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Service Delivery Innovation Profile

Coping Skills Training Helps Adolescents Improve Quality of Life and Ability to Manage Their Diabetes


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Snapshot

Summary

The Yale School of Nursing created a Coping Skills Training program for adolescents with type 1 diabetes that teaches communication and social problem-solving skills, with the goal of improving peer, school, and family relationships and enhancing diabetes self-management. Various studies suggest that the program may be moderately more effective than general diabetes education in helping students improve disease management skills and control blood glucose levels.

Evidence Rating (What is this?)

Moderate: The evidence consists of several small trials that compare various measures of diabetes self-management and blood glucose control in program participants with those receiving diabetes education alone.
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Developing Organizations

Yale University School of Nursing
New Haven, CTend do

Use By Other Organizations

The Web-based program is being offered by several universities across the country as a way to test its efficacy with children from different ethnic groups and from families of varying socioeconomic status.

Date First Implemented

1997
The coping skills program has evolved from a clinic-based service in 1997 to a school- and Web-based program today.begin ppxml

Patient Population

Most of the adolescents with type 1 diabetes who have received services through this program have been 12 and 20 years old.Age > Adolescent (13-18 years); Vulnerable Populations > Childrenend pp

Problem Addressed

Adolescents and teens with insulin-dependent diabetes mellitus (type 1 diabetes) must contend with hormonal changes that make them resistant to insulin; social pressures to engage in unhealthy behaviors; and erratic school and activity schedules that can disrupt regular blood glucose monitoring, diet, and exercise. They frequently struggle with stress and depression, and standard diabetes management education has not been shown to be effective in addressing psychosocial challenges. Behavioral interventions can help but are seldom used.
  • Many psychosocial challenges facing diabetic adolescents: Adolescents with diabetes often face typical struggles for growth and independence from parents and other adults, which can result in poor adherence to the diabetes regimen. In addition, many of the diabetes-related tasks can interfere with the adolescent's drive for peer acceptance, and peer pressure may generate strong conflicts.1
  • Frequent struggles with stress and depression: Research has found that 2 years after diagnosis with type 1 diabetes, children 8 to 14 years old have twice the amount of depression and adjustment problems as do their peers without diabetes.2 Even teenagers who are successfully achieving hemoglobin A1c goals (HbA1c, or average blood sugar levels) with therapy may perceive diabetes as having a negative impact on their lives, be depressed, and find diabetes difficult to manage.3
  • Standard of care not proven effective in dealing with psychosocial issues: Although focused diabetes management education moderately improves metabolic control and is the standard of care in adolescents, its effectiveness in helping adolescents maintain healthy glucose levels, make wise food choices, and maintain a positive approach to managing their disease is limited, as it does not directly address the psychosocial challenges faced by adolescents with diabetes.
  • Behavioral interventions help, but rarely used: Although the addition of behavioral interventions to intense diabetes management during adolescence results in improved metabolic control and quality of life, this support service is rarely provided to adolescents with diabetes.4

What They Did

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Description of the Innovative Activity

The Coping Skills Training program teaches psychosocial coping techniques, such as communication skills, social skills training, social problem solving, conflict resolution, and cognitive behavior modification to adolescents and teens with type 1 diabetes. These skills are taught and rehearsed in small groups of similar-aged adolescents with the help of a trained facilitator. The skills are designed to increase the ability of participants to cope with problems they face on a day-to-day basis (rather than just learning to manage the medical condition). Key elements of the program are described below:
  • Session frequency and logistics: Sessions are taught on a weekly basis for the first 24 weeks, and then on a monthly basis for the next 18 months. Sessions are led by a trainer—a nurse practitioner with experience in pediatric psychiatry and diabetes and/or a psychotherapist who specializes in adolescents and has training in diabetes. Two or three teens meet in a group with the trainer; teens learn from each other and from the trainer during the sessions.
  • Focus on problem-solving and coping skills: The participants review difficult social situations, including managing food choices with friends, decisionmaking about drugs and alcohol, resolving independence/dependence conflicts with parents, and blood glucose testing in public situations. The participants role play, and the facilitator gives feedback on their responses and even models appropriate behavior and responses. Examples of problem-solving skills are described below:
    • Social problem-solving: This skill is designed to help youths handle peer pressure by focusing on the process of how to solve a problem, not necessarily on a specific situation. For example, to teach a teen how to handle peer pressure to drink alcohol at a party, the sessions focus on how to fit in and not look like a "nerd" without risking a hypoglycemic reaction or becoming intoxicated by drinking.
    • Social communication skills training: The sessions focus on common communications problems faced by adolescents with diabetes using real-world examples, such as avoiding blood testing so as not to reveal one's diabetic condition. Each teen takes a turn role playing various responses to typical social situations. During followup groups, the teens discussed how well various responses worked and how they could be improved.
    • Cognitive behavior modification and dealing with stress: This aspect of the program lays out a structured approach to help children deal with stressful situations by helping them recognize their own thoughts and feelings, strengthen their problem-solving abilities, and develop guided self-dialogue to help recognize sources of stress and decrease negative responses to it.
    • Conflict resolution: This aspect of the program helps teens develop the skills necessary to resolve conflicts in a way that achieves positive outcomes for all involved. For example, a 15-year-old girl was eating unhealthy, sugary foods as part of her rebellion over her parents' close control over her diet. The group discussed the fact that the girl wanted greater control over her life, and that her parents wanted her to have a healthy diet. The group suggested that the girl offer her parents a compromise—that she could choose what she ate each day but could only have one sweet.
  • Online, moderated program for adolescents: Because 40 to 50 percent of adolescents could not attend group sessions due to conflicting activities, Yale researchers recently developed and launched an Internet-based program and forum for children and teens with type 1 diabetes. The Web-based program, which is being tested as a clinical trial among children 11 to 15 years old, resembles the clinic-based regimen, with six weekly sessions that feature a discussion among 8 to 10 children and a nurse.

Context of the Innovation

The Yale Children's Clinical Research Center, which assists the faculty of Yale University's Departments of Pediatrics, Child Study Center, Psychiatry, Surgery, Genetics, and Internal Medicine in conducting clinical investigations in children, traditionally focused on innovative approaches to achieving and maintaining optimal control of diabetes in children and adolescents. The center's researchers adapted coping skills training, originally developed for use in schools to help students avoid drugs and alcohol, to adolescents and teens with diabetes as part of the center's Adolescents Benefit from Control of Diabetes Study (also known as the ABCs of Diabetes Study). The researchers recruited teen patients treated at the Yale Diabetes Center, a clinical consultative service of Yale University's Section of Endocrinology and a regional resource for diabetes care and education. The center represents the joint efforts of the Yale School of Medicine, Yale School of Nursing, and Yale-New Haven Hospital, one of the nation's leading health care centers.

Did It Work?

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Results

Various studies suggest that the program may be moderately more effective than general diabetes education in helping students improve disease management skills and control blood glucose levels.
  • Better blood glucose control: A 1-year study of 77 adolescents found that those participating in the program reduced their average blood glucose level to 7.5 percent, achieving a larger decline than did those in a control group receiving general diabetes education (who reduced their average level to 8.4 percent). A 5-year study of 117 adolescents also found significantly more improvement in blood glucose control among participants than among those in the control group.4 A recent randomized controlled trial found that program participants achieved significantly greater reductions in 2-hour glucose levels than did those receiving general diabetes education.5 However, a second recent randomized study found that both program participants and those receiving general diabetes education achieved improvements in blood glucose control, with no significant differences between the groups.6
  • Better disease management skills: The 1-year study found that program participants had significantly better diabetes self-management and overall medical self-management skills than did adolescents receiving just diabetes education.4 A recent randomized trial found no difference, however, between the coping and self-efficacy skills in the two groups.6
  • Substantial projected long-term cost savings: The 5-year study projected a 25-percent reduction in long-term complications from diabetes and multimillion dollar savings if teens enrolled in the program sustained their glucose control and quality of life.4
  • Similar results for online program: Information provided in March 2013 indicates that a 320-patient multisite clinical trial of the online version of Coping Skills Training has been completed. Results, which are similar to those of the in-person program, will be published in Diabetes Care in Spring 2013.

Evidence Rating (What is this?)

Moderate: The evidence consists of several small trials that compare various measures of diabetes self-management and blood glucose control in program participants with those receiving diabetes education alone.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Retooling traditional coping skills training for children with chronic illnesses: Yale University researchers adopted findings on the use of the program and behavioral interventions to improve performance and reduce symptoms in adults and children with a variety of medical conditions. They also reviewed coping skills curriculum that had been developed to help teens resist peer pressure to use drugs and alcohol.
  • Pilot testing in adolescents: Because adolescents generally do not adhere to healthy eating habits and typically exhibit poor disease management skills, the researchers focused first on those between 12 and 20 years old.
  • Pilot testing with younger children and their parents: Researchers tested the program with younger children and their parents to see if it could help children before they entered the rebellious period of adolescence. They found the program to be less effective for preadolescents than for adolescents, probably because this age group is too young for cognitive therapy intervention.
  • Evaluating use of an online program: Information provided in March 2013 indicates that, funded by the American Diabetes Association, the program is currently is evaluating how pediatric diabetes clinics can implement use of the online program in routine practice.

Resources Used and Skills Needed

  • Staffing: In a clinic setting, the trainer is usually a registered nurse (RN) or nurse practitioner with experience in pediatric psychiatry and diabetes, or a family therapist or child psychologist with knowledge of diabetes. However, a master's-level psychotherapist can be used part-time to run the group, or an RN with diabetes and pediatric psychiatry expertise. The trainer, who generally works part-time, works with two to four teen participants.
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Funding Sources

National Institute of Nursing Research; Culpepper Foundation; Yale Children's Clinical Research Center
  • The development of the original, clinic-based program was funded by the National Institutes of Health’s National Institute of Nursing Research and the Culpepper Foundation.
  • The expansion of the program to the Internet has been funded by a $3.5 million grant from the National Institutes of Health's National Institute of Nursing Research.
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Tools and Other Resources

TeenCope Online: Information about the program is available at http://nursing.yale.edu/teencope-online.

National Institutes of Health. Coping skills training improves teens' self-management of diabetes. Available at: http://report.nih.gov/nihfactsheets/Pdfs/Self-management(NINR).pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

The American Diabetes Association provides information about diabetes, treatment guidelines, and community resources. Available at: http://www.diabetes.org/

Silverstein J, Glingensmith G, Copeland K, et al. Statement of the American Diabetes Association: care of children and adolescents with type 1 diabetes. Diabetes Care. 2005;28:186-212. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/full/28/1/186

Adoption Considerations

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Getting Started with This Innovation

  • Find a sponsor: A pediatric diabetes clinic within a hospital or medical center, or an endocrinology practice that specializes in pediatric diabetes, can sponsor coping skills training groups if there are enough patients in the desired age range.
  • Add staff to diabetes care team: Young patients are typically seen by a pediatric endocrinologist, nutritionist, and nurses who provide diabetes care and management training. This program requires the addition of a nurse, child psychologist, or family therapist to provide skills training and cognitive therapy to groups.
  • Recruit participants: Programs cluster children by age, with three to four adolescents making up an ideal group. Program developers recommend that participants have no other health problems, that they have been treated for at least 1 year with insulin, and that they are in a school grade appropriate to their age (within 1 year).
  • Collect baseline measurements: To measure the program's impact over time, participants should be screened for body mass index and blood glucose levels, depression, and other quality-of-life risk factors.
  • Establish meeting time and place: Establish an appropriate meeting time over a 6-week period, and schedule followup meetings for the next year. Coordinate the meetings to ensure that regular medical monitoring can take place during the sessions.

Sustaining This Innovation

  • Continually monitor program impact: Regularly assess the success of the program and make modifications as necessary.
  • Consider program expansion: The program can be targeted at different age groups and chronic conditions and used in different locations, including other schools.
  • Recognize unique problems that girls with diabetes face: Adolescents, especially girls, are more prone to depression, as are female patients with diabetes. Doctors should screen for depression, as recommended by the American Diabetes Association.
  • Do not assume diabetes control improves quality of life: Metabolic control, as measured by blood glucose levels, is not a sufficient indicator of treatment success in adolescents. Quality of life must be considered separately from metabolic treatment goals.
  • Encourage parental involvement: Adolescents whose parents maintain some guidance and control in the management of diabetes have better metabolic control. The challenge is to find the degree of parental involvement that is comfortable for all involved, without risking poorer control due to overinvolvement by parents (due to the child's rebellious nature).

Use By Other Organizations

The Web-based program is being offered by several universities across the country as a way to test its efficacy with children from different ethnic groups and from families of varying socioeconomic status.

More Information

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Contact the Innovator

Margaret Grey, DrPH, RN, FAAN
Dean and Annie Goodrich Professor
Yale University School of Nursing
Office of the Dean
400 West Campus Drive, 3rd floor
Orange, CT 06477
Phone: (203) 785-2393
Fax: (203) 785-3554
E-mail: margaret.grey@yale.edu

Innovator Disclosures

Ms. Grey has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Jaser SS, Faulkner MS, Whittemore R, et al. Coping, self-management, and adaptation in adolescents with type 1 diabetes. Annals of Behavioral Medicine. 2012;43:311-319.

Grey M, Whittemore R, Liberti L, et al. A comparison of two internet programs for adolescents with type 1 diabetes: Design and methods. Contemporary Clinical Trials. 2012;33:769-776.

Davidson M, Boland E, Grey M. Teaching teens to cope: coping skills training for adolescents with insulin-dependent diabetes mellitus. J Soc Pediatr Nurs. 1997;2(2):65-72. [PubMed]

Silverstein J, Glingensmith G, Copeland K, et al. Statement of the American Diabetes Association: care of children and adolescents with type 1 diabetes. Diabetes Care. 2005;28:186-212. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/full/28/1/186

Grey M, Cameron M, Lipman T, et al. Psychosocial status of children with diabetes in the first 2 years after diagnosis. Diabetes Care. 1995;18(10):1330-6. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/abstract/18/10/1330

Grey M, Boland E, Yu C, et al. Personal and family factors associated with quality of life in adolescents with diabetes. Diabetes Care. 1998;21(6):909-14. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/abstract/21/6/909

Grey M, Boland E, Davidson M, et al. Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life. J Pediatr. 2000;137(1):107-13. [PubMed]

Footnotes

1 Silverstein J, Glingensmith G, Copeland K, et al. Statement of the American Diabetes Association: care of children and adolescents with type 1 diabetes. Diabetes Care. 2005;28:186-212. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/full/28/1/186
2 Grey M, Cameron M, Lipman T, et al. Psychosocial status of children with diabetes in the first 2 years after diagnosis. Diabetes Care. 1995;18(10):1330-6. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/abstract/18/10/1330
3 Grey M, Boland E, Yu C, et al. Personal and family factors associated with quality of life in adolescents with diabetes. Diabetes Care. 1998;21(6):909-14. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/abstract/21/6/909
4 Grey M, Boland E, Davidson M, et al. Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life. J Pediatr. 2000;137(1):107-13. [PubMed]
5 Grey M, Jaser S, Holl MG, et al. A multifaceted school-based intervention to reduce risk for type 2 diabetes in at-risk youth. Prev Med. 2009;49(2-3):122-8. [PubMed]
6 Grey M, Whittemore R, Jaser S, et al. Effects of coping skills training in school-aged children with type 1 diabetes. Res Nurs Health. 2009;32:405-18. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 15, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 14, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.