Internalizing and Externalizing Symptoms and Attributional Style in Youth with Diabetes RONALD T. BROWN, PH.D., NADINE J. KASLOW, PH.D., LONNIE SANSBURY, PH.D., LILLIAN MEACHAM, M.D., AND FLOYD L. CULLER, M.D.
Abstract. The psychiatric functioning of 28 youths with insulin-dependent diabetes mellitus was examined. Measures of psychological functioning were related to age at onset, duration of diabetes, and metabolic control, as assessed by HgbAIC. Children diagnosed with insulin-dependent diabetes mellitus at a later age were considered by teachers to have more behavioral problems. Children who had better metabolic control tended to hold themselves responsible for negative events. It is worthwhile to develop interventions to teach diabetic children a realistic balance between taking appropriate responsibility for controllable negative events without taking undue blame for uncontrollable negative events associated with the disease. J. Am. Acad. Child Adolesc. Psychiatry, 1991, 30,6:921925. Key Words: diabetes mellitus, children, adolescents, attributions. During the past decade, there has been an increased interest in the psychosocial factors associated with insulindependent diabetes mellitus (IDDM) in pediatric populations (Johnson, 1988). Although some clinical reports have suggested an association between depression and low self-esteem in children with diabetes (Barglow et al., 1986), other research in this area often has failed to corroborate these observations (Jacobson et al., 1986; Margalit, 1986). Also, parent ratings of diabetic children's behavioral adjustment have not revealed an increased level of psychopathology (Jacobson et al., 1986; Wertlieb et al., 1986). In an effort to clarify issues of psychopathology in children with diabetes, some investigators have focused on the influence of particular diabetes-related factors on psychological functioning. Specifically, age at diabetes onset has been related to measures of adjustment and behavioral problems: youths whose diagnosis was made at a later age have more adjustment and internalizing and externalizing behavioral problems (Allen et al., 1983; Rovet et al., 1987). This finding is not surprising, given the overwhelming clinical evidence that diagnosis of IDDM at adolescence often produces emotional turbulence greater than that typically experienced by healthy adolescents (Johnson and Rosenbloom, 1982). Other investigators have focused upon the relationship between psychopathology, personality factors, and metabolic control. A common hypothesis is that children in poorer metabolic control of their diabetes have more beAccepted June 19, 1991. From the Departments of Pediatrics, Psychiatry, and Psychology, Emory University. Portions of this paper were presented at the 1990 Annual Meeting of the Association for the Advancement of Behavior Therapy, San Francisco, California. The authors acknowledge the assistance ofChildren, s Medical Service and Gwendolyn Bell, M.D., for referring patients to this study. This work was supported by a grant from the Georgia Health Care Foundation. Reprint requests to Dr. Brown, Department of Psychiatry, Emory University School of Medicine, Grady Memorial Hospital, 80 Butler Street SE, Atlanta, GA 30335. 0890-8567/91/3006-0921$03. o%© 1991 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Ado/esc. Psychiatry, 30 :6, November 1991
havioral and personality problems. Research findings have not entirely supported this relationship (e.g., Gross et al., 1984; Kovacs et al., 1986; Rovet et al., 1987). However, White and her associates (1984), using semistructured interviews, found that many children who reported episodes of diabetic ketoacidosis and seizures were characterized by externalizing problems, including oppositional behavior, school truancy, difficulty with peers, and antisocial behavior. Similarly, Ahnsgo and colleagues (1981) found that aggression increased over time in poorly controlled diabetic children, in comparison to healthy controls. Another hypothesis is that a child's psychological adjustment to IDDM is related to the ability to use appropriate cognitive strategies to experience a sense of mastery over the illness and successes and failures in life. Previous research has found that diabetics with an internal locus of control are more knowledgeable about their illness (Lowery and DuCette, 1976) and more adherent to their treatment regimen (Jacobson et al., 1990). In a related vein, empirical work has documented an association between external locus of control, in which children perceived their lives as controlled by outside forces, with less satisfactory adjustment to diabetes (Jacobson et al., 1986). Moreover, there is some evidence that adjustment to IDDM as it relates to locus of control differs by sex. Girls with an external locus of control and boys with an internal locus of control have been found to have more adjustment difficulties (Hamburg and Inoff, 1982). More recent work has focused on attributions of causality in addition to perceptions of controllability. Considerable evidence suggests that a cognitive style in which children make internal-stable-global attributions for negative events in their life is associated with feelings of helplessness, hopelessness, and depression (e.g., Kaslow et al., 1984; Seligman et al., 1984). It is reasonable to speculate that diabetic children with a depressive attributional style have more difficulty adjusting to their illness, and indeed recent evidence has supported this hypothesis (Kuttner et al., 1990). However, Hamburg and his associates (1980) contended that adult diabetics who engage in self-blame (internal attributions for negative events) evidence a greater sense of control
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over illness outcomes and thus , under certain circumstances , behavioral self-blame may be associated with greater coping capacity (Bulman and Wortman , 1977). In fact, empirical evidence has suggested that compared with external factors , children who believed that the control of IDDM was because of their own behavior coped more effectively and showed greater compliance , as reported by their physicians (Tennen et aI., 1984). The purpose of this investigation was to examine the emotional functioning of children and adolescents with diabetes, as rated by self, parent, and teacher reports of behavior. Specifically, the relationship between reports of behavior and diabetes-related factors, including age at onset , duration of IDDM, and metabolic control (HgbA1C), was examined. In addition, the relationship between children's attributions for positive and negative events and these same diabetes-related factors was studied.
Method Subjects
Twenty-eight children (13 boys and 15 girls), aged 6 years 11 months to 16 years 5 months (mean, 12 years 6 months) with IDDM were recruited from diabetes clinics affilitated with a large university public teaching hospital. All children were of average intellectual functioning, as measured by the Wechsler Intelligence Scale for Children-Revised (Wechsler, 1974) (mean IQ = 101, SD = 15.49). The population was of low socioeconomic status. Of these patients, 57% were black, and 43% were Caucasian . IDDM patients and at least one parent were asked during their clinic appointment to discuss possible participation in a study examining psychological and social-cognitive functioning in children with diabetes. No specific data are available on three subjects who refused to participate because of transportation conflicts. Although no specific data are available for these patients, they were from the same low socioeconomic inner-city population . After obtaining informed consent from the child's parent and the child, information was obtained from parents and from a review of medical records about age at disease onset, disease duration, and overall diabetes metabolic control. Specific tests were then administered, and patient, parent , and teacher reports were requested. Procedure
Subjects were tested at the university hospital by a master's-level psychologist. Teacher ratings were mailed and returned within a month of the evaluation. Parents were given a fee to cover out-of-pocket expenses. Measures
Children's reports of their depression-related symptomatology were assessed by the Children's Depression Inventory (CDI) (Kovacs and Beck , 1977), a 27-item self-report scale that taps the cognitive , affective, motivational, and vegetative symptoms of depression. The CDI has high internal consistency and test-retest reliability (e.g., Saylor et aI., 1984). Children's anxiety symptoms were ascertained 922
by the Revised Children's Manifest Anxiety Scale (R-CMAS) (Reynolds and Richmonds, 1978), a 37-item self-report scale that includes 28 items assessing symptoms of anxiety and nine social desirability (lie) items. The scale has high internal consistency and adequate test-retest reliability (Reynolds and Richmond, 1978). Children's attributions for positive and negative events were examined by using the Children's Attributional Style Questionnaire (KASTANCASQ), (Seligman et aI., 1984), a 48-item forced-choice scale that has adequate psychometric properties. Each item comprises a situation (e.g ., "You get good grades") and two possible attributions to explain why the situation occurred (e.g., "I am a hard worker" vs. "Schoolwork is simple"). Children are instructed to choose the alternative that best describes why the event in question happened to them. Half the situations represent good outcomes; half represent bad outcomes . Three dimensions of attributional style (internal/external, global/specific, stable/unstable) are assessed. Two composite scores are derived: a good composite score and a bad composite score. The lower the good and the higher the bad scores , the more depressive the attributional style as conceptualized by the revised learned helplessness theory of depression (Abramson et aI., 1978). Mothers completed the Child Behavior Checklist (CBCL) (Achenbach, 1978), a l03-item behavior problem scale that includes narrow-band factors and two broad-band factors (internalizing and externalizing symptoms of psychopathology). Only the broad-band factors were used for analysis in this study. Broad-band scores also were obtained from the child's teacher at the time of the evaluation by using the Achenbach Teacher Rating Scale (TRS) (Achenbach and Edelbrock, 1981), a companion to the CBCL. These scales, which have been used in a wide range of research studies with children and adolescents. have adequate psychometric properties (Achenbach et aI., 1987). Diabetic-related factors included age at onset, duration of disease, and control of diabetes. To determine diabetic control, each child's most recent glycosylated hemoglobin value (HgbA1C) (all within the preceding 2 months, nondiabetic norm = 4.0 to 6.2) was recorded, because it is the best indicator of overall current diabetic control (Clarson et aI., 1985; Daneman et aI. , 1981; Gabbay , 1976). Multiple regression analyses were conducted to ascertain the relation between diabetes-related variables and the dependent measures. The means, standard deviations, ranges, and frequency distributions of the diabetes-related factors for the sample are presented in Table 1.
Results The means, standard deviations , and ranges for the sample for each of the measures of psychological adjustment and social-cognitive functioning are presented in Table 2. Because previous studies have demonstrated a relationship between sex and chronological age and each of the dependent measures (Nolen-Hoeksema, 1990), it was necessary to control these variables in the analyses. To control the effect of chronological age and sex on the dependent measures, hierarchiacal regression analyses were performed on each of the dependent measures, in which age and sex l.Am.Acad. Child Adolesc.Psychiatry, 30:6, November 1991
YOUTH WITH DIABETES TABLE
1. Means, Standard Deviations, and Ranges f or Diabetes-related Variables
Variable Age (in months) Age at onset (in months) Duration (in months) HgbA,Ca (%)
149.9 109.8 39. I 8.8
so
Range
34.0 47.5 36.0 2.43
83-197 9-170 1-144 5.2-13 .1
Note: N = 28. a Nondiabetic nonn = 4 .G-6.2;f = frequency . Diabetic nonn = 7.G-8.0, with scores grater than 10 indicat ive of poor compliance.
were parceled out. For the KASTAN-CASQ bad composite score, a significant multiple regression was obtained for the metabolic control measure (HgbAIIC)/ when age and sex were controlled (13 = -0.49, P < 0.02) , R2 = -0.58 , F(3 , 21) = 3.62 , P < 0.03. Children who tended to make more internal, stable, and global attributions for negative events evidenced better glycemic control. Additionally, with age parceled out, there was a trend for children with longer duration of illness and poorer metabolic control, "as measured by HgbA1C, to have an attributional style characterized by more external, unstable, and specific attributions for bad events and more internal-stable-global attributions for good events (p < 0.08). Because this analysis only approached significance, the authors were concerned about the possibility of the Type II error because of low power. The power analysis revealed that the power to detect a large effect size, as defined in Cohen (1988), was 0.80. The power to detect a medium effect was 0.50 (Cohen, 1988). Therefore, if the relationship between "nondepressive attributions" had been fairly strong, it would have been detected in this size sample. However, if the relationship was not as strong , it might not have been detected in this size sample . In short, there was sufficient power for a large effect, yet insufficient power for a medium effect. For the TRS externalizing broad-band factor score , when chronological age was controlled, a significant multiple regression was obtained for age at onset (13 = 0.47, P < 0.04) ; R2 = 0.42, F(2, 19) = 6.96, p < 0.005. Thus, children whose IDDM diagnosis was made at a later age tended to be rated by their teachers as having more externalizing behavioral symptoms. Consistent with this , children and adolescents with shorter duration of IDDM also were rated by teachers as evidencing more externalizing behavioral problems when chronological age and sex were controlled (13 = -0.36, P < 0.05), R2 = 0.64, F(2, 19) = 6.52, p < 0.007 . However, it is important to note that although the group means for externalizing behavior on the TRS are within the normal range , the variability within the sample indicates that 29% of children were reported by their teachers to manifest clinically significant degrees (T scores above 65, or 93rd percentile) of behavioral problems. No statistically significant relations were found between measures of diabetic -related factors and self- and parent-reports of psychological adjustment, including the cm, R-CMAS, and the CBCL. In addition, group means for each of these measures were within the normal range . l.Am.Acad. Child Adolesc. Psychiatry, 30:6, November 1991
T ABLE 2. Means, Standard Deviations, and Ranges f or Measures of Internalizing and Externalizing Symptoms and Attributional Style
Measure
N
X
SD
Range
COla
28 28
9.3 10.7
7.4 6.6
G-27 G-29
28 28
59.8 58.6
9.5 6.8
43-82 45-77
22 22
52.5 53.7
9.5 9.5
34-81 39-69
28 28
12.2 7.3
3.0 3.2
4-18 1-15
R-CMASb CBCL (parent)' Internalizing Externalizing TRS (teacher)" Internalizing Externalizing KASTAN-CASQ< Good composite Bad composite
COl = Children's Depression Inventory (Kovacs and Beck , 1977). R-CMAS = Revised Children's Manifest Anxiety Scale (Reynolds and Richmond , 1978). ' CBCL = Child Behavior Check List (Achenbach, 1978). d TRS = Teacher Rating Scale (Achenbach, 1978). • KASTAN-CASQ = Children 's Attributional Style Questionnaire (Seligman et aI., 1984). a
b
Discussion The most striking finding from this investigation is that children who held themselves responsible for negtive events, as assessed on a measure of attributional style (KASTANCASQ), had greater metabolic control, as measured by HgbA 1C. This finding is clinically as well as statistically significant: a significant percentage of our sample (43%) had HgbA1C scores above 10, which indicates poor compliance, despite the fact that the group mean was within the normal range for persons who have diabetes. It is noteworthy that children who hold themselves responsible for negative events do not necessarily hold themselves responsible for positive events. These findings are in line with the work with diabetic adults presented by Hamburg and colleagues (1980) , Bulman and Wortman (1977), and research with pediatric populations (Tennen et al., 1984): persons with diabetes who engage in self-blame (internal attributions for negative events) evidence better control. More specifically, these findings are consistent with recently published data presented by Kuttner and colleagues (1990), who found an association between a learned helplessness attributional style for negative events and metabolic control. Recent studies with healthy college students have shown that a depressive attributional style is a risk factor for the later development of physical symptoms (e.g., Peterson, 1988). Although this finding may appear inconsistent with the data from the present study, the discrepancy may be attributable to differences in the age and the socioeconomic status of patient populations, healthy versus chronically ill patients , and the attributional style predictive of illness versus the style associated with adaptive coping and compliance with medical regimens. In the present study, the youth who had a more "depressive" attributional style took greater responsibility for managing their diabetes and thus evidenced greater compliance, in contrast to findings from the aforementioned college student population (Peterson, 1988),
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BROWN ET AL.
in which a depressive attributional style is a risk factor for the development of physical symptoms. To understand the complex relations between attributional style and both medical compliance and symptom development, future research will need to address more fully the demographic characteristics of the sample, the attributional styles most adaptive for preventing illness, and the styles most effective in enhancing compliance with treatment demands once illness is diagnosed. In keeping with the findings of previous research (Allen et aI., 1983; Rovet et aI., 1987), children with later-onset diabetes and thus shorter duration of the illness manifested more externalizing behavioral problems but only as rated by their teachers. This investigation is one of the first studies to use teacher reports of IDDM symptoms in addition to child and parent reports. Of interest is the finding that only teacher reports suggested that diabetic children, particularly those whose diabetes was of later onset and shorter duration, manifested more externalizing behavioral problems. Current research suggests that teachers may be the most accurate reporters of externalizing behaviors (Loeber et aI., 1990). This underscores the importance of a multiinformant approach, including teachers, for behavioral assessment of children. Despite the finding that teachers reported that these children had more difficulties, the diabetic children did not rate themselves and were not rated by their parents as having significant emotional impairment. The findings concerning the reports of parents and children are consistent with the literature on chronic illness (Stehbens, 1988). Indeed there is a growing body of literature suggesting that diabetes is not necessarily comorbid with psychiatric morbidity (Jacobson et aI., 1990; Kovacs et aI., 1985). Moreover, there was no significant relationship between emotional difficulties and diabetes-related factors. Taken together, these findings might be interpreted to suggest that, although a subgroup of IDDM children (e.g., late onset IDDM youth in whom disease has been diagnosed recently) evidence some behavioral problems, the mean scores on self, teacher, and parent reports suggest that IDDM children are relatively intact emotionally. The ability to generalize the findings is limited by the relatively small number of subjects, their low socioeconomic status, and the study of only one chronic illness group. Future studies should examine the relation of chronic illness and the psychopathology of medically ill children across informants. Studies also need to compare psychological adjustment and attributional style in relation to complicance across a range of chronic illness groups. Also, given that metabolic control of IDDM is significantly associated with family functioning (e.g., Hanson et al., 1989), parental psychopathology, family interaction patterns, and parents' causal attributions regarding negative and positive events in their child's life should be assessed. Based on empirical findings from these proposed studies, psychosocial interventions might be tailored to teach chronically ill children and their parents a realistic balance between appropriate responsibility for controllable negative events and inappropriate responsibility and self-blame for uncontrollable negative events associated with the disease. 924
Specifically, these youths need to be taught the aspects of diabetes that can be controlled (diet, exercise, insulin intake, rotation of injection sites) and encouraged to take appropriate responsibility for managing these aspects of their own care. However, they also need to be supported in the aspects of the illness (e.g., having a chronic illness that is beyond their control as well as accepting the physiological processes associated with the illness, which may occur even during times of good compliance) that are beyond their control. Thus, an attributional style in which they take responsibility for controllable negative events but not for uncontrollable negative events associated with their illness is most adaptive. Moreover, these youths need to be supported in coming to terms with a chronic illness and working through emotionally, cognitively, and behaviorally the limitations that such an illness imposes. Finally, they need to be cognizant of the effects of diabetes on their lives yet not allow the illness to dominate their daily lives. References Abramson, L. Y., Seligman, M. E. P. & Teasdale, J. D. (1978), Learned helplessness in humans: critique and reformulation. J. Abnorm. Psychol., 87:49-74. Achenbach, T. M. (1978), The child behavior profile: 1. Boys aged 6-11. l. Consult. CUn. Psychol., 46:478-488. - - & Edelbrock, C. S. (1981), Behavioral problems and problems and competencies reported by parents of normal and disturbed children aged 4 through 16. Monogr. Soc. Res. Child Dev., 45(1, Serial No. 188). - - McConaughy, S. H. & Howell, C. T. (1987), Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychol. Bull., 101:213-232. Ahnsgo, S., Humble, K., Larsson, Y., Settergren-Carlsson, B. & Sterky, G. (1981), Personality changes and social adjustment during the first three years of diabetes in children. Acta. Paediatr. Scand., 70:321-327.
Allen, D. A., Tennen, H., McGrade, B. J., Affleck, G. & Ratzan, S. (1983), Parent and child perceptions of the management of juvenile diabetes. J. Pediatr, Psychol., 8:129-141. Barglow, P., Berndt, D. J., Burns, W. J. & Hatcher, R. (1986), Neuroendocrine and psychological factors in childhood diabetes mellitus. J. Am. Acad. Child Adolesc. Psychiatry, 25:785-793. Bulman, R. & Wortman, C. B. (1977), Attributions of blame and coping in the "real world": severe accident victims react to their lot. J, Pers, Soc. Psychol., 35:351-363. Clarson, C.; Daneman, D. & Ehrlich, R. (1985), The relationship of metabolic control to growth and pubertal development in children with insulin dependent diabetes. Diabetes Res., 2;237-241. Cohen, J. (1988), Statistical Power Analysis for the Behavioral Sciences, 2nd edition. Hillside, NJ: Erlbaum. Daneman, D., Wolfson, D. H., Becker, D. J. & Drash, A. L. (1981), Factors affecting glycosylated hemoglobin values in children with insulin-dependent diabetes. Pediatrics, 99;847-853. Gabbay, K. (1976), Glycosylated hemoglobin and diabetic control. N. Engl. J. Med., 295:443-444. Gross, A. M., Deicher, H. K., Snitzer, J., Bianchi, B. & Epstein, S. (1984), Personality variables and metabolic control in children with diabetes. J. Genet. Psychol., 146:19-26. Hamburg, B. A. & Inoff, G. E. (1982), Relationships between behavioral factors and diabetic control in children and adolescents: a camp study. Psychosom. Med., 44:321-339. - - Lipsett, L. F., Inoff, G. E. & Drash, A. L. (eds.), (1980), Behavioral and psychosocial issues in diabetes (NIH Pub. No, 801993). Washington, DC: U.S. Government Printing Office. Hanson, C. L., Henggeler, S. W., Harris, M. A., Burgen, G. A. & Moore, M. (1989), Family system variables and the health status
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of adolescents with insulin-dependent diabetes mellitus. Health Psychol., 8:239-253. Jacobson, A. M., Wertlieb, D., Wolfsdorf, 1., Orleans, J. & Vieryra, M. (1986), Psychological adjustment of children with recently diagnosed diabetes mellitus. Diabetes Care, 9:323-329. --Hauser, S. T., Lavori, P. et al (1990), Adherence among children and adolescents with insulin-dependent diabetes mellitus over a fouryear longitudinal follow-up: 1. The influence of patient coping and adjustment. J. Pediatr, Psychol., 15:511-526. Johnson, S. B. (1988), Diabetes mellitus in childhood. In: Handbook of Pediatric Psychology, ed. D. K. Routh. New York: Guilford, pp. 9-31. - - Rosenbloom, A. L. (1982), Behavioral aspects of diabetes mellitus in childhood and adolescence. Pediatr. Clin. North. Am., 5:357369. Kaslow, N. 1., Rehm, L. & Siegel, A. W. (1984), Social-cognitive correlates of depression in children. J. Abnorm. Child Psychol., 12:605-620. Kovacs, M. & Beck, A. T. (1977), An empirical-clinical approach toward a definition of childhood depression. In: Depression in Childhood: Diagnosis, Treatment, and Conceptual Models, ed. 1. G. Schulterbrandt & A. Raskin. New York: Raven, pp. 1-25. - - Feinberg, T., Paulauskas, S., Finkelstein, R., Pollock, M. & Crouse-Novak, M. (1985), Initial coping responses and psychosocial characteristics of children with insulin-dependent diabetes mellitus. J. Pediatr., 106:827-834. - - Brent, D., Steinberg, T. F., Paulauskas, S. & Reid, J. (1986), Children's self-reports of psychologic adjustment and coping strategies during first year of insulin-dependent diabetes mellitus. Diabetes Care, 9:472--479. Kuttner, M. J., Delamater, A. M. & Santiago, J. V. (1990), Learned helplessness in diabetic youth. J. Pediatr, Psychol., 15:581-594. Loeber, R., Green, S. M. & Lahey, B. B. (1990), Mental health professionals' perception of the utility of children, mothers and teachers as informants on childhood psychopathology. Journal of Clinical Child Psychology, 19:136-143.
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Lowery, B. J. & DuCette, 1. P. (1976), Disease-related learning and disease control in diabetics as a function of locus of control. Nurs. Res., 25:358-362. Margalit, M. (1986), Mothers' perceptions of anxiety of their diabetic children. J. Dev. Behav. Pediatr., 7:27-30. Nolen-Hoeksema, S. (1990), Sex Differences in Depression. Stanford, CA: Stanford University Press. Peterson, P. (1988), Explanatory style as a risk factor for illness. Cognitive Therapy and Research, 12:119-132. Reynolds, C. R. & Richmond, B. O. (1978), What I think and feel: a revised measure of children's manifest anxiety. J. Abnorm. Child Psychol., 6:271-280. Rovet, 1., Ehrlich, R. & Hoppe, M. (1987), Behaviour problems in children with diabetes as a function of sex and age of onset of disease. J. Child Psychol. Psychiatry, 28:477--491. Saylor, C. F., Finch, A. J., Spirito, A. & Bennett, B. (1984), The Children's Depression Inventory: a systematic evaluation of psychometric properties. J. Consult. CUn. Psychol., 52:955-967. Seligman, M. E. P., Peterson, C., Kaslow, N. J., Tannenbaum, R. L., Alloy, L. B. & Abramson, L. Y. (1984), Explanatory style and depressive symptoms among school children. J. Abnorm, Psychol., 93:235-238. Stehbens, J. A. (1988), Childhood cancer. In: Handbook of Pediatric Psychology, ed. D. Routh. New York: Guilford, pp. 135-161. Tennen, H., Affleck, G., Allen, D. A., McGrade, B. J. & Ratzan, S. (1984), Causal attributions and coping with insulin dependent diabetes mellitus. Basic and Applied Social Psychology, 5:131-142. Wechsler, D. (1974), Manualfor the Wechsler intelligence scale for children-revised. New York: Psychological Corporation. Wertlieb, D., Hauser, S. T. & Jacobson, A. M. (1986), Adaptation to diabetes: behavior symptoms and family context. J. Pediatr. Psychol., 11:463-479. White, K., Kolman, M. L., Wexler, P., Polin, G. & Winter, R. 1. (1984), Unstable diabetes and unstable families: a psychosocial evaluation of diabetic children with recurrent ketoacidosis. Pediatrics, 73:749-755.
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Abstract. The psychiatric functioning of 28 youths with insulin-dependent diabetes mellitus was examined. Measures of psychological functioning were related to age at onset, duration of diabetes, and metabolic control, as assessed by HgbAIC. Children diagnosed with insulin-dependent diabetes mellitus at a later age were considered by teachers to have more behavioral problems. Children who had better metabolic control tended to hold themselves responsible for negative events. It is worthwhile to develop interventions to teach diabetic children a realistic balance between taking appropriate responsibility for controllable negative events without taking undue blame for uncontrollable negative events associated with the disease. J. Am. Acad. Child Adolesc. Psychiatry, 1991, 30,6:921925. Key Words: diabetes mellitus, children, adolescents, attributions. During the past decade, there has been an increased interest in the psychosocial factors associated with insulindependent diabetes mellitus (IDDM) in pediatric populations (Johnson, 1988). Although some clinical reports have suggested an association between depression and low self-esteem in children with diabetes (Barglow et al., 1986), other research in this area often has failed to corroborate these observations (Jacobson et al., 1986; Margalit, 1986). Also, parent ratings of diabetic children's behavioral adjustment have not revealed an increased level of psychopathology (Jacobson et al., 1986; Wertlieb et al., 1986). In an effort to clarify issues of psychopathology in children with diabetes, some investigators have focused on the influence of particular diabetes-related factors on psychological functioning. Specifically, age at diabetes onset has been related to measures of adjustment and behavioral problems: youths whose diagnosis was made at a later age have more adjustment and internalizing and externalizing behavioral problems (Allen et al., 1983; Rovet et al., 1987). This finding is not surprising, given the overwhelming clinical evidence that diagnosis of IDDM at adolescence often produces emotional turbulence greater than that typically experienced by healthy adolescents (Johnson and Rosenbloom, 1982). Other investigators have focused upon the relationship between psychopathology, personality factors, and metabolic control. A common hypothesis is that children in poorer metabolic control of their diabetes have more beAccepted June 19, 1991. From the Departments of Pediatrics, Psychiatry, and Psychology, Emory University. Portions of this paper were presented at the 1990 Annual Meeting of the Association for the Advancement of Behavior Therapy, San Francisco, California. The authors acknowledge the assistance ofChildren, s Medical Service and Gwendolyn Bell, M.D., for referring patients to this study. This work was supported by a grant from the Georgia Health Care Foundation. Reprint requests to Dr. Brown, Department of Psychiatry, Emory University School of Medicine, Grady Memorial Hospital, 80 Butler Street SE, Atlanta, GA 30335. 0890-8567/91/3006-0921$03. o%© 1991 by the American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Ado/esc. Psychiatry, 30 :6, November 1991
havioral and personality problems. Research findings have not entirely supported this relationship (e.g., Gross et al., 1984; Kovacs et al., 1986; Rovet et al., 1987). However, White and her associates (1984), using semistructured interviews, found that many children who reported episodes of diabetic ketoacidosis and seizures were characterized by externalizing problems, including oppositional behavior, school truancy, difficulty with peers, and antisocial behavior. Similarly, Ahnsgo and colleagues (1981) found that aggression increased over time in poorly controlled diabetic children, in comparison to healthy controls. Another hypothesis is that a child's psychological adjustment to IDDM is related to the ability to use appropriate cognitive strategies to experience a sense of mastery over the illness and successes and failures in life. Previous research has found that diabetics with an internal locus of control are more knowledgeable about their illness (Lowery and DuCette, 1976) and more adherent to their treatment regimen (Jacobson et al., 1990). In a related vein, empirical work has documented an association between external locus of control, in which children perceived their lives as controlled by outside forces, with less satisfactory adjustment to diabetes (Jacobson et al., 1986). Moreover, there is some evidence that adjustment to IDDM as it relates to locus of control differs by sex. Girls with an external locus of control and boys with an internal locus of control have been found to have more adjustment difficulties (Hamburg and Inoff, 1982). More recent work has focused on attributions of causality in addition to perceptions of controllability. Considerable evidence suggests that a cognitive style in which children make internal-stable-global attributions for negative events in their life is associated with feelings of helplessness, hopelessness, and depression (e.g., Kaslow et al., 1984; Seligman et al., 1984). It is reasonable to speculate that diabetic children with a depressive attributional style have more difficulty adjusting to their illness, and indeed recent evidence has supported this hypothesis (Kuttner et al., 1990). However, Hamburg and his associates (1980) contended that adult diabetics who engage in self-blame (internal attributions for negative events) evidence a greater sense of control
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over illness outcomes and thus , under certain circumstances , behavioral self-blame may be associated with greater coping capacity (Bulman and Wortman , 1977). In fact, empirical evidence has suggested that compared with external factors , children who believed that the control of IDDM was because of their own behavior coped more effectively and showed greater compliance , as reported by their physicians (Tennen et aI., 1984). The purpose of this investigation was to examine the emotional functioning of children and adolescents with diabetes, as rated by self, parent, and teacher reports of behavior. Specifically, the relationship between reports of behavior and diabetes-related factors, including age at onset , duration of IDDM, and metabolic control (HgbA1C), was examined. In addition, the relationship between children's attributions for positive and negative events and these same diabetes-related factors was studied.
Method Subjects
Twenty-eight children (13 boys and 15 girls), aged 6 years 11 months to 16 years 5 months (mean, 12 years 6 months) with IDDM were recruited from diabetes clinics affilitated with a large university public teaching hospital. All children were of average intellectual functioning, as measured by the Wechsler Intelligence Scale for Children-Revised (Wechsler, 1974) (mean IQ = 101, SD = 15.49). The population was of low socioeconomic status. Of these patients, 57% were black, and 43% were Caucasian . IDDM patients and at least one parent were asked during their clinic appointment to discuss possible participation in a study examining psychological and social-cognitive functioning in children with diabetes. No specific data are available on three subjects who refused to participate because of transportation conflicts. Although no specific data are available for these patients, they were from the same low socioeconomic inner-city population . After obtaining informed consent from the child's parent and the child, information was obtained from parents and from a review of medical records about age at disease onset, disease duration, and overall diabetes metabolic control. Specific tests were then administered, and patient, parent , and teacher reports were requested. Procedure
Subjects were tested at the university hospital by a master's-level psychologist. Teacher ratings were mailed and returned within a month of the evaluation. Parents were given a fee to cover out-of-pocket expenses. Measures
Children's reports of their depression-related symptomatology were assessed by the Children's Depression Inventory (CDI) (Kovacs and Beck , 1977), a 27-item self-report scale that taps the cognitive , affective, motivational, and vegetative symptoms of depression. The CDI has high internal consistency and test-retest reliability (e.g., Saylor et aI., 1984). Children's anxiety symptoms were ascertained 922
by the Revised Children's Manifest Anxiety Scale (R-CMAS) (Reynolds and Richmonds, 1978), a 37-item self-report scale that includes 28 items assessing symptoms of anxiety and nine social desirability (lie) items. The scale has high internal consistency and adequate test-retest reliability (Reynolds and Richmond, 1978). Children's attributions for positive and negative events were examined by using the Children's Attributional Style Questionnaire (KASTANCASQ), (Seligman et aI., 1984), a 48-item forced-choice scale that has adequate psychometric properties. Each item comprises a situation (e.g ., "You get good grades") and two possible attributions to explain why the situation occurred (e.g., "I am a hard worker" vs. "Schoolwork is simple"). Children are instructed to choose the alternative that best describes why the event in question happened to them. Half the situations represent good outcomes; half represent bad outcomes . Three dimensions of attributional style (internal/external, global/specific, stable/unstable) are assessed. Two composite scores are derived: a good composite score and a bad composite score. The lower the good and the higher the bad scores , the more depressive the attributional style as conceptualized by the revised learned helplessness theory of depression (Abramson et aI., 1978). Mothers completed the Child Behavior Checklist (CBCL) (Achenbach, 1978), a l03-item behavior problem scale that includes narrow-band factors and two broad-band factors (internalizing and externalizing symptoms of psychopathology). Only the broad-band factors were used for analysis in this study. Broad-band scores also were obtained from the child's teacher at the time of the evaluation by using the Achenbach Teacher Rating Scale (TRS) (Achenbach and Edelbrock, 1981), a companion to the CBCL. These scales, which have been used in a wide range of research studies with children and adolescents. have adequate psychometric properties (Achenbach et aI., 1987). Diabetic-related factors included age at onset, duration of disease, and control of diabetes. To determine diabetic control, each child's most recent glycosylated hemoglobin value (HgbA1C) (all within the preceding 2 months, nondiabetic norm = 4.0 to 6.2) was recorded, because it is the best indicator of overall current diabetic control (Clarson et aI., 1985; Daneman et aI. , 1981; Gabbay , 1976). Multiple regression analyses were conducted to ascertain the relation between diabetes-related variables and the dependent measures. The means, standard deviations, ranges, and frequency distributions of the diabetes-related factors for the sample are presented in Table 1.
Results The means, standard deviations , and ranges for the sample for each of the measures of psychological adjustment and social-cognitive functioning are presented in Table 2. Because previous studies have demonstrated a relationship between sex and chronological age and each of the dependent measures (Nolen-Hoeksema, 1990), it was necessary to control these variables in the analyses. To control the effect of chronological age and sex on the dependent measures, hierarchiacal regression analyses were performed on each of the dependent measures, in which age and sex l.Am.Acad. Child Adolesc.Psychiatry, 30:6, November 1991
YOUTH WITH DIABETES TABLE
1. Means, Standard Deviations, and Ranges f or Diabetes-related Variables
Variable Age (in months) Age at onset (in months) Duration (in months) HgbA,Ca (%)
149.9 109.8 39. I 8.8
so
Range
34.0 47.5 36.0 2.43
83-197 9-170 1-144 5.2-13 .1
Note: N = 28. a Nondiabetic nonn = 4 .G-6.2;f = frequency . Diabetic nonn = 7.G-8.0, with scores grater than 10 indicat ive of poor compliance.
were parceled out. For the KASTAN-CASQ bad composite score, a significant multiple regression was obtained for the metabolic control measure (HgbAIIC)/ when age and sex were controlled (13 = -0.49, P < 0.02) , R2 = -0.58 , F(3 , 21) = 3.62 , P < 0.03. Children who tended to make more internal, stable, and global attributions for negative events evidenced better glycemic control. Additionally, with age parceled out, there was a trend for children with longer duration of illness and poorer metabolic control, "as measured by HgbA1C, to have an attributional style characterized by more external, unstable, and specific attributions for bad events and more internal-stable-global attributions for good events (p < 0.08). Because this analysis only approached significance, the authors were concerned about the possibility of the Type II error because of low power. The power analysis revealed that the power to detect a large effect size, as defined in Cohen (1988), was 0.80. The power to detect a medium effect was 0.50 (Cohen, 1988). Therefore, if the relationship between "nondepressive attributions" had been fairly strong, it would have been detected in this size sample. However, if the relationship was not as strong , it might not have been detected in this size sample . In short, there was sufficient power for a large effect, yet insufficient power for a medium effect. For the TRS externalizing broad-band factor score , when chronological age was controlled, a significant multiple regression was obtained for age at onset (13 = 0.47, P < 0.04) ; R2 = 0.42, F(2, 19) = 6.96, p < 0.005. Thus, children whose IDDM diagnosis was made at a later age tended to be rated by their teachers as having more externalizing behavioral symptoms. Consistent with this , children and adolescents with shorter duration of IDDM also were rated by teachers as evidencing more externalizing behavioral problems when chronological age and sex were controlled (13 = -0.36, P < 0.05), R2 = 0.64, F(2, 19) = 6.52, p < 0.007 . However, it is important to note that although the group means for externalizing behavior on the TRS are within the normal range , the variability within the sample indicates that 29% of children were reported by their teachers to manifest clinically significant degrees (T scores above 65, or 93rd percentile) of behavioral problems. No statistically significant relations were found between measures of diabetic -related factors and self- and parent-reports of psychological adjustment, including the cm, R-CMAS, and the CBCL. In addition, group means for each of these measures were within the normal range . l.Am.Acad. Child Adolesc. Psychiatry, 30:6, November 1991
T ABLE 2. Means, Standard Deviations, and Ranges f or Measures of Internalizing and Externalizing Symptoms and Attributional Style
Measure
N
X
SD
Range
COla
28 28
9.3 10.7
7.4 6.6
G-27 G-29
28 28
59.8 58.6
9.5 6.8
43-82 45-77
22 22
52.5 53.7
9.5 9.5
34-81 39-69
28 28
12.2 7.3
3.0 3.2
4-18 1-15
R-CMASb CBCL (parent)' Internalizing Externalizing TRS (teacher)" Internalizing Externalizing KASTAN-CASQ< Good composite Bad composite
COl = Children's Depression Inventory (Kovacs and Beck , 1977). R-CMAS = Revised Children's Manifest Anxiety Scale (Reynolds and Richmond , 1978). ' CBCL = Child Behavior Check List (Achenbach, 1978). d TRS = Teacher Rating Scale (Achenbach, 1978). • KASTAN-CASQ = Children 's Attributional Style Questionnaire (Seligman et aI., 1984). a
b
Discussion The most striking finding from this investigation is that children who held themselves responsible for negtive events, as assessed on a measure of attributional style (KASTANCASQ), had greater metabolic control, as measured by HgbA 1C. This finding is clinically as well as statistically significant: a significant percentage of our sample (43%) had HgbA1C scores above 10, which indicates poor compliance, despite the fact that the group mean was within the normal range for persons who have diabetes. It is noteworthy that children who hold themselves responsible for negative events do not necessarily hold themselves responsible for positive events. These findings are in line with the work with diabetic adults presented by Hamburg and colleagues (1980) , Bulman and Wortman (1977), and research with pediatric populations (Tennen et al., 1984): persons with diabetes who engage in self-blame (internal attributions for negative events) evidence better control. More specifically, these findings are consistent with recently published data presented by Kuttner and colleagues (1990), who found an association between a learned helplessness attributional style for negative events and metabolic control. Recent studies with healthy college students have shown that a depressive attributional style is a risk factor for the later development of physical symptoms (e.g., Peterson, 1988). Although this finding may appear inconsistent with the data from the present study, the discrepancy may be attributable to differences in the age and the socioeconomic status of patient populations, healthy versus chronically ill patients , and the attributional style predictive of illness versus the style associated with adaptive coping and compliance with medical regimens. In the present study, the youth who had a more "depressive" attributional style took greater responsibility for managing their diabetes and thus evidenced greater compliance, in contrast to findings from the aforementioned college student population (Peterson, 1988),
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BROWN ET AL.
in which a depressive attributional style is a risk factor for the development of physical symptoms. To understand the complex relations between attributional style and both medical compliance and symptom development, future research will need to address more fully the demographic characteristics of the sample, the attributional styles most adaptive for preventing illness, and the styles most effective in enhancing compliance with treatment demands once illness is diagnosed. In keeping with the findings of previous research (Allen et aI., 1983; Rovet et aI., 1987), children with later-onset diabetes and thus shorter duration of the illness manifested more externalizing behavioral problems but only as rated by their teachers. This investigation is one of the first studies to use teacher reports of IDDM symptoms in addition to child and parent reports. Of interest is the finding that only teacher reports suggested that diabetic children, particularly those whose diabetes was of later onset and shorter duration, manifested more externalizing behavioral problems. Current research suggests that teachers may be the most accurate reporters of externalizing behaviors (Loeber et aI., 1990). This underscores the importance of a multiinformant approach, including teachers, for behavioral assessment of children. Despite the finding that teachers reported that these children had more difficulties, the diabetic children did not rate themselves and were not rated by their parents as having significant emotional impairment. The findings concerning the reports of parents and children are consistent with the literature on chronic illness (Stehbens, 1988). Indeed there is a growing body of literature suggesting that diabetes is not necessarily comorbid with psychiatric morbidity (Jacobson et aI., 1990; Kovacs et aI., 1985). Moreover, there was no significant relationship between emotional difficulties and diabetes-related factors. Taken together, these findings might be interpreted to suggest that, although a subgroup of IDDM children (e.g., late onset IDDM youth in whom disease has been diagnosed recently) evidence some behavioral problems, the mean scores on self, teacher, and parent reports suggest that IDDM children are relatively intact emotionally. The ability to generalize the findings is limited by the relatively small number of subjects, their low socioeconomic status, and the study of only one chronic illness group. Future studies should examine the relation of chronic illness and the psychopathology of medically ill children across informants. Studies also need to compare psychological adjustment and attributional style in relation to complicance across a range of chronic illness groups. Also, given that metabolic control of IDDM is significantly associated with family functioning (e.g., Hanson et al., 1989), parental psychopathology, family interaction patterns, and parents' causal attributions regarding negative and positive events in their child's life should be assessed. Based on empirical findings from these proposed studies, psychosocial interventions might be tailored to teach chronically ill children and their parents a realistic balance between appropriate responsibility for controllable negative events and inappropriate responsibility and self-blame for uncontrollable negative events associated with the disease. 924
Specifically, these youths need to be taught the aspects of diabetes that can be controlled (diet, exercise, insulin intake, rotation of injection sites) and encouraged to take appropriate responsibility for managing these aspects of their own care. However, they also need to be supported in the aspects of the illness (e.g., having a chronic illness that is beyond their control as well as accepting the physiological processes associated with the illness, which may occur even during times of good compliance) that are beyond their control. Thus, an attributional style in which they take responsibility for controllable negative events but not for uncontrollable negative events associated with their illness is most adaptive. Moreover, these youths need to be supported in coming to terms with a chronic illness and working through emotionally, cognitively, and behaviorally the limitations that such an illness imposes. Finally, they need to be cognizant of the effects of diabetes on their lives yet not allow the illness to dominate their daily lives. References Abramson, L. Y., Seligman, M. E. P. & Teasdale, J. D. (1978), Learned helplessness in humans: critique and reformulation. J. Abnorm. Psychol., 87:49-74. Achenbach, T. M. (1978), The child behavior profile: 1. Boys aged 6-11. l. Consult. CUn. Psychol., 46:478-488. - - & Edelbrock, C. S. (1981), Behavioral problems and problems and competencies reported by parents of normal and disturbed children aged 4 through 16. Monogr. Soc. Res. Child Dev., 45(1, Serial No. 188). - - McConaughy, S. H. & Howell, C. T. (1987), Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychol. Bull., 101:213-232. Ahnsgo, S., Humble, K., Larsson, Y., Settergren-Carlsson, B. & Sterky, G. (1981), Personality changes and social adjustment during the first three years of diabetes in children. Acta. Paediatr. Scand., 70:321-327.
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Lowery, B. J. & DuCette, 1. P. (1976), Disease-related learning and disease control in diabetics as a function of locus of control. Nurs. Res., 25:358-362. Margalit, M. (1986), Mothers' perceptions of anxiety of their diabetic children. J. Dev. Behav. Pediatr., 7:27-30. Nolen-Hoeksema, S. (1990), Sex Differences in Depression. Stanford, CA: Stanford University Press. Peterson, P. (1988), Explanatory style as a risk factor for illness. Cognitive Therapy and Research, 12:119-132. Reynolds, C. R. & Richmond, B. O. (1978), What I think and feel: a revised measure of children's manifest anxiety. J. Abnorm. Child Psychol., 6:271-280. Rovet, 1., Ehrlich, R. & Hoppe, M. (1987), Behaviour problems in children with diabetes as a function of sex and age of onset of disease. J. Child Psychol. Psychiatry, 28:477--491. Saylor, C. F., Finch, A. J., Spirito, A. & Bennett, B. (1984), The Children's Depression Inventory: a systematic evaluation of psychometric properties. J. Consult. CUn. Psychol., 52:955-967. Seligman, M. E. P., Peterson, C., Kaslow, N. J., Tannenbaum, R. L., Alloy, L. B. & Abramson, L. Y. (1984), Explanatory style and depressive symptoms among school children. J. Abnorm, Psychol., 93:235-238. Stehbens, J. A. (1988), Childhood cancer. In: Handbook of Pediatric Psychology, ed. D. Routh. New York: Guilford, pp. 135-161. Tennen, H., Affleck, G., Allen, D. A., McGrade, B. J. & Ratzan, S. (1984), Causal attributions and coping with insulin dependent diabetes mellitus. Basic and Applied Social Psychology, 5:131-142. Wechsler, D. (1974), Manualfor the Wechsler intelligence scale for children-revised. New York: Psychological Corporation. Wertlieb, D., Hauser, S. T. & Jacobson, A. M. (1986), Adaptation to diabetes: behavior symptoms and family context. J. Pediatr. Psychol., 11:463-479. White, K., Kolman, M. L., Wexler, P., Polin, G. & Winter, R. 1. (1984), Unstable diabetes and unstable families: a psychosocial evaluation of diabetic children with recurrent ketoacidosis. Pediatrics, 73:749-755.
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