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Yale program yields vastly improved control
Giving teen-agers with Type 1 diabetes some concrete tools to deal with real-world issues around their disease and around the transition to adulthood can make a major difference in metabolic control, Yale researchers have found.
Teens given cognitive restructuring and problem-solving training at the beginning of the four-year study not only dropped their HbA1c from an average of 9% to 7.8% in six months, but also improved overall metabolic control by 42%, according to Margaret Grey, RN, PhD, associate dean for research at the Yale School of Nursing in New Haven, CT.
The Coping Skills Training (CST) group and a control group received intensive medical management of their disease which included three or more daily insulin injections or an external insulin pump, self-monitoring at least four times daily, monthly outpatient visits, and interim telephone contacts over a four-year period.
The only difference in their treatment was that the CST group participated in at least four and as many as eight weekly sessions followed by monthly meetings that spread over six months.
Grey says her team was so impressed with the results that they offered CST to the control group after the first year of the study.
Those sessions, modeled after alcohol and drug rehabilitation programs, were intended to "increase the ability of adolescents with diabetes to cope with the problems they face on a daily basis and to be more effective in achieving therapeutic goals," Grey wrote.
Don’t see possibilities in the middle
If such training can give teen-agers a sense of competence by retraining them to appropriate forms of behavior, Grey theorizes, they will be better equipped not only to manage their diabetes effectively, but to manage their more generalized life experiences in a better way.
"Teen-agers have a black-and-white viewpoint of the world," says Grey. "They see a choice before them and they see it as entirely one way or another instead of the 100 possibilities in the middle."
For example, Grey says, a teen-ager out with friends who needs to check his blood sugar might see only two choices: monitor in front of friends who don’t know about his diabetes or don’t monitor at all.
"Often he will chose not to monitor at all, when there may be several other options. The Coping Skills Training helps him to see what those other options might be," Grey says.
Those same kinds of choices could bleed over into helping patients make healthy choices about what and when to eat, making decisions about drugs and even in handling conflict with parents and siblings.
The CST groups of two or three patients and a health care professional rely heavily on role playing, because it allows the adolescent to learn from a health care professional and from their peers.
"Most young kids with diabetes do really well," says Grey. "We all know it’s in adolescence that the problems begin. So if we can help them see alternatives, negotiate a win-win with them and sometimes with their parents we can help ease these transition difficulties."
Sticking with kids through those difficult times is an essential component of diabetes care for teen-agers, says Loretta Clark, RN, CDE, a diabetic nurse educator in the Johns Hopkins University Medical Center pediatrics unit in Baltimore.
Although Johns Hopkins does not provide specific coping skills training, Clark sees the value of it. "We provide support even at the darkest times for these kids, and those do happen during the teen-age years," she says.
Johns Hopkins’ diabetes program doesn’t have a specific coping skills component, but Clark says such training is provided on an informal basis.
Some health care professionals say any patient will do better if he receives additional attention.
Clark says it is part of her philosophy to give the teen-agers more nurturing, support, time, and recognition: "It’s important to recognize when they meet their goals and let them know they are doing well."
Grey rejects that the simple additional attention can be credited for the 42% improvement in metabolic control in the CST group. "They know perfectly well what they should do. What this program does is help them translate what they should do into what they are willing to do when they’re out there in the real world."
Most importantly, says Grey, the short course in coping skills seemed to stick with the teen-agers, at least over the four years of the study. She recently received a grant from the National Institutes of Health to continue her study of the original group for four more years. If her results hold up, they could mean a 25% reduction in long-term complications for those patients.
After the first year, the reduction in HbA1cs in the CST group held.
"They told us their quality of life had improved. That surprised and excited us," says Grey. "And they also said they could continue to take care of themselves better."
Grey plans to expand her work to preadolescents and their parents on the theory that metabolic and social crises could be prevented if children entered their teen years with coping skills firmly under their belts.
Translating coping skills training into the real world is not a terribly difficult or expensive task, says Grey, who says she is currently analyzing data to determine the actual cost of the program.
"It doesn’t take a highfallutin’ person to run the program. It’s quite straightforward," she says. "And the relative cost for the benefits the kids get in terms of potential long-term outcomes is really quite good."
Grey has made copies of her protocol available upon request for others. Contact her at (203) 737-2420.