INT’L. J. PSYCHIATRY IN MEDICINE, V O l . 7 ( 2 ) ,1976-77

PSYCHIATRIC STATUS OF DIABETIC YOUTH IN GOOD AND POOR CONTROL

JOHN F. SIMONDS, M. D. Associate Professor of Psychiatry University of Missouri School of Medicine

aBsrRacr Two groups - identified as “good control” and “poor control” - of 40 diabetic youth, between 6 years and 18 years, matched for age, sex and duration of diabetes, were interviewed by a child psychiatrist who was not aware of the status of their diabetic control. After each interview psychiatric diagnoses, interpersonal conflicts and noninterpersonal conflicts were determined. At the same time, mothers completed a children’s behavorial-emotional symptom checklist. Six psychiatric diagnoses were made (7% per cent occurrence): four in the poor control group and two in the good control group, not a significant difference. Fifty per cent of the psychiatric diagnoses were found in the prepubertal girls who had the earliest onset of diabetes. A significantly greater number of patients in poor control had interpersonal conflicts compared with patients in the good control group. Mothers of patients in poor control had checked significantly more behaviors as slight and considerable-severe problems compared to mothers of patients in good control. Five per cent of the patients in good control and fifteen per cent of the patients in poor control stated that they experienced a “different” self-image because of their diabetes. The frequency of psychiatric diagnoses (7% per cent) for the entire group was not higher than literature reports of serious psychiatric disorders in normal population studies.

Introduction Medical control of diabetes in children and adolescents is essential for the prevention of later complications. Good control depends on daily insulin injections, urine testing for sugar three or four times daily, adequate exercise, appropriate meal planning and avoidance of sweets. Poor diabetic control has often been attributed to psychological disorders in the patient. This study undertook to investigate the psychiatric status of diabetic chddren and adolescents. The research results hoped to clarify statistically 133 0 1977,Baywood Publishing Co.. Inc.

doi: 10.2190/UPB0-49X7-UJMP-M3TM http://baywood.com

134 / JOHN F.SlMONDS

whether there were differences in the psychiatric status of youth who were in poor diabetic control as compared to children who were in good diabetic control and whether age, sex and duration of illness were significant variables.

Review of Literature Many authors have compared diabetics and non-diabetic controls with varying conclusions. Swift et al. found the diabetic group to be less adequate in self percept and to manifest a greater degree of anxiety and dependency [ 11 . He gave an abnormal psychiatric classification to 50 percent of the diabetic group and also found the home and peer adjustment to be significantly worse among diabetics. Greater intelligence, higher family income, birth orders after first born, later age of onset and shorter duration of illness were associated with better diabetic control. In the Loughlin et al study of 114 diabetic children attending summer camp, 40 percent were considered pscyhologically abnormal and ketosis was twice as frequent in this abnormal group [2]. Other studies have also stressed the maladjustment of diabetic children [3-91. Kubany et al. on the basis of MMPI studies concluded that diabetics were no more predisposed to behavioral abnormalities than non-diabetics [ 101 . Khurana et al, after questioning children and parents at a diabetic summer camp, regarded the children to be reasonably adjusted depending on the adjustment and acceptance of the parents [ 1 11 . Poor diabetic control seemed to occur more often when parents were indifferent. More recently Olatawura compared fifty children between five years and thirteen years with fifty matched controls [12]. The results of interviews and behavior ratings indicated that diabetic children were not significantly more disturbed than controls. In Sweden, Sterky found the frequency of mentally disturbed children to be the same in both diabetic and non-diabetic groups of children on the basis of mental status observation and historical report of mental symptoms [ 131. With advancing age, however, the diabetic group had an increase both in the number of children with mental symptoms and in the number of mental symptoms per individual. The diabetics in poor control lived in unfavorable family situations and displayed greater frequency of mental symptoms. Diabetic control has also been the subject of clinical research study. Crowell [ 141 ,comparing various psychological test results of seventeen diabetic patients in good control with fourteen diabetic patients in poor control, and with twenty-two rheumatic fever patients, found no significant differences between the diabetics in good control and those in poor control and attributed previous differences between groups to social class differences. Koski [15] ,in a comparison of thirty diabetic Finnish children in fair to good control and thirty diabetic children in poor control, found that those in poor control had a Younger age of onset and a longer duration of illness and most likely came from families of the lower social classes. The psychiatric status as determined

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from interviews was judged to be a neurosis or personality disorder in eleven patients with good control and in eighteen patients with poor control. Another author, Sexton, regarded psychopathology to be more important than pathophysiology in determining the control of diabetes [ 161 . The adjustment of children to their diabetes seems to depend on a number of factors. Bennett and Johannsen suggested a relationship between personality and such factors as duration of diabetes, insulin dose, insulin reactions, parental control, sex difference, age difference and socioeconomic status [I71 . On the other hand, Fisher et a1 found no relationships between duration of disease, age of onset of disease, severity of disease and the type of later behavior [ 181 . Parental reactions to a child’s diabetes can affect the degree of the child’s adjustment and thus the level of diabetic control. Parental attitudes to children’s diabetes were classified by Starr as “overly indulgent,” “overly anxious,” “controlling punitive” and “disinterested neglectful,” and the resulting types of psychopathology in the children as “anxious personality,” “compulsive personality,” “depressive personality,’’ “passive-dependent personality” and “delinquent personality” [ 191 . The child or adolescent can affect his diabetes negatively by eating too little, too much or the wrong foods, not checking his urine, fabricating a urine report to be positive or negative, forgetting his insulin injection, or taking too much or too little insulin; the motivation for such behaviors may be to punish self [20], to punish parents [21] , to gain sympathy [20], or to assume a more dependent role. When diabetes has its onset in childhood, the treatment techniques would seem to create more adjustment problems than the disease itself. The young child must be taught how to check his urine for sugar and acetone and, eventually, how to give his own insulin injections. Diet restrictions and the feeling of being different may also be a problem for the adolescent who is trying to identify with his peer group. Since restriction of physical activities is no longer a therapeutic practice, most diabetic children do not appear different from their peers except in their dietary limitations. The emotional aspects of diet regimentation, insulin injections, urine testing and the importance of the physician-patient relationship have been summarized [22]. Emphasizing the effects of regimentation, Kennedy claimed that psychological problems of diabetic children were due to diet restrictions which led to compulsivity and delinquency [23]. Lichtenstein also raised the question of the diet producing harmful effects on mental development and character formation [24], stating that the “liberation of a diabetic child from its position of being different from other children must be beneficial to the child’s mental development, character formation and social adjustment.” In a study by Knowles et al [6] ,on the other hand, the unmeasured diet appeared to affect a group of diabetic patients no differently from the rigid diet. When two groups of diabetic children were placed on a “strict regimen” and a “not so

136 I JOHN F.SIMONDS

strict regimen,” Sterky found no differences in mental symptoms between the two groups [ 131 . One would assume from the conflicting literature that diabetes may produce emotional problems in some predisposed children who might have developed emotional problems no matter what the stressful circumstances. Emotional problems in turn can affect diabetic control, the final determination of which is dependent on multiple factors. Methodology The diabetic population for this study was selected from children and adolescents 6 years of age and older, under treatment for at least six months at the University of Missouri Medical Center. At the time of the investigation there were 180 patients coming regularly for diabetic followup care. Twenty-two of the patients were under 6 years of age and thirteen of the remaining patients had been under Medical Center care less than six months. The children’s diabetic treatment program at the University of Missouri Medical Center is directed by Dr. Robert Jackson who utilizes insulin injections twice daily and structured quantified meal planning to attain, insofar as practicable, freedom from hypoglycemia and glycosuria [25]. DIABETIC CONTROL RATINGS

At the time of each outpatient clinic visit a diabetic control rating was made by the treating physician. Of the five possible categories of diabetic control, the percentage of patients older than six years and under treatment longer than six months were: good control (22.1 percent), good to fair control (26.9 percent), fair control (13.8 percent), fair to poor control (32.4 percent) and poor control (4.8 percent). The criteria used for determining the category of control were based on: 1) historical data obtained from parents or guardians with due consideration given to the reliability of the history, 2) reliable urine test reports from home, 3) physical examination, especially growth rate and presence or absence of insulin pads, and 4) laboratory data at the time of the examination (e.g., urine and blood tests). It was assumed that the diabetic control rating made by the diabetes expert was a valid measure. Jackson and Guthrie summarized the following objective criteria for determining the five diabetic control ratings [25]. 1 ) Good diabetic control: occasional (less frequently than every other day) minimal transient glycosuria, i.e., no more than a trace of sugar in one of four daily urine specimens, no known ketonuria, no clinically significant hypoglycemia. 2) Good fo Fair diabetic control: minimal transient glycosuria in 10 percent to 25 percent of urine specimens, no known ketonuria, no clinically significant hypoglycemia. 3) Fair diabetic control: minimal glycosuria in 26 percent to 5 0 percent of urine specimens, occasional ketonuria especially during infection, some episodes of mild hypoglycemia.

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4 ) Fair to Poor diabetic control: 5 1 percent to 75 percent of urine specimens have varying amounts of glucose, occasional ketonuria, occasional ketoacidosis, some clinical episodes of moderate hypoglycemia may occur. 5 ) Poor diabetic control: varying amounts of glucose in most urine specimens, i.e., more than 75 percent of specimens, more frequent episodes of ketoacidosis, clinical hypoglycemia may occur more frequently, growth rate may be decelerated.

DIABETIC CONTROL: CASE EXAMPLES

The following case histories of patients are characteristic of the specific categories of diabetic control:

1) Good: A 15-year-old boy, diagnosed as diabetic seven months prior to the interview, was taking 30 units of insulin daily and was following a 2800 calorie diet. Since onset of diabetes his urine tests were 98 percent negative for sugar and 100 percent negative for acetone. Blood sugar level was 90 mg percent at 10 a.m. He had never experienced ketoacidosis or insulin reactions. Physical examination was normal and his weight was at the 55th percentile. The boy was active in sports and social activities. His parents had a good understanding about the diabetic condition and maintained supervision over the youth’s selfmanagement. 2) Good to Fair: A 13-year-old boy, whose diabetes was over 10 years duration, had maintained 75 percent of his tested urine specimens free of any glycosuria. Following the onset of his diabetes he had never been acidotic and during upper respiratory infections he would require supplementary doses of insulin. Insulin reactions were infrequent and not clinically significant. His weight was at the 84th percentile and his height almost one standard deviation above the mean. Since the youth was slow to understand management techniques, both parents shared giving injections and testing the urine. At the time of interview there were no physical abnormalities and a 10 a.m. blood sugar was 70 mg percent. 3 ) Fair: A 13-year-old boy with diabetes for five years was taking 36 units of insulin and following a 2400 calorie diet. His family had a difficult time managing the boy’s diabetes because of mother’s poor health and financial problems. The boy did his own urine testing which was regarded to be of questionable reliability. About 50 percent of the urine specimens tested were free of glucose and the positive specimens were mostly 1+ and 2+. Occasionally the urines showed positive acetone. There was never any history of ketoacidosis, and insulin reactions occurred once monthly. Physical examination was normal, weight was at the 40th percentile, and 9:40 a.m. blood sugar was 102 mg percent.

4) Fair to Poor: A 13-year-old girl from an affluent family had been diagnosed as a diabetic two and one-half years prior to the psychiatric interview. She followed a 2400 calorie diet and took 30 units of insulin daily. Her diabetic control had progressively worsened and she twice required hospitalization for

138 / JOHN F.SlMONDS

ketoacidosis. For six months prior to interview, 60 percent of her urine tests had been positive for sugar and 15 percent of the urine tests were positive for acetone. Insulin reactions occurred once or twice monthly. The girl was overindulged by her parents and consequently would eat sweets when she desired. Mother had some trouble following instructions for the management of her daughter’s diabetes during illness. At the time of evaluation physical exam was normal, weight was at the 16th percentile and mid-morning blood sugar was 420 mg percent. 5) Poor: A 13-year-old girl from a family of low socioeconomic status had diabetes for more than ten years. Her permissive parents did not carefully supervise her choice of foods. She usually ate large quantities of food and her weight was at the 99th percentile. Although during the first six years of her diabetes insulin reactions were frequent, these reactions diminished markedly in the next four years. Ketoacidosis was never a problem. During the six months prior to her interview 90 percent of urine specimens were positive for glucose (ranging from 2+ to 5+) and occasional urine specimens were positive for acetone. At the time of evaluation she was taking 95 units of insulin daily. Her physical examination was normal except for some areas of atrophy on the thighs and marked obesity. A noon blood sugar was 170 mg percent. PSYCH1ATR I C STATUS

The psychiatric status of each subject was evaluated by the investigator on the basis of a forty minute semistructured psychiatric interview without the presence of a parent (see Table 1). The exact wording of the questions was modified to suit the age and educational level of the subject, and if particular responses suggested conflicts, the problem area was explored in detail. This study assumed the validity of the psychiatric interview for determining psychiatric diagnoses [26]. The purpose of the interview was to elicit the nature of relationships between the youth and family members and peers, to inquire about specific behavioral-emotional responses, to evaluate study, work and play habits, and to determine reactions to diabetes and treatment regimen. Because of time and family inconvenience factors, the investigator was not able to conduct separate interviews with the parents, a technique often helpful but not essential to making a psychiatric diagnosis. Psychiatric status of subjects was determined at three levels of severity (progressing from the most severe to the least severe): 1) Those with psychiatric disorder, diagnosed according to the criteria in the Group for the Advancement of Psychiatry’s report on children’s diagnoses [27]. (When no diagnosis was made, gross psychiatric normalcy was assumed, based on the following criteria: a) intact ability to relate to most people in the youth’s environment, but this did not exclude conflicts with certain individuals, b) progressive social, cognitive, emotional, sexual and

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Table 1. Guide for Semistructured Interview with Children and Adolescents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.

What makes you happy? How d o y o u know when you are happy? What makes you sad? What d o you do when you are sad? Are you sad or happy most o f t h e time? What makes you nervous? [Explain nervousness t o subject.] H o w d o you know when you are nervous? Are you calm or nervous most o f the time? What makes you angry? H o w frequently d o you get angry? What d o you d o when you are angry? What do you like most about yourself? What d o you dislike most about yourself? What i s the best thing that has happened t o you? What is the worst thing that has happened t o you? What i s the worst thing you have ever done? What d o you like most about your family? I s there anything about your family you would like t o change? Do you feel accepted in your family? What chores d o you have t o do? What d o you t h i n k about your parents' rules? H o w d o your parents discipline [explain discipline t o subject1 you when y o u misbehave or d o something n o t approved? Do you regard your parents' discipline t o b e fair? H o w d o you get along w i t h your father, mother, brothers, sisters, friends? What are your favorite activities w i t h your father, mother, brothers, sisters, friends? What d o you like t o talk about w i t h your father, mother, brothers, sisters, friends? H o w many friends d o you have? H o w d o you spend your leisure time w i t h your friends? What d o you like t o d o when you play? Are there any people w h o d o n o t like you? If so,f o r what reasons? How d o you get along at school? What is your best subject at school? What is the hardest subject for you? What were your grades f o r last year? H o w much time do you spend studying? H o w d o you get along w i t h y o u r teachers? H o w d o you get along w i t h your classmates? Does anyone at school make f u n o f you? I f so, for what reason? What are your favorite activities, hobbies or special interests? What plans do you have f o r the future (including career)? D o you have any worries about yourself, family, friends or school? Do y o u think you have any emotional problems or difficulty getting along w i t h others? What is the hardest aspect about being diabetic? Have you felt different because of your diabetes? [Explain meaning of feeling different.] Are you restricted in any way because of your diabetes? Do other children make it difficult f o r you because of your diabetes?

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moral development, c) ability to work, study and play in a balance that did not interfere with any one function, and d) ability to cope with emotions such as anxiety, anger and sadness.) 2) Those not diagnosed as having psychiatric disorder, but who had significant interpersonal conflicts or problems with peers, parents, siblings, teachers.

3) Those not diagnosed as having psychiatric disorder, but who indicated during the interview that they had significant conflicts which did not directly affect their relationships to other people, henceforth referred to as “noninterpersonal conflicts,” e.g., difficulty adjusting to diabetes treatment techniques, to a family move, to school subjects, or to other environmental stresses. When a psychiatric diagnosis was made by the investigator, interpersonal conflicts and noninterpersonal conflicts were necessarily present. On the other hand any type of conflict could exist without a psychiatric diagnosis being made. Usually, interpersonal conflicts were present in association with noninterpersonal conflicts. In order to have some parental input, mothers (the most likely parent to bring the youth to the clinic appointment) were asked to complete a children’s behavioral, emotional symptom checklist of 102 items such as overactivity, temper tantrums, fighting with boys, disobeys father, tattles on children, sadness, tension, and bedwetting. Mothers were instructed to consider only those items which were applicable during the preceding year. Each behavior and symptom could be graded in severity as no problem, slight problem, considerable problem or severe problem. The results of this checklist were used not to determine psychiatric status but rather to collect information from another source and to use the data in comparing patients in good control with patients in poor control. From the investigator’s experience, parental reports of severity of children’s behavior are often a reflection of parental tolerance level for that behavior rather than an indication of true psychopathology. Nevertheless, the frequency of occurrence of particular items were indicative of trends in the population under study. After all patient interviews were completed, the medical charts were reviewed to collect basic data such as birthdate, duration of diabetes, status of diabetic control, frequency of insulin reactions and ketoacidosis, and the weight and height at the time of the interview.

Study Group Two groups of forty diabetic subjects between ages six years and eighteen years were selected by a child health nurse working with the diabetic team and the groups were matched for age, sex and duration of diabetes. The criteria used

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by the nurse to select a patient for the child psychiatrist to interview were: 1) patients, six years of age or older, had come to the University of Missouri Medical Center diabetic clinic regularly for a minimum of six months and followed a two shot regimen; and 2) diabetic control status could be classified as good, good to fair, fair to poor or poor during the previous six-month period. Thus, patients in fair control were not included in the study. During a nine-month period the child psychiatrist came to the diabetic clinic to interview those patients selected by the nurse from a pool of patients coming for routine clinic appointments. From a total of 145 patients who met the age and duration of treatment requirements, twenty patients were excluded because their diabetic control was fair. Another forty-five patients (18 in good control, 13 in good to fair control, 9 in fair to poor control, and 5 in poor control) were not included because they were not needed for the matched groups which were filled on a chronologically consecutive basis. When particular subgroups (see Table 2) were fdled, no further patients in those categories were interviewed. Fourteen subjects given a good control rating and 26 subjects given a good to fair control rating were united into one group, henceforth to be referred to as the “good control group.” Thirtyeight subjects given a fair to poor control rating and two subjects given a poor control rating were joined to make a second group, henceforth to be referred t o as the “poor control group.” A child health physician determined the status of diabetic control, which was not known to the child psychiatrist prior to the interview. Each group of forty subjects was divided into eight cells of five patients (see Table 2). The total group of forty subjects included subgroups of twenty boys and twenty girls, twenty prepubertal subjects and twenty postpubertal subjects, twenty subjects with shorter duration of diabetes and twenty subjects with longer duration of diabetes. Postpuberty in boys was defined as fourteen years and older, and in girls as older than the age of menarche (never less than 12 years in this study). When diabetes had been diagnosed four years or more prior to the date of interview, the subject was included in the “longer” duration group; when diagnosed less than four years prior to the date of interview, the subject was included in the “shorter” duration group. After completion of interviews, the two groups were compared for significant socioeconomic differences, but none Table 2. Distribution of Patients in Study Groups Boys Over 4 Years Under 4 Years Duration Duration

Girls Over 4 Years Under 4 Years Duration Duration

Prepu berty

5

5

5

5

Postpuberty

5

5

5

5

142 / JOHN F.SIMONDS

Table 3. Mean Ages of Patients and Mean Duration of Diabetes Boys

Girls

Good

Poor Control

Mean Age Years

Mean Duration Years

Mean Age Years

Mean Duration Years

Prepuberty Long Prepuberty Short postpuberty Long Postpuberty Short

11.56 10.80 15.10 13.42

5.33 1.90 5 .ao 1.62

12.02 9.90 15.60 15.52

7.50 1.22 7.65 1.25

Prepuberty Long Prepuberty Short Postpuberty Long Postpuberty Short

11.26 10.27 14.60 15.42

7.46 1.90 6.96 2.80

11.52 10.43 15.13 16.05

6.12 1.92 6.35 3.20

were found. Essentially, both groups included children from middle class families of farmers, tradesmen, salesmen, teachers, technicians, skilled workers, managers and professionals.

Results The mean ages of patients and the mean duration of diabetes for the eight subgroups are listed in Table 3. In the good control longer duration group, boys had their diabetes for longer periods of time than the girls. Otherwise the mean duration of diabetes for similar groups were closely matched. More girls than boys had psychiatric diagnoses, interpersonal conflicts and noninterpersonal conflicts, but the differences were not significant (see Tables 4 and 5). Six psychiatric diagnoses were made (7% percent occurrence) and all Table 4. Psychiatric Status of Girls Psychiatric Diagnosis

Good Control

Poor Control

Interpersonal Conflicts, No Diagnosis

Nonin terpersonal Conflict Only

No Conflicts

1 1 0 0

3 2 4 4

Prepuberty Long Prepuberty Short Postpuberty Long Postpuberty Short

0

0

1 2 0 1

Total

1

4

2

13

Prepuberty Long Prepuberty Short Postpuberty Long Postpuberty Short

3 0 1 0

0 2 1 3

0 2 2 2

2 1 1 0

Total

4

6

6

4

Grand Totals

5

10

a

17

0 1

PSYCHIATRIC STATUS OF DIABETIC Y O U T H

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Table 5. Psychiatric Status of Boys Psychiatric Diagnosis

Good Contro I

Poor Control

Interpersonal Conflicts, No Diagnosis

Nonin terpersonal Conflict Only

No Conflicts

0

0 1

1 0 1 1

0

4 5 3 3

Total

1

3

1

15

Prepuberty Long Prepuberty Short Postpuberty Long Postpuberty Short

0 0 0 0

2 0 3 4

1 1 0 1

2 4 2 0

Total

0

9

3

8

Grand Totals

1

12

4

23

Prepuberty Long Prepuberty Short Postpuberty Long Postpuberty Short

0

0

0 1

were regarded as mild disorders not in need of specific treatment by a psychiatrist. Three girls were diagnosed as having “reactive disorders” with mixed manifestations of anxiety, depression and compulsivity. Two girls in poor diabetic control were diagnosed as having “overly dependent personality disorders” and one boy in good diabetic control had an “oppositional personality disorder.” Fifty percent of the psychiatric diagnoses were found in prepubertal girls who had longer duration diabetes in poor control. This group, which made up only 6 percent of the sample, had the earliest onset of diabetes (i.e., between 1 and 5 years of age). The following is a vignette of an adolescent girl diagnosed as having “reactive disorder .” REACTIVE DISORDER: CASE EXAMPLE Brenda was a 15-year-old girl who lived in a rural area. She was diagnosed as having a “reactive disorder” manifested by symptoms of anxiety, reaction formation and compulsivity. She tended to be a nervous youth who worried about many relationships. During the interview moderate depression, anxiety, guilt and feelings of inferiority were present. Her self-concept was low and she did not think that others liked her. At school she had difficulty getting along with a physical education teacher whom she said made “smart remarks” about her diabetes and criticized her for not participating in gym activities (during the 8th and 9th grades she was excused from certain gym activities because of frequent insulin reactions). She got along with other teachers and students and her grades were above average. Although she had not dated, she maintained a number of male and female friends with whom she enjoyed group activities.

144 / JOHN F.SlMONDS

In the family setting, she had a good relationship with her two sisters and her father. She felt her mother was too critical and on occasions there were verbal arguments between mother and daughter. When she “sassed” her mother, she was “grounded” or “yelled at.” Her anger toward mother and teacher was handled by talking it out with friends. She regarded herself as “nervous” about diabetic control, school work, family and peer relationships. These nervous feelings often caused headaches and stomachaches. Although she had been diagnosed a diabetic seven years previously, there was not a good adjustment to the idea of being diabetic. She often worried about her blood sugar levels and because of insulin reactions in the past she worried about going places alone. The patient was also concerned about what others would think of her if she had an insulin reaction. Not wanting to seem different from her peers, she was not particularly careful about avoiding sweets in front of friends. She gave her own insulin shots 60 percent of the time and was compulsive about taking her snacks. Often she perceived anxiety reaction symptoms as insulin reactions. Mother’s questionnaire responses listed only six of 102 items as a slight problem (in contrast to the findings of the psychiatric interview).

Chi square analyses of two by two tables, which compared numbers of patients in good and poor diabetic control groups with numbers of patients given or not given a psychiatric diagnosis, failed to show significant differences (see Table 6). On the other hand significantly more patients in poor control had interpersonal conflicts compared with patients in good control (see Table 6). Significantly more patients in poor control had some type of conflict or diagnosis compared with patients in good control (see Table 6). With diabetic control a constant, two by two tables were set up to compare age, sex and duration variables with the psychiatric status variables. The number of subjects in six sets of tables (males in good control with females in good control, males in poor control with females in poor control, older patients in good control with younger patients in good control, older patients in poor control with younger patients in poor control, longer duration patients in good control with shorter duration patients in good control, longer duration patients in poor control with shorter duration patients in poor control) were compared utilizing chi square tests and no significant differences were found. Thus, subjects in the postpubertal age group did not have significantly more or less psychiatric diagnoses or conflicts than subjects in the prepubertal age group provided the status of diabetic control was equal. The same was true for females compared with males and longer duration diabetics compared with shorter duration diabetics. The Mann Whitney U-test and the Z-value were obtained to compare differences between mothers’ ratings for behavioral-emotional symptoms in the subjects. The number of behaviors rated as slight problems and the number of behaviors rated as considerable or severe problems were summed for each subject. This sum was given a relative ranking which was then applied in the Mann Whitney formula. Mothers of subjects in poor control had checked significantly more behaviors as either slight (p=.003) or considerable-severe (p=.034) problems compared to mothers of subjects in good control.

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Table 6. Analysis of Psychiatric Status of Total Patients Psychiatric Diagnosis

No Psychiatric Diagnosis

Good Control

2

38

Poor Control

4

36

interpersonal Conflicta

No Interpersonal Conflict

Good Control

9

31

Poor Control

19

21

Any Conflictb

C

p = n.s.

xl! = 4 . 4 5 p .05 k.Id

Psychiatric status of diabetic youth in good and poor control.

Two groups -- identified as "good control" and "poor control" -- of 40 diabetic youth, between 6 years and 18 years, matched for age, sex and duration...
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