirectional relationship. Psychosocial factors affect glycemic control indirectly,

via their influence on adherence behavior [16], or directly via stress which is associated with

changes in glucose regulation in diabetic patients [17]. Some of the psychosocial problems

consistently associated with T1DM are diabetes distress, co-morbid psychiatric disorders,

cognitive deficits resulting in poor scholastic performance, adherence related issues, family

issues and needle phobia. Untreated psychosocial issues can lead to increased physical

symptoms, cardiovascular complications and depression [13] and needs to be screened and

addressed at the earliest.

Diabetes Distress

Children with T1DM may suffer from stress caused by having diabetes. Diabetes distress refers

to quality of life issue due to a combination of medical and psychological burden, as diabetes is a

chronic and complex malady that creates emotional distress [18]. Children with high diabetes

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distress show lower levels of satisfaction with life, self-esteem, and self-efficacy [19]. Diabetes

distress can influence diabetes management and treatment outcomes in an unfavorable way as

patients dealing with greater level of diabetes related emotional distress have lesser compliance

with anticipated treatment plan like adherence to dietary regimen, exercising on regular basis,

monitoring of blood glucose levels frequently, and taking medications as prescribed [20].

Intervening before symptoms of psychological distress start can prevent the development of the

diabetes distress [21].

Comorbid Psychiatric disorders

Children with T1DM are at a greater risk for emotional, behavioral and psychological difficulties

[22]. Young T1DM patients have higher prevalence of affective disorders [23]. Depression is the

most common psychiatric disturbance among diabetic children, following anxiety [24]. One

study found the prevalence of mild depression in T1DM youth to be at 14% while moderate to

severe depression at 8.6% [25]. Symptoms of depression are associated with an increased risk of

severe hypoglycemia, being hospitalized with diabetes complication, and poorer quality of life

[26]. In addition, diabetic children with emotional problems have more difficulties in disease

management than children with better psychological adjustment [24]. There is also increased

incidence of eating disorders among patients with T1DM [27]. The standardized mortality rate in

patient with concurrent T1DM and anorexia nervosa patients is 2.18 [28]. The high prevalence of

psychiatric disorders in children with T1DM increases the odds for repeat hospital admission for

diabetes [27]. This is because co-morbid psychiatric disorders result in poorer control of the

illness as such children are less likely to adhere to treatment regimens [29]. Hence, disturbed

children with diabetes are at risk for adverse physical and mental health outcomes. As

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maladjustment in children negatively affects glycemic control and subsequent metabolic

functioning [6], psychosocial supports are crucial in managing children with T1DM.

Cognitive Deficits

T1DM is a key risk factor for cognitive deficits, and children with T1DM have mild cognitive

impairments [30]. T1DM may adversely affect children's verbal intelligence quotient, resulting

in a decreased full intelligence quotient [31]. Before diagnosis and treatment, children with

T1DM may have experience prolonged hyperglycemia; and post treatment, they are vulnerable

to blood glucose excursions, both hypoglycemia and hyperglycemia, putting these children at

risk for cognitive side effects. Children with longer duration of diabetes, earlier age of diabetes

onset have lower test scores in comprehension, abstract reasoning and intelligent quotient

compared to non-diabetics [32]. They tend to have significantly more school absences, and

although for most children, diabetes alone is not associated with lower academic performance,

poorer academic performance tended to occur in children with poorer diabetic control [33].

Hence children with T1DM need special clinical attention where their academics are concerned.

Adherence related issues

Diabetes presents unique issues for children as it requires strict adherence to daily treatment

tasks. Simple things, such as going to a birthday party, playing sports, or staying overnight with

friends or relatives need to be carefully planned. Diabetes management demands strict dietary

and exercise regimens, frequent blood glucose monitoring, and adherence to medications, but in

a developing child this can be a huge challenge [6]. This results in higher risk for reduced

physical, emotional, and social well-being in terms of quality of life [15]. As a result, diabetes in

children is associated with stress and distress for both the child and the family. Nonadherence is

tightly linked to suboptimal glycemic control, increasing morbidity, and risk for premature

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mortality [34]. Hence, it is essential to instill routines in child's daily activities to increase the

likelihood of treatment adherence [35].

Family issues

Families play key role in the adjustment of children to diabetes; therefore, issues in family can

greatly influence glycemic control [36]. Family factors that predict poor glycemic control

include low family support, single parent, and family conflict [37]. Children who experience

high levels of family conflict show poor adherence to treatment [38]. Conflicts over diabetes

management may also lead to stressful parent-child relations. Stressors such as divorce, family

arguments, or abuse can lead to elevated blood glucose levels [39]. Dysfunctional family

interactions, authoritarian parenting, and diabetes-related family stress have been consistently

associated with worse glycemic control [40]. Authoritative parenting style, characterized by

warmth and structure, is associated with better adherence to the diabetes regimen; while, poor

communication skills and family conflict are associated with problems with adherence and

glycemic control [41]. Diabetes is stressful for both the children and their families. The presence

of a chronic pediatric condition is a recognized source of distress among family members, which

can lead to disruptions in intrafamilial relationships, family structure, and family cohesion [42].

Caregivers may feel that they need to be vigilant and constantly monitor their child’s diabetes

[43]. Parents often worry about long-term complications, and may have conflicts over

management, such as diet issues, poor adherence to treatment, and child’s resistance to the

painful process of injection, all of which influence the child’s glycemic control [40]. They fear

that their child will experience severe hypoglycemia, especially when it is associated with

adverse reactions like seizures or a loss of consciousness. They are extremely concerned about

how poor glycemic control is influencing their child’s physical growth and development; often

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feel guilty for having transmitted the genetic components of diabetes to their child; and worry

that they have not done enough to manage the disease [44]. Parents also report feelings of

depression and anxiety, which may be precipitated by their guilt or worry about the child’s future

[41]. Also, the close parental supervision that children with diabetes demand can lead to sibling

rivalry, and siblings may fear developing diabetes themselves [44]. Hence, there is a need for

family intervention by a supportive health care team.

Needle phobia

Another common issue in children with T1DM is fear of self-injecting and self-testing. The

process of injecting and blood glucose testing through finger pricking can cause high levels of

distress [45]. Not only the child’s personal experiences, but parent's reactions to needles can also

play a role in child’s anxiety. Very few research studies are available on prevalence of needle

phobia in T1DM. One cross-sectional study reported that 32.7% children with T1DM having

multiple daily injections had needle fear [46]. Intense fear of self-injecting insulin can precipitate

psychological distress, poor adherence and compromise glycemic control [47]. Successful self-

management involves routine self-testing and self-injecting of insulin. As metabolic control may

be improved by reducing the fear of injection [48], screening for needle phobia is necessary.

Role of Mental Health Professionals

The care of children with T1DM involves complex procedures including daily blood glucose

testing, dietary monitoring, intensive insulin therapy and physical activity to maintain metabolic

control in the face of pancreatic failure. Not only do children with T1DM struggle with adhering

to a complex medical regimen and daily completion of multiple self-care behaviors, but they also

face a number of stressors and challenges which includes the impact of diabetes on social

interactions with family members, peers, and teachers; and the interference of symptoms such as

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hypoglycemia with daily activities. Although children with diabetes are at a greater risk for

emotional and behavioral problems [49], psychological aspect of the disease is often missed with

most of the emphasis being given to the strict maintenance of blood glucose. As many of the

barriers to and facilitators of treatment adherence in pediatric diabetes are psychosocial in nature,

the child may need support from mental health professionals who can help the child and family

through the challenging times. Mental health aspect of diabetes management is being

increasingly recognized, and it is recommended that children with diabetes and their families are

given timely and ongoing access to mental health services as they may be experiencing

psychological issues that impact the management of diabetes.

Researchers have looked at role of psychologists in providing behavioral intervention as part of

multidisciplinary diabetes care, and have found that mental health professionals play significant

role in facilitating adherence behaviors [50]. It is therefore important that children diagnosed

with diabetes and their families undergo a psychosocial assessment and a psycho-education

session at diagnosis. A referral may be made to a mental health professional when there is: poor

adherence and resistance to treatment, issues with family, siblings and peers, limited social

support, academic difficulties, co-morbid psychiatric illness such as anxiety, depression, eating

disorders, behavioral problems, body image disturbances, and so on.

Psychosocial Evaluation

Psychosocial assessment, psycho-education and treatment are an ongoing process. Multi-

informant approach to the assessment of symptoms of psychological difficulty in children with

diabetes has been found to be of great value in management of psychosocial problems [26]. A

detailed evaluation of the child and family is the first step. American Diabetes Association [51]

recommends assessment of symptoms of diabetes distress, Comorbid psychiatric disorders and

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cognitive deficits using appropriate standardized tools at the initial visit, at periodic intervals,

and also inclusion of caregivers and family members in this assessment. Life circumstances that

can affect physical and mental health outcomes, child’s strengths and difficulties, family issues,

parenting styles, sibling relationships, stressors, child’s temperament and coping styles should

also be incorporated in the assessment as they help plan an effective management. Interview with

the child will provide crucial information about how the child perceives the illness, locus of

control, impact of the disease on the child’s life, academics, peer relationships, family

relationships, and perceived support from various sources. However, to elicit such intimate

information it is important to establish good rapport with the child. Understanding the child’s

difficulties is requisite in planning management, and an individual treatment plan may be made

based on the outcome of the assessment.

Some of the assessments tools that may be used to screen children who may need psychosocial

support are:

� The Pediatric Quality of Life Inventory [52]: is an instrument designed to measure

health-related quality of life in children.

� Issues in Coping with IDDM- Parent/Child scale [53]: is used to measure perceptions and

issues related to their diabetes management.

� Diabetes Knowledge Scale - child version [54]: is a questionnaire to measure knowledge

about diabetes in children.

� Child Behavior Check List [55]: is a screening tool to assess for children’s behavioral and

emotional problems in children.

� The Revised Child Anxiety and Depression Scale [56]: is a self-report measure intended

to assess children's symptoms corresponding to anxiety and depression.

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Management

American Diabetes Association [51] recommends that psychosocial problems be addressed as

soon as they are identified, and if an intervention cannot be initiated during the visit when the

problem is first identified, then a follow-up visit or referral to a qualified professional may be

scheduled during that visit. Management plan for children with T1DM will need to address

various issues, and include a complete psychoeducation to the child and all family members

regarding the cause, course and future management challenges, as well as clearing myths and

misconceptions. This will include addressing practical problems such as storage of insulin, and

deciding who will be responsible for injections, monitoring of diet, etc. Other concerns include

dealing with parental psychopathology if any, and ensuring parents do not overprotect or restrict

child’s activities. There is also a need to ensure some semblance of normalcy in child’s life by

not allowing diabetes to overshadow everything else.

Psychologists will need to work with the child, family, siblings and sometimes peers in order to

facilitate change. Behavioral change often fails when patients are coerced but succeeds when

practitioners work with patients to build discrepancy between their behaviors and aspirations,

and then support the patients as they contemplate and ultimately make change for their own

salient reasons [34]. It is also important for psychologists to look out for mental health issues

such as depression, anxiety and cognitive deficits. A number of techniques including behavioral

strategies, cognitive behavior therapy, family therapy, group therapy may be used depending on

the presenting complaints. Some of the common techniques used are:

Motivational interviewing

Motivational interviewing is one approach designed specifically to help facilitate health behavior

change [57]. It is a collaborative conversation style that elicits intrinsic motivation by guiding

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patients to explore and resolve ambivalence about behavior change by evaluating their perceived

pros and cons of change in relation to their current lifestyle, and thereby strengthening

commitment to behavior change. Motivational interviewing has had promising results in short-

term, uncontrolled studies in children, with significant improvements in anxiety, positive well-

being, satisfaction, and belief that self-care mattered in control of diabetes [34].

Adherence intervention

Adherence interventions using a combination of educational, behavioral strategies and problem-

solving skills have been shown to promote adherence in children [58]. Working together with the

child to solve problems with adherence gives the counselor a chance to reinforce problem-

solving skills [59]. Health care provider team, in partnership with the child and caregivers, can

develop a personal diabetes plan for the child that puts a daily schedule in place to keep diabetes

under control. The plan helps the child follow a healthy meal plan, get regular physical activity,

check blood glucose levels, take medication as prescribed, and manage hyperglycemia or

hypoglycemia. Visual reminders and cues may also be used to aid the child. For example,

leaving medication where it is sure to be noticed, or leaving notes to themselves, or pairing

taking medications with other well-established behaviors such as eating meals or brushing teeth.

A major barrier to self-management and compliance is fear of needle. Children may be taught

techniques to reduce the pain during finger prick such as pricking the lateral aspect of the finger

and avoiding pricking the thumbs and index fingers or to utilize alternative testing sites for some

time [60]. Additionally, techniques such as distraction, hypnosis, systemic desensitization,

coping skills, combined cognitive behavior therapy, and relaxation techniques such as deep

breathing, have been found to help children with needle phobia [61] [62].

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Family Intervention

Managing diabetes in children is most effective when the entire family gets involved. Family

involvement is an important predictive factor for glycemic control [40]. Participation of the

entire family in educational programs on disease management and psychotherapeutic programs

for stress management will help children deal with the stress of treatment and achieve desired

glycemic control, as parent’s behavior is a factor for creating independent and responsible

patients who can take care of their diabetes [40]. Diabetes education should involve the child as

well as family members. Families can be encouraged to share concerns with health care

providers to get their help in the day-to-day management of diabetes. Various researches have

acknowledged the importance of the family–patient construct [34]. Therefore, many behavioral

interventions have aimed at optimizing adherence and glycemic control in children with diabetes

by targeting the family unit. It is essential to maintain family support around diabetes

management tasks, as children of families who sustain parental involvement in diabetes

management have better outcomes [63]. Family communication, conflict resolution, and

problem-solving skills are critical elements of effective family management of diabetes in

children [64]. Interventions become successful when children benefit from understanding,

support, and skills of family members in a context that avoids diabetes-specific family conflict;

by assisting parents and children work on communication skills, problem solving, and

minimizing family conflict in relation to diabetes [34]. Moreover, parents value education from

health care professionals that would provide them with solutions to diabetes management

dilemmas [65]. Mental health professionals can support caregivers by helping them identify their

strengths and by providing affirmations and encouragement if their confidence for managing

their child’s diabetes decreases. Parents also need to be taught to be alert for signs of depression,

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anxiety eating disorders; and seek appropriate treatment. Addressing parent’s fears, guilt and

sibling rivalry are also equally salient in management.

Peer Intervention

Peers can be a significant source of constructive support. Peer group intervention is aimed at

increasing diabetes knowledge and social support by teaching them how to be supportive, in

order to increase their positive influence on the child’s diabetes care regimen. Encouragement by

peers helps children perform diabetes related tasks which they had been afraid to do previously.

Talking with other children who have diabetes helps children feel less isolated and less alone in

having to deal with the demands of diabetes. They get an opportunity to discuss issues they share

in common that others in their peer group may not understand, and they can share solutions to

problems they have encountered. Often, these programs teach children how to deal with

increased exercise, reinforcing the fact that diabetes should not limit them in their ability to

perform strenuous physical activity. However, although assessment of peer support has received

some attention, there are limited studies that have examined the impact of peer support on

children’s diabetes management. In one pre-post trial where adolescents with diabetes and their

best friends participated in a group intervention, adolescents and their friends demonstrated

higher levels of knowledge about diabetes and support, as well as a higher ratio of peer to family

support, improved self-perception, and decreased diabetes-related conflict post intervention [66].

Recent research suggests that peer-based interventions could help manage diabetes, by increasing

knowledge, coping, quality of life, self- confidence, self-care, satisfaction with the perceived

social support, social skills, and diabetes-related conflicts which have a significant bearing on

compliance and management [67].

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Special issues in India

Despite being the most common chronic disease in children and adolescents, T1DM has not

received the attention it requires in India. Many children die of undiagnosed diabetes or shortly

after diagnosis because of poor blood sugar control [68]. It has been found that T1DM is

encountered majorly in the under-privileged children [69], and most T1DM cases are dealt in

government hospitals as they offer free supply of insulin [70]. The wide disparities in

socioeconomic levels, educational background, and availability of diabetes care pose major

hurdles in the management of this disease in India [69]. Challenges in Indian population include

lack of awareness of the disease amongst general public, stigma, looking for a cure using native

treatments, and lack of information about packaged foods and nutritional needs of the child.

Ignorance may be due to low participation rates in educational programs, as India has one of the

lowest participation rates in educational problems [71]. Another concern is the lack of

accessibility to health services, especially in rural India leading to long distance travel to health

services. Barriers to care are at many levels, right from diagnosis to availability of trained

physicians, infrastructure, insulin, and psychosocial support. Although urban population has

better access to reliable screening methods and treatment; investigation facilities and

infrastructure are poor in rural areas. Insulin availability, acceptability, affordability and storage

are also major concerns with up to 80% patients lacking a good storage facility at home [69].

These issues may result in poor diabetes screening and non-adherence to diabetic management

[72]. There is also a wide variation in treatment across the country due to lack of standardized

treatment guidelines and protocols.

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Proposed Psychosocial Intervention Model in T1DM

Psychosocial problems are well established and accepted as a significant contributor to symptom

severity and treatment adherence in children with diabetes. However, there is a lack of attention

given to psychosocial issues in management of diabetes in children in India. While, improved

access to care and better health outcomes for children with T1DM are desirable, there is no clear

consensus on how best to achieve these goals [11]. Most of the intervention studies are

conducted in Western countries and its applicability considering the unique challenges that are

usually encountered in the Indian context is not known due to dearth of randomized control trials

on effectiveness of such interventions.

Although importance of addressing psychosocial issues is recognized, there are no specific

guidelines or models available for screening and intervention for unique psychosocial issues in

children with T1DM in India. Furthermore, it is not known to what extent the pediatric health

care professionals identify and address psychosocial issues in children. Hence, simple and

practical guidelines that can be easily incorporated into routine clinical practice are the need of

the hour.

Based on the current empirical literature and guidelines issued in western countries [73], we

propose a model that takes various psychosocial issues into consideration in order to provide

holistic care to children with diabetes, and to prevent escalation of mental health issues by

addressing them at the earliest. The goal is to:

1. Promote screening and periodic assessment for all children diagnosed with T1DM for

early identification of psychosocial problems and referral to appropriate professionals

when they cannot be managed in primary care setting.

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2. Help the child achieve a developmentally appropriate awareness of the nature of his or

her condition in order to increase treatment adherence.

3. Promote self-management through diabetes education.

4. Encourage parental involvement in order to build a strong child-caregiver management

unit, so that parents can serve as coaches, and help monitor their child's increasing

responsibility for self-management.

In order to meet the above-mentioned goals of diabetes education, treatment adherence and self-

management, we recommend following procedures:

1. Multidisciplinary Team: Management of children with T1DM requires a

multidisciplinary approach. In order to optimize the effectiveness of care and reduce the

risk of complications, it is critical that the diabetes care team include members with

appropriate training in clinical, educational, diet and lifestyle, as well as mental health

aspects of children with diabetes.

2. Diabetes Education: Diabetes Education may be provided following diagnosis of

diabetes which is considerate of child’s developmental level. Diabetes education must

address questions such as, what is diabetes, what are acceptable blood glucose levels,

what is insulin therapy and injection technique, and what is hypoglycemia and risks

associated with it. Ongoing diabetes education is recommended during subsequent

follow-ups. The diabetes education should also promote self-management by teaching

children to monitor blood glucose levels regularly, identifying symptoms of

hypoglycemia, to take medications as prescribed on time and to take the injections

themselves.

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3. Nutrition education: Nutrition education is aimed to educate the child and family on

different types of food and its impact on the body, healthy eating guidelines, food

selection and preparation; and also address difficulties that may be encountered in

monitoring calorie intake, conflict or stress associated with food, eating patterns or blood

glucose control. A meal plan may be prepared that is age appropriate which not only

ensures proper nutrition for growth but also helps keep blood glucose levels in the target

range. Portion sizes and healthy food choices at meal and snack time should also be

discussed.

4. Physical activity Education: Children and their families must also be educated about

importance of regular physical activity. The child and their families must be assessed for

family lifestyle, current physical activity level and limitations, and must be educated

about insulin effects, benefits, risks and optimum levels of activity, so that they have

glycemic awareness and control before, during and after physical activity.

5. Addressing mental health issues: Psychologists, social workers and psychiatrists play an

integral role in the management of children with T1DM and their families. The child

may be screened for psychosocial issues and mental health difficulties at initial diagnosis

of diabetes, and may be periodically evaluated for mental health issues during follow-

ups. Issues such as needle phobia, depression, anger, anxiety, behavior problems, eating

issues or body image disturbances, and other mental health issues which are beyond the

scope o the physician may be addressed by them. Subtle issues which often go unnoticed

such as guilt and grief, bullying, low self-esteem, marital stress, family conflicts and

treatment adherence may also be addressed during therapy sessions. Another major

concern is cognitive deficits and academic decline. Children with T1DM require a

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routine academic or cognitive screening, and when found positive, they may be further

evaluated through neuropsychological assessments. Such children may require

supportive measures within the school and at home.

Conclusion and Future Directions

T1DM is the most common endocrine-metabolic disorder in children worldwide, and has shown

an exponential rise in recent years. These children face a lifetime of diabetes ahead. The impact

of the illness reaches far beyond the physical symptoms of the disease. Often the emotional

distress, psychiatric comorbidity, and psychosocial impact on the quality of life of these children

complicates the effective management of their disease, but may remain hidden for years before

clinicians recognize the extent to which the psychosocial and behavioral components of diabetes

are impacting both the course and prognosis of the disease.

In India, the availability of psychological support is quite low for patients with T1DM [13],

which may be attributed to lack of awareness of such services, or lack of effective referral

systems. Hence structured programs involving diabetes awareness and patient education are

required. Printed educational materials such as videos and booklets with illustrations may be

developed in regional languages to improve knowledge and adherence to treatment. It is

imperative that mental health professionals become more interdisciplinary, familiar with larger

health care culture, willing to expand their skill sets, and collaborative with other health

disciplines both from a patient-care and a larger advocacy perspective [74].

Anganwadi workers who have been a bridge between the rural population and doctors, have been

underutilized in management of children with diabetes. With adequate training, Anganwadi

workers can help combat the current diabetes epidemic in India. An optimal treatment plan

requires paying attention to every nuance of a complex condition like T1DM, in order to enable

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individuals to manage their condition without experiencing diminished quality of life [75].

Hence, there is a need to develop interventions that consider various factors such as cultural

influences, personal, family, and community resources, and provide a tailor-made care that goes

along with the lifestyle of the individual, as such interventions are more likely to be successful

[76].

Going forward, crucial roles for psychologists will be to adopt and advocate a public health

perspective, to investigate efficacious interventions which may be easily implemented in routine

pediatric diabetes care, and to develop strategies to train mental health providers, Anganwadi

workers and medical practitioners to evaluate and treat common psychosocial issues that impact

children with T1DM. This integration of psychosocial care and ensuring access to services will

greatly benefit the children with T1DM and their families.

Conflict of interest: None declared

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Sahithya BR, PhD Scholar, Vijaya Raman, Professor of Clinical Psychology, Department of

Psychiatry, St. John’s National Academy of Health Sciences, Bangalore