The Impact of Diabetes on Adolescent Development

The Experiences of Teenagers with Diabetes Attending a Summer Camp

Maria Iole Colombini* and Emanuela Schivalocchi

Institute for Child and Adolescent Psychoanalytic Psychotherapy and San Raffaele Hospital, Milan, Italy

Abstract: Background: Diabetes is a particularly difficult burden for the young adolescent, who is confronted with a
chronic and potentially life-threatening illness in addition to the developmental challenges of adolescence. Adolescents with this illness are at risk for impaired psychosocial functioning as well as poor glycemic control and its many consequences.
Method: In this article we describe some aspects of the emotional experience of adolescents aged 12 to 14 who are confronted with the sense of limitation caused by diabetes. These descriptions are based on our observations of youngsters who attended a special summer camp aimed at helping them acquire the ability to manage their clinical condition. This camp also offered the teenagers the opportunity to tell something about themselves, their narratives focusing on emotions rather than on the functioning of their body (Barbieri, 2005).
Conclusions: The camp experience facilitated a better understanding of diabetes, a realistic self-appraisal, and age appropriate self-management of the diabetes. An essential aspect of the camp was an interdisciplinary approach in which a psychologist played an important role. An intervention in which adolescents told their stories which was modeled on a popular TV reality show that was designed to facilitate the development of mentalization and the creation of narratives that supported healthy development in the face of chronic illness.
Keywords: Diabetes, adolescent development, auto-determination process, chronic illness, doctor-patient relationship, illness as a persecutory object, self-narration.

…The eruption of menacing reality in the form of an illness pouring into the adolescent’s life means that the adolescent patient’s inner narrative dimension must henceforth take place on a stage beneath which is placed an explosive time-bomb with a defective timer…

Barbieri

2005

THE IMPACT OF DIABETES ON DEVELOPMENT

A substantial body of knowledge has emerged confirming the paramount importance of psychosocial factors in diabetes, especially when it affects adolescents (Dalameter, 2009). Not only are adolescents with diabetes at high risk for psychological and social impairment, including psychiatric illness, (Delamater, 2009; Schneider, 2009), but psychosocial stress and poor coping can influence the outcome of the disease directly (Northam, Lin, Finch, Werther & Cameron, 2010; Anderson, 2009; Helgeson, Siminerio, Escobar, & Becker 2009; Herzer & Hood, 2010) and indirectly through poor adherence to treatment, especially during the adolescent stage (Jaser, 2010; Quittner, Modi, Lemanek, Ievers-Landis, & Rapoff, 2008).
Given this reality, a bio-psychosocial approach to health and disease is particularly necessary in the case of juvenile diabetes, a chronic illness that requires an involvement of not only the diabetes care team but also of family members (Anderson, Ho, Brackett, Finfelstein, & Laffel, 1997; Anderson, *Address correspondence to this author:  dott.ssa Maria Iole Colombini, Via Collegno, 15-20158 Milan, Italy; Tel: +39 02 66809595; Fax +39 02 66809595; E-mail: iolecolombini@yahoo.it
Svoren & Laffel, 2007; Horton, Berg, Butner & Wiebe, 2009; Lewin, Storch, Geffken, Heidgerken, Williams, & Silverstein, 2005). To intervene effectively, it is crucial to understand how diabetes affects the developmental process of adolescence. In this article, we will review the impact of diabetes on adolescent development and describe a special summer camp for young adolescents with diabetes that includes a range of interventions designed to promote optimal development and effective disease management.

THE BODY, ONCE TAKEN CARE OF BY PARENTS

In general, adolescents gradually become less dependent on how they are viewed by adults as they develop their own
ideas about who they are, and progress towards an adult identity. At the same time, the care of the body, once under
the almost exclusive care of the parents, is gradually taken over by the growing teenager. The onset of a chronic disease, however, blocks this process inducing a loss of external control and leading to a state of regression. Diabetes confronts the sick with a sense of deterioration and deficit. Both adolescence and the disease involve a change of “system stateorganism” (Carbone, 2009). While adolescence involves the extension of resources, relationships and personal fulfillment, diabetes entails an awareness of limitations; the onset 2210-6774/13 $58.00+.00 © 2013 Bentham Science Publishers 246 Adolescent Psychiatry, 2013, Vol. 3, No. 3 Colombini and Schivalocchi of diabetes makes the young patient aware that from now on he will have to live with a body that is restricted, impaired, and fragile.

DEPENDENCE AND SELF-DETERMINATION OF THE TEENAGE PATIENT SUFFERING FROM DIABETES

The terrain in which the teenage patient most readily enacts a struggle for autonomy and self-determination is that of adherence to the treatment. On one hand there is a desire to take full control of the body and to build up defenses against the intrusive adult attitudes of control but, on the other hand the illness makes the adolescent dependent on his family. Forced to accept the rules coming from the adults’ world, the adolescent feels trapped in the stage of childhood which he had started abandoning much earlier.  s Winnicott has stated, “the rapid alternation between defiant independence and regressive dependence, even a coexistence of the two extremes at one moment in time” is typical of normal adolescence (1965, p. 81). In the presence of a chronic disease, even more extreme behavior can emerge: an apparent lack of fear of danger, an inability to imagine a future, living day by day, going beyond limits and, in general, defying adults (Michaud, 1989). The struggle for a sense of autonomy may lead the teenager with diabetes to disregard any therapeutic regimen, putting his own health at risk. This behavior may be a passive/ aggressive way of expressing himself, which leaves him at the mercy of the disease leading to an extreme challenge against the world of adults. At the edge of survival, in order to ‘feel alive’, without depending on adults’ recommendations and prescriptions, he is able to choose and push aside, in an illusory way, his dependency on adults. Anxiety about loss and the possibility of death can trigger defensive denial, which functions as a protection against the narcissistic wound of the disease. Denial allows the teenager to maintain the illusion of power and control. But he will be unable to move toward a realistic acceptance of the limitations caused by the disease.

DIABETES AS A PERSECUTORY OBJECT

Diabetes makes the body of the teenage patient a place of narcissistic betrayal. The strangeness of the disease can be perceived as a hostile and intrusive force that changes the balance of the adolescent’s history (Gislon, 1993). At a symbolic level the disease is an inner persecutory object, which lives parasitically both in the mind and the body and makes the mentalization process of the latter more difficult (Barbieri, 2005).
Suffering and distress that are too difficult to control easily induce a regression. The need to adhere to a treatment program in turn leads to dependency, which triggers, in addition to the experience of the body being attacked and invaded, culminating in continuous frustration and limitation.
Insulin, the substance necessary to restore body balance, is generally perceived as redemptive; but on a symbolic level, in the minds of some teenagers it can also be felt as venomous and symbolically linked to addiction and drug abuse.

SOCIAL INTEGRATION

Social integration is facilitated if sick teenagers can be quickly accepted into the circle of friends once the diagnosis of diabetes has been defined. Conversely, if the limits imposed by the clinical condition involve a narrowing of opportunities to share with peers, the result can be exclusion and stigmatization, particularly risky for the establishment of a personal identity. In an attempt to feel less different, the teenager may reject the constraints of the disease, becoming non-compliant with the instructions of adults (i.e. dietary recommendations, keeping a diary of the glycemic level, control of carbohydrate values, meal times and injections). This is often the easiest path, one that makes the youth feel more like his peers, perhaps more acceptable to the others.

THE TEENAGE PATIENT’S RELATIONSHIP WITH THE DOCTOR

A good relationship with a doctor is a crucial factor for the satisfactory coping with a chronic disease. In the relationship with the physician the teenager has the opportunity to assume responsibility for his treatment and thus test his own abilities to be capable and independent. Young patients require physicians to be deeply involved with them as a human being, and to enable them to gradually build up trust by testing their relationship. In general, the young patient requires that the other, the adult care provider, is present, responding empathically and in a non-confrontational manner.
This places a considerable emotional burden on the adult who, by taking charge of the functioning of the adolescent’s
body, takes on the difficult task of meeting the needs of the vulnerable adolescent. When adolescents perceive that the doctor genuinely wants to improve their condition, and shows warmth and affection, an alliance can be developed, aimed at promoting health, with shared responsibility for errors and success in disease management (Nobili & Sala, 2005).
In the case of diabetic youths, from the onset doctors, in general all health professionals represent a protective barrier with respect to a possible glycemic deregulation or serious ketoacidosis, the continuous threat posed by the chronic condition. Their questions to doctors commonly reflect various fears and anxieties regarding their ability to cope with the disease. They look to the health care providers for information about the workings of their bodies, and also expect them to be receptive to their needs for autonomy.
These young people have a heightened sensitivity to their health care providers’ responses, which may exacerbate or alleviate their inner suffering and the discomfort arising from their chronic condition. In order to help the teenager understand the functioning of his body and how to care for it, the physician must be able to accommodate the deepest expressions of the feelings of self in a phase of individuation and play a supporting role in the developmental thrust. This is a first step in allowing the young patient to develop strategies to overcome potentially traumatic events related to the disease.
There are situations where doctors have difficulty in relating to adolescents and to their phase-specific needs (Carbone, 2003). In particular, this is likely to happen when the young patients are categorized and treated with a “prefabricated” approach applied automatically to all. FurtherAdolescents with Diabetes Adolescent Psychiatry, 2013, Vol. 3, No. 3 247 more sometimes the anxiety of the doctor about the teenagers’ adherence to treatment may lead him or her to act without having sufficiently taken into account the emotional stability of the young patient. For example, informing the patient matter-of-factly of the risk of serious complications related to the poor response to treatment is in effect treating the adolescent like an adult, even though he has not yet reached an appropriate level of maturation. Finally, a satisfactory relationship between the doctor and the adolescent patient requires on one hand holding the adolescent responsible for his behaviour, and on the other, considering both the successes and failures in the adolescent’s journey towards self-care as steps necessary to develop selfsufficiency.
We agree with Carbone that, if the teenager who falls ill can adhere to the treatment plan laid out by adults caring for
him, and succeeds in managing his condition, he will gain from therapeutic care a sense of wellbeing and strength, and the possibility of an enhanced life (2009). In the next section we describe a summer camp program for young adolescents with diabetes designed to foster self-management of their illness.

THE SUMMER CAMP EXPERIENCE: A MULTIFACETED INTERVENTION

The summer camp for children and adolescents with diabetes is an overnight 10 days camp staffed by doctors, nurses, teachers, animators and a psychologist. The program was designed by the team of the Center of Endocrinology and Adolescent Pediatrics Unit of the San Raffaele Hospital in Milan and sponsored by the families’ association for children with diabetes. It includes classes focusing on the control of the disease and adjustment to the treatment plan. Most activities take place in groups. The availability of a group of peers facilitates an affective experience crucial to the development of personal identity and contributes significantly to the process of individuation that characterizes this delicate stage of growth. The emphasis on peer involvement is in keeping with the normal evolutionary process of adolescence, which involves a passage from the family group, the school class group, to group experiences with peers who share common interests (i.e. a sport, learning a language, hobbies and so on).
For most of these youngsters, the camp is their first experience away from the family in a group context where they encounter others of the same age, who suffer from the same disease. The camp is a meeting ground where the young patients interact with some adults having specialized skills working together in a network. In fact, in addition to providing medical and scientific knowledge of the factors necessary to balance the bodily function deficit, the camp experience also offers the young patients a chance to understand, through the sharing and comparison, the emotional aspects related to the dynamics of interpersonal relationships and the sense of self.
The healthcare worker at the camp holds a flexible approach to children with diabetes, which necessitates a transition between providing professional guidance and serving as a parental figure. He sometimes plays the role of confidant, because the reality of the context of summer camp forces the doctor to get involved in close relationships with young patients. The expectations on the part of children of the doctor may be unrealistic; the doctor may embody paternal or superego elements, or maternal characteristics of reassurance and support. An interdisciplinary health care team is an important aspect of the camp, in accordance with the International Society for Pediatric and Adolescent Diabetes Consensus Guidelines (Delamater, 2009). This team provides round the clock assistance, promoting self-management of diabetes in a variety of ways (for example, how to give the insulin shot, how to calculate the different doses of insulin, how to recognize various feelings related to their diabetes).

THE INTERDISCIPLINARY HEALTH CARE TEAM

The Nurses. Working closely with the diabetes doctors, the nurses are the health providers who work very closely with adolescents, giving them explanations and practical guidelines by checking their daily intake and providing doctors important clues on the autonomous capabilities of patients. Through the daily interaction with these nurses the teenager may experience a gradual improvement of his adherence to the treatment.
The Psychologist. The psychologist at the camp, usually female, has been highly regarded by the medical team. The psychologist interacts with adolescents both during group and individual sessions. The teenagers themselves have brought up specific topics, during individual informal talks. Her presence in all their programmed activities gives the adolescents the possibility of speaking with her any given moment of the day without the need to make a formal appointment. This has been very useful to the children who have seen her as a maternal figure and non-judgmental listener, able to reflect with them about their feelings and experiences.
A Young Adult with Diabetes. The presence at the summer camp of a young man with diabetes offers the adolescents
the opportunity to realize that it is possible to grow up and lead a normal life. They are able, with this special adult, to express their doubts, perplexities, motivated by deep anxieties, to confess to being afraid of what might happen over time both on a physical (blindness, kidney problems, and other complications) and on an emotional level (“I wonder if I’ll get married and especially if I’ll have children”). The presence of this young adult has thus worked for the adolescents as an antidote to their anxiety over the transition to adult life.

THE EXPERIENCE OF “TAKING THE THRONE” AS IN THE “BIG BROTHER” SHOW

In the summer camp an arrangement was set up, modeled on the popular reality TV show, “Big Brother,” in which all
youngsters were provided with an individual space to tell their stories about diabetes, in front of a camera that videorecorded their talks. Just as the TV characters, who are forced to share all their experiences all day long, are given a private moment, at the summer camp the adolescents were given a private space, a so-called “confessional.”’ They were encouraged to speak about their feelings related to their illness, and about aspects of their daily life, such as their relationships with parents, their bodies, and peers. The teenagers 248 Adolescent Psychiatry, 2013, Vol. 3, No. 3 Colombini and Schivalocchi were reassured that only the health staff would be viewing their recordings, in order to better understand how they were feeling about the diabetes condition, and that they would not be judged. No one observed the narratives in the throne room while they were being recorded. The sessions offered the teenage patients a new opportunity to develop a new postdiabetes narrative, the narrative of one’s self with respect to their state of health, incorporating an altered process of mentalization of the body. This was also the perfect time to reveal
concerns that had been hidden up to now.

EMOTIONAL THEMES EMERGING FROM THE NARRATIVES

Acting younger. The following case illustrates how a teenager can adopt attitudes aimed at always being under an adult’s protection, especially if the peer group fails to provide reassurance in the transitional phase of adolescence.
At the camp Angelo was isolated from the rest of the group, seeking physical contact with all adults, especially with the doctors, nurses, educators or psychologist, for a need for protection similar to that available from his parents in his home. From the psychologist he sought not just physical proximity, but also explanations of the recommendations of the doctors, or some sort of practical support, for example when he had to fill out a questionnaire to show what he had learned at the camp up until that moment. Close to his peers facing the same test, Angelo seemed hesitant and unsecure, on the values of doses of insulin needed to correct a given level of glucose in the blood. Even though he had a learning disability, we felt his insecurity in this case was not caused by his schooling difficulties, but by his comparison with peers. This rather reflected his need for emotional support from an adult because of his feelings of discomfort. When it was his turn to record his narrative, he declared: “I am happy that I have the teacher to help me. I’m glad someone is with me, I’m happy that my mother will pay more attention to me and worry about me because of my diabetes illness”. The attitude revealed a bottomless hole and the need to feel supported face to face with peers who seemed more mature and subtle, who sometimes made fun of him, making him feel different even though he was in an environment with others who had the same illness. In response to their teasing, Angelo broke down into inconsolable crying, or exploded into fits of rage.
An ambivalent approach toward their growing up too fast emerged from some of the narratives: on one side they pretend to become independent in their daily life managing diabetes without the supervision of a parent and, on the other hand they behave at the camp as if they need to have an adult close by as much as possible, in order to be protected.
Luigi, a boy of 13, who appeared younger than his age, seemed comfortable in the peer group, although he often seemed to prefer the presence of an adult. L. declared: “Ever since I have had diabetes my mother is more concerned about me and pays more attention to what I do. I am happy about this.” At the camp each morning he presented himself in the medical room, always greeting whatever adult was there with a kiss, clinging to the person’s arm. He often carried with him the puppet used by the doctors to teach how to give self-injections and notified the physician on duty the value of his blood sugar levels. As if the physical contact with the adult present is not enough to fill the perceived void, Luigi’s puppet seemed to bear witness to his need for a transitional object. Luigi always sought the most maternal of the workers at the camp, a regressive tendency induced by his illness. However, being viewed by adults and peers as a child made him strive to hide his dependency needs with pathetic attempts at disguise. In the evening when all of the campers were allowed to go out together, Luigi took the psychologist by her hand, clinging on to her for the time required to process a difficult decision, also asking her to go with him. All this was because he wanted to purchase a black shirt with skulls, in stark contrast to his appearance as a blond-haired little boy with an angelic face. However, he was not able to complete his plan to show an aggressive look. Later, when faced with the application of the pump, he asked the doctor to call home and tearfully vented his feelings with his mother telling all the strain and partly the slight pain he had experienced.
Attempts at disappearing. Often the disease activates in the young patient archaic and maladaptive defensive mechanisms, such as blocking thoughts about the illness, or failing to recognize states of mind which could be loneliness, disappointment and rage, in attempts to deny suffering. Some teenagers responded to feelings of loneliness by attempting to disappear, hoping no one would notice them. Tina, an introverted girl, who was shy, had difficulty in relationships with peers, and was at unease with her own body. At the camp, she remained on the sidelines, quiet, inconspicuous, poorly integrated into the group of peers, trying not to be noticed, never seeking contact, physical or verbal, with adults who tried to involve her several times during lessons on diabetes and occasions of group play. She rejected the idea of talking about herself in the narratives.
The feeling of being different. Julia was very keen to talk about her difficulties in accepting the limitations induced by diabetes: her videotaped narrative looked almost like an act of revenge towards adults who seemed either too reassuring or very threatening. “I have been living with diabetes from birth and I have so many problems! They (the adults) say ‘it’s nothing, just learn to manage it’ (mimicking the voice of her parents who are trying to minimize her chronic condition). Sometimes I feel as if I have cancer and, in order not to feel different when I am with my friends, if they ask me if I want a granita (crushed ice with syrup), I act as if having the illness should not affect my life. I actually feel as if I am different, because I can’t eat everything … and because I am afraid that others will say I’m addicted to something when I have to give myself an injection…” As to the attitude of protective parents: “Sometimes I feel stressed out because my parents say that if I don’t take care of myself, sooner or later I’ll die or become blind. Then if I get Adolescents with Diabetes Adolescent Psychiatry, 2013, Vol. 3, No. 3 249 angry …they treat me like a normal human being, but there is so much stress involved!”
The adjective “normal” often appears in the talk of these youngsters: “I am normal, although sometimes I feel as if I am different”, “Having diabetes is a normal thing for me because I have had it since I was a young child,” “Here at the camp, I feel like a normal teenager.” Clara reported that at the beginning she thought she would lose her non-diabetic friends, but then, contrary to her expectations, she found out that friends are not lost due to an illness and now she has a “normal” relationship with them.
Strategies for feeling competent. Hyper-adaptive attitudes and seemingly stabile emotional control may actually hide anxiety in the face of a situation where these teenagers often do not know the details or the long-term consequences
of their illness. For Wanda, a lively and alert girl, well-integrated into the group, the self-narration, helping her to recognize a dimension of finitude and frailty, seemed to preserve her ability to think of her own wellbeing, and so to exist and evolve in the direction of greater self-awareness, and improve her reflective functioning. Her statement about the diabetes ”I have been living with it so long and I’m used to it” was her attempt to keep her anxiety at a tolerable level by minimizing it. At the camp, she was able to relate to both peers and adults, in a way that enhanced her sense of competence. She could accept help without feeling dependent, learning how to use the insulin pump with other teenagers in a shared space and in the presence of health workers, something that she greatly appreciated. She revealed that at home she would have been afraid to use this device, because “at home there are parents, while here there are doctors and I feel safer.” This remark confirmed the frequent feeling shared among health care workers who come into contact with these families, that parental anxiety hinders the activation of their children’s healthy resources and capabilities. Other youngsters showed different ways of keeping control of their anxiety regarding a future too easily imagined as unpredictable and threatening. For example, Francesco worried about possible complications related to chronic disease, saying he was very interested in new medical discoveries, to the areas of research and development: “When I grow up I want to become a diabetes doctor to better understand what happens.” When mentioning physical perceptions related to the treatment, he minimized the feeling of pain: “Injections bother me a bit, they hurt a little but are bearable” revealing in this way his tendency to deny emotional distress caused by diabetes.
Some diabetic teenagers are able to ask adults who take care of them for a detailed explanation of what is happening to their body. Others prefer not to go into detail on the possible consequences of a more or less correct adherence to medical recommendations, of how the treatment program works and specific reactions to insulin. Differentiating between these opposing orientations, each of which is related to attempts of anxiety control, requires a thorough knowledge of the emotional history of each youngster. For example, during the summer camp Tina gave the impression of being shy and depressed; she was unable able to ask questions about her health.
When she returned from the camp the doctors’ concerns for Tina made them agree with her parents on a check-up in the outpatient pediatric department, including an appointment with the psychologist. During the individual session Tina appeared very reserved and fatigued and emotionally flat. Soon it emerged that she felt inadequate not only to the tasks of managing her diabetes, but also to dealing with her fatigue at school, and relationships with peers. She seemed to be expressing her sense of having lost control not only over her own body, but more generally about her life, highlighting a process induced by chronic illness that, in her case, had damaged her sense of self-efficacy and her self-esteem. Psychotherapy was recommended for her to help her rework the emotional dynamics and restore her growth process.

PARENT-CHILD RELATIONSHIPS

Attitudes of adults—parents, doctors, teachers—oriented toward strict control, judgment or devaluation, easily provoke in the young patient with diabetes a sense of inadequacy. Others, distant or cold, deprive the young person of opportunities to confront his limits, to acquire gradually the ability to take care of the body, self-determination, and a mature awareness of personal growth.
One of the themes that frequently emerged from the narratives was the parents’ tendency to focus on their childrens’ diabetic condition as the explanation for all distress experienced by the child. Parents could not readily distinguish problems related to diabetes from normal problems of adolescence. Like most adolescents, these teenagers at camp reported their parents as having difficulty accepting the normal evolutionary process of adolescence and relinquishing a sense of control over their childrens’ moods and emotions. (Maggiolini & Pietropolli Charmet, 2004). As one teenager put it: “It bothers me that, even when I’m sad for some other reason, my parents ask me if my sadness has to do with diabetes.”
During the initial phases of the disease, many of these adolescents, in an inconscious desire to protect their families, tried to minimize their suffering, acting in a pseudo-mature fashion. They affirmed that at the beginning, they had to sustain, support, and calm down their parents, playing an adult role while they were suffering from a crisis themselves. One adolescent, who related well to peers and adults, often asking staff for confirmation or support regarding how to handle diabetes, recounted his personal experience and expressed the desire to be alone, sending out a silent message about his wish for autonomy; however, he added “controlling myself well avoids making my parents worry too much.” Parental concern, however could also be viewed positively.
Although parents were often depicted as burdened with feelings of guilt, helplessness and inadequacy induced by the
chronic condition of their children, at the same time, the adolescents were pleased at the increased attention and kindness they received from their parents because of their status and it also showed that ” they still cared” about them.

DISCUSSION

Adolescence can be considered as a stage changing not only the appearance and physical functioning, but also the inner world. We can hypothesize that from the time of onset of the illness; the adolescent with diabetes will experience a rupture not only in his health status but also in the continuity of his/her emotional life. The continuity of the adolescent’s life is disrupted by the illness and becomes a transitional phase characterized by a deep narcissistic betrayal. As Barbieri states, “….the illness is an explosive time-bomb with a defective timer which could stop, but could also speed up or slow down, at pleasure, leaving the actor (the adolescent) at the mercy of a bizarre and sadistic fate” (2005, p. 43).
It is very important to understand the approach of each adolescent to the illness, and to differentiate between the healthy responses of protest and rebellion, and those due to denial of the deficit and to the fear of feeling inadequate, or of being different from peers (Carbone, 2009). Coping with diabetes in adolescence involves adjusting to a different selfimage, changes in the relationship with parents and peers, and new daily living needs. This is equally true whether the illness starts during adolescence or earlier. In this summer camp there were both adolescents who had onset of diabetes during adolescence and those who had it since childhood.
We did not observe a significant difference between the two groups with respect to their attitude toward the disease and the compliance to the treatment. From the onset of the disease an adolescent suffering from diabetes is no longer the same person, being forced to redefine himself in relationship with both the intrapsychic and the interpersonal self. With the disease experienced as an inner object of persecution, one outcome may be a surrender to despair and a depletion of thought. The disease, however, can be a stimulus for regrouping the fragmented self.
The experiences of the young adolescents in our program as temporary “throne-sitters” as in the reality show “Big Brother” facilitated the development of narratives that promoted a cohesive sense of self and the regaining of an equilibrium that had been lost in the face of the challenges of their illness. Their narratives reflected their trauma and their attempts to process it. To our surprise, they also experienced a secondary benefit from their illness, which allowed them to keep an infantile bond with the parent and to resist movement in the direction of empowerment that could cause insecurity and anxiety.
Physicians and other health care providers can significantly influence the psychological outcome for the adolescent with diabetes. If the relationship between a physician, as the adult responsible for the health, and a teenage patient is established on a basis of trust, he or she becomes an interlocutor whom the child can confide in. Elements such as acceptance, honesty, empathy, are essential for a meaningful relationship between the teenager with diabetes and the adult who cares for him. In this way the doctor supports not only the management of the disease and the treatment plan, but also important life choices. Consequently he can play the role of holder of emotions and personal memories, of existential perceptions related to the teenager’s relationships with relatives and the world outside the family circle. The doctor, in turn, will inevitably find himself confronted with his own adolescent history, with all its conflicts and its highly charged emotions. The possible discomfort associated with the reactivation of all the above-mentioned factors could interfere with his paying enough attention to the current needs and potential of the young person in his care. The doctor’s role is particularly complex because it involves both management of the young patient’s condition and maintaining a relationship with the young patient that fosters healthy development. An infantilizing approach by doctors may adversely affect the child’s perception of his illness and his life choices. Conversely, an approach that facilitates the adolescent’s empowerment and supports the capacity to cope with the disease can bring coherence to the fragmented and often confusing experience. Through the doctor’s understanding of the adolescent’s emotional needs and communication of this awareness, the doctor enhances the process of mentalization in the adolescent. The young patient can thus have the experience of “being in the mind” of the doctor.
We agree with Michaud that the treatment with the teenager should be discussed, and even negotiated (1989). Finally, the doctor must be able to communicate in a positive way with a teenager and express confidence in the young person’s capabilities, without the pretence of wanting to change him. This positive approach will favor the teenage patient so that he can succeed and he has the strength to overcome his obstacles and difficulties.

ABOUT THE AUTHORS

Maria Iole Colombini is a psychologist, psychotherapist, and teaching analyst at the Institute for Child and Adolescent Psychoanalytic Psychotherapy in Milan, Italy. She is also a consultant in the Department of Pediatrics and Neonatology at the Center for Child and Adolescent Endocrinology at the San Raffaele Hospital in Milan, Italy.
Emanuela Schivalocchi is a psychologist and student at the Institute for Child and Adolescent Psychoanalytic Psychotherapy and a trainee in the Department of Pediatrics and Neonatology, Center for Child and Adolescent Endocrinology, San Raffaele Hospital, Milan, Italy.

REFERENCES

Anderson, B. (2009). Psychosocial care for young people with diabetes. Pediatric Diabetes, 10 Suppl 13:3-8.
Anderson, B. J., Ho, J., Brackett J., Finfelstein D., & Laffel, L. (1997). Parental involvement in diabetes management tasks: Relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus. Journal of Pediatrics, 130, 257-265.
Anderson, B. J., Svoren, B., & Laffel, L. M. (2007). Initiatives to promote effective self-care skills in children and adolescents with diabetes mellitus. Disease Management and Health Outcomes, 15, 101-108.
Barbieri, G. L. (2005). Trasformazioni narrative del Sé nell’adolescente ammalato [Narrative transformation in the self of the sick adolescent] in F. Vanni (Ed.) Adolescenti, corpo e malattia [Adolescents, body and disease] (pp. 37-49). Milan: Franco Angeli. Adolescents with Diabetes Adolescent Psychiatry, 2013, Vol. 3, No. 3 251
Carbone, P. (2003). Le ali di Icaro. Rischio e incidenti in adolescenza [The wings of Icarus: Accident risk in adolescence]. Turin: Bollati Boringhieri.
Carbone P. (2009). Adolescenti, medici e malattie. Una psicoanalista in corsia [Adolescents, doctors and diseases. A psychoanalyst on the wards], in R. Goisis e S. Bonfiglio Senise (Eds.), Essere adolescenti oggi [To be an adolescent today]. Milan: Quaderni del Centro Milanese di Psicoanalisi Cesare Musatti.
Delamater, A. M. (2009). Psychological care of children and adolescents with diabetes, ISPAD Clinical Practice Consensus Guidelines Compendium. Pediatric Diabetes, 10 (Suppl. 12), 175-1841.
Gislon, M. C., (1993). Adolescenza e discontinuità [Discontinuity in adolescence]. Turin: Bollati Boringhieri.
Helgeson, V. S., Siminerio L., Escobar, O., & Becker, D. (2009). Predictors of metabolic control among adolescents with diabetes: A 4-year longitudinal study. Journal of Pediatric Psychology, 34, 254-270.
Herzer, M., & Hood, K. K. (2010). Anxiety symptoms in adolescents with type 1 diabetes: Association with blood glucose monitoring and glycemic control. Journal of Pediatric Psychology, 35, 415-425.
Horton, D., Berg, C. A., Butner, J., & Wiebe D. J. (2009). The role of parental monitoring in metabolic control: Effect on adherence and externalizing behaviors during adolescence. Journal of Pediatric Psychology, 34, 1008-1018.
Jaser, S. S., (2010). A pilot study of observed parenting and adjustment in adolescents with type 1 diabetes and their mothers, Journal of Pediatric Psychology 35, 738-747.
Maggiolini, A., & Pietropolli Charmet, G. (2004). Manuale di psicologia dell’adolescenza: compiti e conflitti [Handbook of adolescent psychology: Tasks and conflicts]. Milan: Franco Angeli.
Lewin, A. B., Storch, E. A., Geffken, G. R., Heidgerken, A. D., Williams, L. B., & Silverstein, J. H. (2005). Further examination of a structured adherence interview of diabetes for children, adolescents, and parents. Children’s Health Care, 34, 149-164.
Michaud, P. A. (1989). Gli adolescenti portatori di una malattia cronica: per un approccio globale [Adolescents who have a chronic disease: A comprehensive approach]. In T. Senise (Ed.). L’adolescente come paziente [The adolescent as patient] Milan: Franco Angeli. Nobili, R., & Sala A. (2005). L’adolescente di fronte alla malattia cronica: due esperienze, fibrosi cistica e insufficienza renale terminale, con diverso carico terapeutico e differente “invasione” del corpo [The teenager in the face of chronic disease: Two experiences, cystic fibrosis and end stage renal disease, treatment with a different burden and different “invasion” of the body] in F. Vanni (Ed.). Adolescenti, corpo e malattia [Adolescents, body and illness]. Milan: Franco Angeli.
Northam, E. A., Lin, A., Finch, S., Werther, G. A., & Cameron, F. J. (2010). Psychosocial well-being and functional outcomes in youth with type 1 diabetes 12 years after disease onset. Diabetes Care, 33, 1430-1437.
Quittner, A. L., Modi, A. C., Lemanek, K. L., Ievers-Landis, C. E., & Rapoff, M. A. (2008). Evidence-based assessment of adherence to medical treatments in pediatric psychology, Journal of Pediatric Psychology, 33, 916-936.
Schneider, S., (2009). Assessment of an illness-specific dimension of selfesteem in youths with type 1 diabetes, Journal of Pediatric Psychology, 34, 283-293.
Winnicott, D. (1965). The family and individual development, London: Tavistock Publications Ltd. Received: November 11, 2011 Revised: April 10, 2013 Accepted: May 04, 2013