Psychosocial Development And Diabetes In The Schoolaged Child

The primary developmental tasks of the child during the elementary school years include: making a smooth adjustment from the home to the school setting; forming close friendships with children of the same sex; obtaining approval from this peer group; developing new intellectual, athletic and artistic skills; and evaluating him/herself positively when comparing his/her abilities to those of the peer group12'13.

Psychological development in school-aged children is assessed primarily with respect to the child's sense of self-esteem and the development of peer relationships. In a careful review of the early empirical psychosocial literature on children with diabetes, Johnson concluded that: 'most youngsters with diabetes do not have psychological problems, but among those who do, peer relationship difficulties are quite common... Among all of the personality traits assessed, the evidence for peer or social relationship problems seems the strongest' (p. 101)8.

Studies of self-esteem in school-aged children with diabetes have consistently linked low self-esteem and poor social-emotional adjustment to poorly-controlled diabetes8'9. Herskowitz-Dumont and colleagues37 found a significant association between recurrent diabetic ketoacidosis (DKA) over 8 years post-diagnosis and higher ratings of behaviour problems and lower levels of social competence, as measured by psychological testing in the first year after diagnosis. Similarly, Liss et al.38 found that children who had been hospitalized with DKA in the preceding 12 months reported lower levels of self-esteem and social competence than children who had no episodes of DKA in the same period. In addition, a significantly larger proportion of the DKA group met the diagnostic criteria for at least one psychiatric disorder (88% vs. 28%).

Because the development of peer relationships is an important aspect of the school-age years, it is crucial to examine how diabetes interferes with social development. Several older interview studies have shed light on this topic. Bregani et al39. emphasized that during this developmental period, children with diabetes often begin to feel a heightened sense of frustration and of social stigma from their dietary restrictions. The authors pointed out that the child's emerging self-awareness and ability to reflect on his/her diabetes and to compare him/herself with peers made the child very vulnerable to feelings of inadequacy. Similarly, Zuppinger et al.40, in interviews with 23 children with diabetes at this age, found that half of the sample identified teasing from peers and difficulty in accommodating meal schedules to school activities as the major difficulties in following the diabetic diet. Leaverton41 also suggested that the most common resentment of the child with diabetes in the elementary school years is following a planned diet because it gives an obvious sign to peers that the child is different. In addition to food restrictions and regularity of meal timing, the need for frequent blood glucose monitoring and insulin injections can emphasize differences and make peer acceptance more difficult15.

Kovacs and colleagues42 found in a longitudinal study of school-aged children newly diagnosed with diabetes that 25% of their sample of school-aged children reported being teased by peers about their diabetes. When asked about the most difficult aspects of diabetes, insulin injections and dietary issues were most commonly cited. Despite the difficult regimen and challenges to peer acceptance, children's self-ratings indicated good self-esteem and few signs of emotional distress in the first year of life with diabetes. Children in this study also reported showing their diabetes supplies to their friends and demonstrating glucose testing, which suggested that the children were actively trying to integrate diabetes into their lives.

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