1. TRANSITIONS OF SELF- MANAGEMENT RESPONSIBILITIES FROM CHILDHOOD THROUGH ADOLESCENCE TO YOUNG ADULT REBECCA RUID, PH.D. REBECCA.RUID@VTMEDNET.ORG

2. WOULD YOU… ALLOW YOUR CHILD TO DO THIS…. OR EXPECT THEM TO DO THIS…

3. OBJECTIVES Gain an understanding of the stages of human growth and development Recognize how this process parallels the expectations we should have in transitioning responsibility for diabetes related care as individuals age Promote effective self-care as children develop and transition into young adulthood

4. BRAIN DEVELOPMENT.

5. HUMAN DEVELOPMENT Social/Emotional Language/Communication Cognitive Movement/Physical

6. EARLY MIDDLE CHILDHOOD (AGES 6-8) SOCIAL/EMOTIONAL Increasing independence from parents and family Increasing attention to friends Less focus on self and more on others COMMUNICATION Better at describing experiences and sharing thoughts and feelings COGNITIVE Rapid development of mental skills PHYSICAL Increasingly independent with dressing and other self- care More physically capable (i.e., catching a ball) MIDDLE CHILDHOOD (AGES 9-11) SOCIAL/EMOTIONAL Stronger more complex peer relationships (particularly same sex) Ongoing increasing independence from family More aware of body COMMUNICATION Let the arguments begin! COGNITIVE Increased attention span Concrete thought dominates Cause-effect relationship poorly understood Stronger perspective taking but still stronger “self” than “other” focus PHYSICAL Beginning puberty and increasing body awareness

7. EARLY ADOLESCENCE (AGES 12-14) SOCIAL/EMOTIONAL Continued increasing independence Vacillate with regard to confidence Increased moodiness More easily influenced by peers (substance use often begins) COMMUNICATION Decrease in affection and communication with parents Better able to express feelings through talking COGNITIVE More ability for complex thought and analytic thinking (related to an increase in white matter in the corpus callosum which allows right and lest hemisphere communication) – but still very concrete and “here and now” PHYSICAL Hormones! More concern with body image, looks, and clothes Fine motor control improves TEENAGERS/MIDDLE ADOLESCENCE (AGES 15-17) SOCIAL/EMOTIONAL Identity development Increased independence in preparation for young adulthood More interest in opposite sex and spending more time with friends than parents Deeper capacity for more intimate relationships COMMUNICATION Better able to provide reasons for choices COGNITIVE Learning more about their work habits More concern with their future (cause/effect better understood) Growth in abstract thought unless stressed PHYSICAL Boys still completing developing

8. YOUNG ADULTHOOD/LATE ADOLESCENCE (AGES 18-21) SOCIAL/EMOTIONAL Well established identity/sense of self becomes more solid Emancipation (vocational/technical/college and/or work; adult lifestyle) Realizations of own limitations & mortality Establishment of ethical and moral value system More capable of intimate, complex relationships COMMUNICATION Relate to family as an adult COGNITIVE Abstract thought better established ( More future oriented; better able to understand, plan and pursue long range goals) PHYSICAL Physical maturity and reproductive growth leveling off and ending Usually comfortable with body image – establishment of sexual identiy

9. HOW SHOULD THIS AFFECT HOW WE CARE FOR OUR CHILDREN AND ADOLESCENTS WITH DIABETES? IT SHOULD AND IT SHOULDN’T!

10. Encourage Scaffolding - When parents stay involved in diabetes care studies show better control If too much is expected to soon the result may be low self-esteem and a sense of failure and poor adherence may follow. Ignore the specific ages I listed and instead focus on where an individual is developmentally!  Get this information by asking questions regarding development outside of diabetes  Ensure that expectations outside of diabetes are consistent with development  Assess where an individual is with regard to willingness to accept increased self- management Often times the goal in the pediatric endocrine clinic is not based on the “ideal compliance”

11. MOTIVATIONAL INTERVIEWING A collaborative, person-centered form of guiding to elicit and strengthen motivation for change (Miller & Rollnick, 2009)

12. Four MI Principles: 1.Express empathy 2.Develop discrepancy 3.Roll with resistance 4.Support self-efficacy/autonomy Strategies: 1.Open-ended questions 2.Affirmation 3.Reflective listening 4.Summary

13. RESILIENCE Resilience is dynamic. Problem solving ability Mastery A support network Positive outlook

14. OUR CLINIC AT FAHC The team social worker meets all newly diagnosed patients and their families at their two week out visit or earlier. The team psychologist, meets families at 6 weeks post- diagnosis. Patients and their families have been divided into one of four categories: A = Patients and families who need little to no support; only seen during times of anticipated transition B = Patients and families who’s needs have not been clearly identified; seen each visit to continue to assess for needs C = Patients and families who require ongoing psychological support services; seen each visit to provide therapeutic services and/or contact with outside clinicians providing such services D = Patients and families who require ongoing social work support services; seen each visit to provide resources and support F = Patients and families who have refused additional support services repeatedly; only seen during times of anticipated transition

15. ANTICIPATED TRANSITIONS Patients in all categories will receive services at times of anticipated transitions which include: Before entry to Elementary School – support, consistency, and normalizing will be addressed as well as appropriate expectations for self-care Before entry to Middle School – a need for ongoing supervision expectations for self- care, use of consequences, and the relationship between knowledge and behavior will all be addressed Before entry to High School – a need for ongoing but decreasing supervision and increasing expectations for self-care will be addressed Before graduation – safety planning

16. HELPFUL RESOURCES http://ndep.nih.gov/transitions/index.aspx Health Care Transition Workbook by John Reiss, Ph.D. and Robert Gibson, MSOTR/L, Ph.D. Developed out of the University of Florida www.studentswithdiabetes.com Motivational Interviewing in Health Care: Helping Patients Change Behavior / Edition 1 by Stephen Rollnick, William R. Miller, Christopher C. ButlerStephen RollnickWilliam R. MillerChristopher C. Butler rebecca.ruid@vtmednet.org