teaching teens to cope: coping skills training for adolescents with insulin-dependent diabetes...

Teaching Teens to Cope: Coping Skills Training for Adolescents With Insulin-Dependent Diabetes Me1 1 it us Maryanne Davidson, Elizabeth A. Boland, and Margaret Grey

PURPOSE. To review the potential use and

application of coping-skills training in teaching

adolescents effective ways of managing the

stressors related to living with diabetes mellitus.

POPULATION. Adolescents ages 23 to 20 with

insulin-dependent diabetes mellitus who are

participating in the research project, "Nursing

Intervention to Implement DCCT Therapy in

Youth" at Yale University School of Nursing.

CONCLUSIONS. Teaching adolescents with diabetes

mellitus to use appropriate coping skills may help

them cope with the day-today management of the

illness and aid in long-term adaptation.

PRACTICE IMPLICATIONS. Research has suggested

that the use of effective coping skills may aid in

healthy long-term adaptation to diabetes mellitus.

Thus, nurses caring for adolescents with this

illness should teach and be role models for these

effective coping strategies.

Key words: Adolescents, coping skills training,

diabetes mellitus

JSPN Vol. 2, No. 2, April-June, 1997

Ma yanne Davidson, MSN, CPNP, is a lecturer, Yale University School of Nursing, and Coping Skills Trainer with the project, "Nursing Intervention to Implement DCCT Therapy in Youth;" Elizabeth A. Boland, MSN, APRN, PNP, is the Trial Coordinator for the project; and Margaret Grey, DrPH, CPNP, F A A N , is principal investigator of the project, Independence Foundation Professor of Nursing, and Associate Dean for Research and Doctoral Studies, Yale University School of Nursing, Nezv Haven, CT.

Children with chronic illness face many more diverse stressors than their healthy peers (Olson, Johansen, Powers, Pope, & Klein, 1993). Emotional and social pres- sures for these children include feeling different from peers and striving to develop eventual independence from their parents, while at the same time feeling dependent and vulnerable to the illness. Disease-specific stressors also exist for these children. For example, those with diabetes contend with the ever-present fear of hypoglycemia, fears of future medical complications, and feelings of guilt for possible wrongdoing when faced with hyperglycemia. Thus, continual adaptation and the ability to cope with these physically and emotionally stressful demands is imperative (Hanson, Harris, Relyea, Cigrang, Carle, & Burghen, 1989).

Coping, or adaptation to stressful events, begins with the onset of the disease and continues throughout the life of these children (Olson et al., 1993). In fact, the ability of an individual to cope with a long-term illness may be responsible for significant variations in the disease course and response to the treatment regimen (Band, 1990). Studies with adults (Marlott & Gordon, 1985) have demonstrated that when an individual cannot cope effectively with a problem or "high risk" situation, confidence is decreased for dealing with the next problem, and a less effective coping strategy will be employed. Because of the higher rate of psychosocial maladjust- ment in children with chronic illness (Breitmayer, Gallo, Knafl, & Zoeller, 1992; Grey, Cameron, Lipman, & Thurber, 19951, these youth may be more at risk to utilize dysfunctional strategies to cope.

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Teaching Teens to Cope: Coping Skills Training for Adolescents With Insulin-Dependent Diabetes Mellitus

Bandura (1986) has suggested that individuals can actively influence many areas of their lives, and when a person can practice and rehearse new behaviors, such as learning to cope successfully with a problem situation, self-efficacy and self-confidence can be enhanced. It is hypothesized, therefore, that behavioral modification interventions promoting the use of more effective coping mechanisms to deal with adversities may be especially worthwhile for children with chronic illnesses. Coping- skills training allows youngsters to develop and strengthen various coping skills. This approach uses behavioral and cognitive- behavioral interventions, usu- ally in small group settings, to teach a variety of coping skills, such as relaxation, social skills, assertiveness, and cognitive activities (Forman, 1993). The purpose of this paper is to describe the application of coping-skills training for adolescents with diabetes mellitus, using experience from a clinical trial investigating the impact of such training for adolescents who are undertaking intensive management of their diabetes.

Review of Coping-Skills Training Literature

Originally developed with adults, training in interpersonal and coping skills has been shown to be an effective strategy to improve performance and reduce sympto- mology in a variety of conditions. These techniques have been shown to be effective in adult patients with cancer (Arathuzik, 1994) and diabetes (Rubin, Peyrot, & Saudek, 1992), and in reducing premenstrual symptoms in women (Kirkby, 1994; Morse, Dennerstein, Farrell, & Varnavides, 1991). Coping-skills training also has been used with test-anxious college students (Smith, 1989), individuals with alcoholism (Eisler, Miller, & Herson, 19741, families with multiple needs (Eisler & Herson, 1973), and those seeking weight loss (Kayman, Arnold, King, Stefanick, & Wood, 1990).

Forman (1993) reviewed the literatun? on coping-skills training for children and adolescents and concluded that such interventions can ”teach children and adolescents personal and social coping skills that can assist them in dealing with potential stressors they encounter in their

daily lives and the stress reactions that may result from these situations” (p. 15). Coping skills training has been demonstrated to reduce substance abuse (Forman, Linney, & Brondino, 1990), improve social adjustment (Bierman & Furman, 1984), prevent smoking (DelGreco, Brietbach, Rumer, McCarthy, & Suissa, 1986), and reduce negative responses to stressors (Elias, Gara, Ubriaco, Rothbaum, Clabby, & Schuyler, 1986) in children and adolescents. Prim, Blechman, and Dumas (1994) found that this technique also improved social skills and reduced aggression in a sample of children exhibiting high rates of aggressive behavior, and these effects were maintained six months post-intervention.

Coping-Skills Training for Children With Chronic Illness

There have been a few empirical studies that have examined the influence of coping skills training on various outcomes in children and adolescents with chronic illnesses. Varni, Katz, Colegrove, and Dolgin (1993) randomized 64 children ages 5 to 13 years with newly diag- nosed cancer to either a Social Skills Training experimen- tal treatment group or a School Reintegration standard treatment group. The social skills training, comprising three individual 60-minute sessions with two follow-up booster sessions following their return to school, focused on cancer-related interpersonal difficulties in regards to peers, handling teasing and name-calling, and assertiveness training. Those children who received this intervention were found to have fewer behavioral problems, greater classmate and teacher social support, and a higher level of school competence.

Coping-skills training also has been found to be effective for children with chronic cardiac conditions. Campbell, Berry, and Lamberti (1995) compared the effects of two different methods of preparing children with congenital heart disease for surgery. Forty-eight child-caregiver dyads (children ages 4-12) were assigned to either a treatment group receiving coping-skills training and information, or to a control group receiving information as routinely provided. The coping-skills intervention included rationale for the surgical procedure, and

66 JSPN Vol. 2, No. 2, April-June, 1997

information about emotional/physical sensations they would experience. Additionally, the children were taught active and avoidant coping strategies and given personal attention in the hospital by a multidisciplinary cardiac treatment team. Children who received the coping-skills training in addition to routine information were more cooperative and less upset while hospitalized, demonstrated better adjustment at home after discharge, and had higher functioning in school. Their caregivers expressed greater confidence in their ability to care for their children both in the hospital and after discharge.

Sanders and colleagues (1 989) evaluated the efficacy of an eight-session cognitive-behavioral program for 16 school-age children with recurrent nonspecific abdominal pain. Multiple measurements of pain behavior and pain intensity were utilized. Results demonstrated a reduction in level of pain for both groups; yet those in the treatment group improved quicker, and a larger pro- portion of these children were pain free at the three- month follow-up evaluation.

Coping-Skills Training for Youth With Diabetes

In children with diabetes, several small studies have examined the impact of coping-skills training on overall disease adaptation. Since education alone does not improve self-care or metabolic control (Bloomgarden et al., 1987), behavioral training programs that increase the ability of a child to cope with daily problems they face may be more effective. Gross, Johnson, Wildman, and Mullet (1982) used social-skills training to develop effective coping-skills in five pre-adolescent children with diabetes. With tlus intervention, the children were able to learn the necessary skills to cope with social situations related to their disease; behaviors they learned also generalized to untrained situations. Gross, Heiman, Shapiro, and Schultz (1983) later replicated this study, and taught social skills to 11 children with IDDM, evaluating the intervention with a multiple baseline design. The children who received this training had enhanced social skills, but metabolic control was not improved relative to comparison group subjects.

Older children with diabetes, especially adolescents, are particularly vulnerable to stressors related to their illness. They face unique stressors related to their developmental status and the adaptation to an illness requiring day- to-day management. These stressors include iden- tity struggles, independence/dependence issues, peer acceptance, and social competence, among others, all of which are further confounded by living with a chronic illness. Coping-skills training groups, which focus on both healthy development and healthy adaptation, offer children many avenues to strengthen their coping skills and, therefore, could be especially helpful for children in this age group. Despite the promise of coping-skills training for children, little research has been done on this intervention in this specific population. Follansbee (1984) has analyzed the effect of a psychosocial intervention that included cognitive problem-solving and assertiveness training techniques in 48 adolescents with IDDM. While this intervention initially resulted in increased levels of assertiveness and decreased passivity, these effects were not maintained over time, demonstrating that further reinforcement of coping-skills training techniques may be necessary to maintain positive effects over time, especially in an adolescent population.

We are currently exploring the value of coping-skills training for adolescents with IDDM. The following are examples of the skills being taught in this project.

Social Problem-Solving

Peer pressure is an issue all adolescents face at some point in their development. For adolescents with chronic illness, the pressure may be felt even more intensely, and the consequences more costly. Social problem-solving is one coping skill adolescents can rely on when faced with peer pressure. This skill is designed to help youngsters look at potential ways of handling situations and raises awareness of possible consequences of their decisions. Teaching teens effective social problem-solving focuses on the process of how to solve a problem, not necessarily on specific content. Forman (1993) identifies six major problem-solving steps: (1) idenhfy the problem, (2) determine

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goals, (3) generate alternative solutions, (4) examine consequences, (5) choose the solution, and (6) evaluate the outcome. The following example illustrates how teens with IDDM were exposed to the process of problem-solving that can be generalized to other similar situations.

The topic of peer pressure to drink alcohol at a party was examined. The teens in the group identified the problem as whether or not to drink the alcohol which was readily available. The next step in the process was the generation of goals related to the problem. These goals included such items as not becoming intoxicated, avoiding a hypoglycemic reaction, and not looking like a ”nerd.” The teens then looked at all the possible solutions to the problem and the potential consequences of each solution. The solution of “not drinking” was discussed and carried the consequences of being safe, but looking like a “nerd” and not fitting in. Drinking modestly without inebriation was the second solution. With this solution the teens felt they would “look O K and have fun, but the possibility of a hypoglycemic reaction still existed. The third solution was to become inebriated. This solution carried the possible consequences of trouble with parentdliiends, medical complications, and having a severe hypoglycemic reaction, where everyone at the party would then know about his/her diabetes. The final solution was not to go to the party and possibly miss the fun, but be safe and avoid the problem entirely. The group of teens chose the solution of drinking modestly. In follow-up groups the teens spoke about the pros and cons of their decisions based on their experiences outside the group. The next step for this group was how to communicate, in a social situation, their desire to limit their alcohol intake as they had decided.

Communication Skill Training

Social problem-solving is often closely connected to communication skill training. Communication skills are

essential tools for adolescents who developmentally are learning to manage themselves successfully in the world. These tools are aimed at helping individuals express themselves in ways that are clear, appropriate, and con- structive. Under the umbrella of communication skills fall social-skills training and assertiveness training.

Social-skills training. Cartledge and Milburn (1980) and Goldstein, Sprafkin, Gershaw, and Klein (1980) pro- vide models for social-skills training. These models are designed to teach children skills that will enable them to work with peers and adults in a manner resulting in positive outcomes for all. Positive experiences result in enhanced self-concept, peer p u p acceptance, and overall improved psychological adjustment. Training of these skills includes providing concrete instructions on how to handle a social situation, allowing participants to witness a role play of an appropriate model, practicing their own role play, providing feedback on the role play, and real life practice with group follow-up. This approach is illustrated in the following example.

One 15-year-old male with IDDM began the pat- tern of not testing his blood glucose prior to playing ice hockey, despite the risk of hypoglycemia from prolonged and vigorous exercise. When his behavior was explored it was determined that the teen was in fact coping with this problem, although not in a way recommended by his healthcare provider-”I just tank up on Gatorade before I go out.” The coping-skills group was helpful in exploring a solution to his concerns. Essentially, the teen ran the risk of running excessively high blood sugars from ingesting large amounts of Gatorade. The teen also realized he did not test his blood sugar to avoid peers learning he had diabetes. In the past he had been asked many questions by peers and was the target of unwanted comments. Hence, the group helped this teen idenhfy the roots of his behavior, and the work of restructuring his response was begun. The group concluded that testing prior to a game was really the healthiest response. The group then handled the issue of


what to say to peers when the questions began about testing and diabetes, not an unusual problem for each group member. Each teen took a turn role playing various responses to unwanted attention and questions. The responses were audiotaped and reviewed by the teens. The most effective responses, such as ones that were closed-ended, maintained privacy, and often included a sense of humor, were earmarked and the role plays were refined until the best response was reached. Follow-up groups allowed for discussion related to what skill they had tried and how the skill could be strengthened and/or improved.

In this example, the training helped these teens become aware that their thoughts affect their actions, and it helped them learn ways of managing social situations. Acquisition of this skill allows the teen to problem- solve in other social situations where actions and decisions directly affect health and well-being.

Assertiveness training. Assertiveness skills allow children with chronic illness the opportunity to express themselves in direct, honest, and appropriate ways. Group settings are the ideal means for this type of training. Groups allow children to observe the behaviors of others as well as reflect upon their own behavior and its effect on others. Role play is also an important compo- nent of this type of training.

Susan was upset because she believed she had lost a babysitting job after mentioning she had IDDM. Ruling out other factors, she concluded that diabetes had been her downfall. In reviewing Susan’s experience, she had ”mentioned” her chronic illness to the parent despite having been employed by this family for quite some time. The parent made no comment to Susan so she dropped the subject, believing, therefore, that her diabetes was perceived as ”OK by the parent. Yet, Susan never heard from this parent again. Coping-skills training helped this teen express herself in a more direct, open manner. Susan used role play to prac-

tice alternate responses to the same and similar situations. Susan also role played the part of the parent. This experience allowed her the opportunity to observe her behavior from the perspective of another, as well as giving her insight into how the other may have felt in that particular situation. Having a better sense of the mother’s concerns, Susan learned that in the future she could encour- age the mother to ask her more questions about diabetes.

Cognitive-Behavior Modification

Cognitive-behavior modification is a structured approach designed to help children deal with stressful situations through recognition of their own thoughts and feelings, problem-solving, and guided self -dialogue. This process is designed to help children recognize sources of stress and decrease negative responses to stress. Coping-skills training groups help children become aware that the thoughts they may be experienc- ing may not necessarily be fact.

In one group of teen-age boys with IDDM, each boy identified that meeting a girl for a first date was a potentially stressful situation. The boys were encouraged to talk out loud their worst fears. As a group, each fear was examined, and the discussion was centered on the rationality or irrationality of these fears. Once this process was complete each boy practiced a dialogue to counteract his fears. For most children, a major step is becoming aware that internal dialogue exists and can have an impact on behavior. For example, John’s worst fear was that he would ”pass out” from hypoglycemia on the first date. The group and John counteracted this fear by reviewing a more realistic internal dialogue. “I have never passed out in the six years I’ve had diabetes. The chances of me passing out are really very slim. I can tell if I’m low. I just tested before I left the house. If I get low, I can always say I’m hungry and can get something to eat.” The

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goals of this process included increasing the teen’s awareness of his own thoughts and the impact those thoughts have on his behavior, learning the process of counteracting negative thoughts, and increasing self-esteem by establishing more realistic, positive thoughts. All are vital for children with chronic illness who struggle with issues of self- esteem and disease management on a daily basis.

Conflict Resolution

Conflict during the teen years provides an important avenue for social and psychological development. While conflict is most often thought of in destructive terms, according to experts, non- destructive conflict also may result in growth and positive change (Deutsch & Brickman, 1994). Helping teens develop the skills necessary to resolve conflicts that result in positive outcomes for all parties involved is the basis of conflict-resolution training. The struggle for independence, characteristic of adolescence, can be a time of great conflict for teens. For those with chronic illness, this struggle most often will exist between the teen and his or her primary caretakers, and it can be quite intense. Many illnesses demand that children depend on their primary caretakers for medical supervision and guidance. Conversely, the additional close responsibility the caretaker has had with the child in dealing with the illness may contribute to greater diffi- culty in‘letting go. If the parties involved utilize destructive means of conflict resolution as a teen becomes more independent, not only is development impeded, but the medical condition also may become the focus of the struggle resulting in adverse outcomes of the illness.

Marie is a 15-year-old adolescent with a 14-year history of IDDM. Throughout most of her life, Marie’s mother has managed most aspects of her illness. At 15, Mane believes she is ready to assume greater responsibility for her management. When Marie began working in a coping-skills training group, her diet consisted predominantly of Ore0 coolues, gum with sugar, and candy. For any ado-

lescent, this diet would be deemed unhealthy, but for Marie, this diet meant high blood sugars, poor nutrition, and poor metabolic control. Restrictions related to her diet were common topics of discussion within the family and in public. Marie often would hide in her room to eat in fear that her father would find her eating foods that were not on her diet, and she would then be ”punished.” She was unable to discuss her diet with her parents since any discussion led to screaming, yelling, and increased control of food in the house. Marie has learned to cope with this conflict by eating junk food (exactly opposite of her parents wishes) whenever she has the opportunity. Consequently, this conflict between Marie and her parents has resulted in both parties “losing” and Marie’s health being placed at risk. While the parents lose because their daughter has an unhealthy diet, Mane loses because her health is compromised.

Conflict-resolution training focuses on reworking situations such as the one described, with the hope of find- ing a solution to the conflict with better outcomes for the adolescent and others. The first and foremost aspect of this training is development of the understanding that in any conflict, both parties can win, and each and every conflict should be approached in that manner. The adolescent is helped to focus on clear communication and problem-solving skills. Increased awareness of one’s own style and potential habits that may impede resolution are explored.

For Marie, the h s t step was realizing that she and her parents wanted different tlungs-both parties really did not want the control of her diet. The parents were concerned about Marie’s health; Marie was concerned about control. For both parties to win, each had to communicate clearly what it wanted and what it could tolerate. A possible outcome for Marie and her parents would be a com- promise where Mane chose what she ate each day, and would be allowed one sweet as part of the


overall daily plan devised by the healthcare team. This resolution would give both parties what they wanted: Mane would have the control and her parents would be pleased with her diet. Marie was able to rehearse this skill through role playing as part of the coping-skills group, allowing her to test responses, reflect on her own behavior, and appre- ciate the feelings of her parents.

Conclusions and Implications for Nursing Practice

Unfortunately, the majority of studies examining the impact of coping-skills training on healthy adaptation and illness management have been small, uncontrolled trials, so conclusions are difficult to draw from the data. Although more research is needed, the consistency of findings, as well as our anecdotal report, suggest that nurses working with adolescents can use some of these principles in planning and providing care for adolescents with diabetes. When teens are found to lack positive skills such as problem-solving and assertiveness, providers can help them learn and rehearse these skills. It appears that small groups of adolescents solving problems together are most effective; however, individual work with the adolescent could be helpful as well.

Referral to coping-skills training groups can serve multiple functions for teens with diabetes. These groups can be a reservoir of support and understanding for teens who may feel isolated from peers due to their unique struggle with chronic illness. Groups also allow for sharing of information and ideas, and can act as a template for the practice of new behaviors. It is within this setting that skills can be taught not only for day-today coping with diabetes, but also for long- term adaptation to living with a chronic condition.

Acknowledgments. Preparation of this manuscript was sup- ported in part by grants from the Culpeper Foundation and the National Institute of Nursing Research (R01-NR04009) to Margaret Grey and the Children’s Clinical Research Center grant M01-RR06022, General Clinical Research Centers Program, National Center for Research Resources, NIH. Names of participants have been changed to protect their anonymity.

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Author contact: Maryanne Davidson, MSN, CPNP Yale University School of Nursing PO. Box 9740 New Haven, CT 06536- 0740 [email protected]

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