Melanie Cole, MS (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. I'm Melanie Cole, and today we're talking about diabetes and mental health. Joining me is Dr. Mercedes Palacios. She's a Licensed Clinical Psychologist, Licensed Marriage and Family Therapist, and she works as a Pediatric Psychologist at CHOC.

Dr. Palacios, thank you so much for joining us today. As we get into this topic, what are some of the common emotional responses that are associated with living with diabetes? And to set this for the listeners, Type 1 diabetes, typically found in juveniles and in children as young as seven or eight, and Type 2, which is more of a lifestyle diabetes that we're now seeing in teenagers, correct?

Mercedes Palacios, Ph.D., LMFT: Yes, Melanie, that's correct. I currently work as a Pediatric Psychologist at CHOC, and I'm also part of our endocrinology team as their Attending Psychologist in clinic. So I do tend to work with a lot of kiddos that either have Type 1 or Type 2 diagnosis.

And some of the common emotional responses that I often see in clinic are just feelings of sadness, increased anxiety or worry that's really hard for them to control, or feelings of anger and frustration. Another big piece to note is that diabetes is a complex chronic health condition and most people do live long, healthy, happy lives, right?

But at the same time, we know that oftentimes it is common for mental health conditions to come up, particularly in different points where there's increased stressors or periods of adjustment. So, when kiddos or families are newly diagnosed, when maybe they've experienced a hospitalization stay that was longer length than they thought it would, or during stressful life events that just makes managing diabetes a lot harder. So that is when we might see some of the emotional responses come up a little bit more.

Host: I imagine that there are so many for the whole family, really, because when you're living with diabetes, there's much to manage, especially with Type 1. Whether it's exercise, foods that they eat, their insulin, glucose monitoring, there's so many things to manage that it can be overwhelming, I imagine, for the patient and for the parents of these children.

So speak about when you talk about emotional responses, Dr. Palacios, school, peers, feeling left out, not able to eat the same things or do some of the same things. Do you see that as well, that these kids are feeling different than other kids? Maybe they even wear a glucose monitor or an insulin pump.

Mercedes Palacios, Ph.D., LMFT: Absolutely. Yes. So that is very common reaction that we might see, feeling, you know, nervous to wear their devices, even though it's helpful for their health, they don't want to be able to share that diagnosis with their peers. Oftentimes they're worried about what if their sensor beeps while they're in class and what are people going to say, not wanting to answer certain questions or certain responses from their peers.

And that leads to increased anxiety. Oftentimes, like you described, there is so many steps to diabetes cares. It's not just a one time thing. It's multiple times a day. Every time they eat, they have to make sure that they are being mindful of their blood sugars. So it's also something that separates them from peers at times, having to go to the nurse often, or, needing extra accommodations, which they don't like. As teens, as young youth, they don't want to feel different than their peers. So that causes additional stress and, frustrations for them, which makes it hard. And contributes to sometimes what we see in terms of the diabetes distress or the burnout of I don't want to do this anymore.

Or not wanting to take care of their needs, because they want to avoid those interactions or feelings.

Host: Well then let's talk about the burnout or depression because there are so many things that they have to manage. And I've known a few college kids over the years that are living with diabetes and for them being in a college campus and dorms and such, it's very hard not to fall into the trap of over drinking and binging and, just wanting to be a part of everything. What are some of the signs and symptoms that parents can look out for that says, your child is really going through something?

Mercedes Palacios, Ph.D., LMFT: I do want to highlight that diabetes distress, can be a common reaction. When we think about it, just the everyday stressors of managing something so complex and difficult, and that is, we can normalize that. We can definitely say, Hey, it makes sense that you're stressed and that this is hard.

When it becomes diabetes burnout, that's when we see extreme feelings of frustration or feeling discouraged by their cares. Some of the youth I've worked with have described it as feeling mentally and physically exhausted by their cares. So some of the signs and symptoms to look out for is when we're noticing the youth feeling more sad, a lot more worried, when they are managing their cares, noticing also that it's not just sadness they can easily shake off.

It's lasting for longer periods of time, it's also maybe happening more days than not. So longer periods, they're not able to kind of move past in some ways. We might also notice increased irritability or crankiness and just frustration about wanting to engage in their cares. And those are some signs and symptoms that we want to make sure that we're mindful of so that we know when they might need additional help and support. Especially if it starts to impact any of their activities or things that they need to do. The example that you gave of, you know, students in college, if they're maybe having lower energy levels, not wanting to go to class or not feeling as motivated to go to class. We might often see also troubles with sleep or sleeping more than normal. Once you start to see some of those symptoms impacting functioning and their ability to do the things that they need to do, that's when we might, be more concerned. So we mostly want to pay attention to the duration, the severity, and just the frequency of some of those symptoms. We also know that with diabetes, when you have low or high blood sugars, it actually impacts your motivation and your mood, and you might physically not feel well. So we want to also differentiate between, are we seeing mood changes or is it related to maybe the blood sugar levels of what they're experiencing in that moment as well?

Host: So, if a child is struggling with some of these symptoms that you've just described, what are some things that parents and caregivers can do to support them, and when is it time to bring in the professionals, such as yourself, to help the children deal with this really important part of their life that's going to be a part of their life for probably their whole life?

Mercedes Palacios, Ph.D., LMFT: I would say that one of the main things that I often recommend is making sure that we're increasing communication between parents and kiddos, and encouraging that be able to talk about their feelings. And that can look like, you know, so many different ways.

So number one, of course, talking to their parents or encouraging them to talk to other trusted adults in their life. It could also be more creative like drawing their feelings, journaling, encouraging them to talk and share with their friends, to find that social support as well and validating more than anything that it's okay to have these different emotional reactions.

Oftentimes, I find that parents want kiddos to not feel sad or not feel anxious or might, encourage them, Hey, it's okay, you got this. And that's great. And at the same time, if they do feel sad, it's okay to say, Hey, your feelings are valid. Let's talk through that, right?

Let's work together as a team to address that. Another big thing that I would always recommend is encouraging kiddos to continue to engage in the activities that they already enjoy, that they already know make them feel happy. A lot of the times youth might get, confused with the diabetes diagnosis and feel like, wait, I have to stop doing all the things that I used to do, or this makes me so different.

And what we want to do is actually encourage them to continue to do everything that they love to do, while diabetes is going to change some aspects, it doesn't have to change all of the activities that they already love. So encouraging continuing in sports, dancing, bike riding, going on walks, listening to music, doing those things together with the youth can be really helpful.

Parents can also encourage relaxation strategies or mindfulness strategies to help overall manage some of the mood or pieces that might come up. and I would say another huge aspect is working as a team. Parents can provide help and support as needed. So especially if parents are noticing maybe an increase in burnout or noticing symptoms of anxiety or depression, this can be a time where parents can say, Hey, I'll take over the cares for a while, or I'll supervise while you're doing it, or maybe provide additional reminders, kind of working as a team together, so the kiddos don't have to feel like they have to do it all by themselves.

And at the same time, providing maybe positive reinforcement or praising them along the way. One thing that I often recommend is talking about blood sugar numbers as if, in a neutral and non judgmental way, maybe avoiding using the term good numbers or bad numbers. Because, oftentimes that contributes to maybe that pressure that youth might feel.

So instead we can focus on, okay, these numbers are giving us information, and they tell us what to do next, like, what we can do to take care, to get you back in range, but not necessarily getting mad at the youth for a certain number or things like that, which make it a lot harder to manage.

And just creating that space to talk about it, talk about their feelings and, talk about what are the difficult pieces about diabetes management.

Host: So, when you are working with these kiddos, what do you do with them to help them? Because, I mean, obviously, depression, and as we talked about, burnout, and feelings of insecurity, self esteem, there's a lot that goes into it. What do you do to help them?

Mercedes Palacios, Ph.D., LMFT: One of my main strategies is definitely helping to validate their feelings. Encouraging that they're able to have this safe space to talk about what they're feeling. Another big, piece of treatment that we use is a cognitive behavioral therapy approach, where we do help address any of the unhelpful thoughts that might be coming in about diabetes management and helping reframe or think about it differently in a more positive way, in terms of how they can change their mood, their thoughts, and be able to change the way that they might be feeling about their diagnosis or the things that they have to manage.

Another big component of my work is working with the family. So some of the strategies that I mentioned earlier, that is what I often do in my treatment and help parents and youth figure out what is a good plan that will work for them to work collaboratively. How can we help them feel like they're working as a team as opposed to, having a negative interaction or a lot of difficulties with communication related to diabetes.

So a lot of positive communication with families and youth, and then helping them also advocate for what their needs are and being able to communicate with the medical team. So helping them come up with questions that they might have and working collaboratively in that way as well.

Host: What about siblings? Because I guess, when there's somebody in the family living with a chronic disease, sometimes the siblings will feel like that child gets all the attention and that they've got the issues and that the parents care more about them. Do you work with the siblings when you say you work with the family? Do you ever see that kind of thing?

Mercedes Palacios, Ph.D., LMFT: Absolutely. Yes. So I definitely see that often. And a lot of, just, dynamics that shift the family and the way that they interact with each other. So I do see that often. I actually don't personally, have siblings join often because here at CHOC, we do have a short term model. We have what's called our medical coping clinic and we really make it a targeted approach with kiddos.

And I often involve parents, but we don't do more like family therapy. When I do feel like that is the main concern or something that's coming up for a family, I provide referrals for community clinics that do focus more on family support. And at the same time, I do provide parents with strategies that they can use, ways that they can build in quality time with all of their children, you know, in different ways to help address maybe some of the concerns that are coming up with attention, and then also helping siblings and their youth be able to work as a team together of how they can, support each other in that way as well.

Host: Wrap it up for us with your best advice for the parents listening when they're thinking about their child that's living with diabetes and the mental and emotional health and resilience that really we look to our children to help them build that. What's your best advice here?

Mercedes Palacios, Ph.D., LMFT: My best advice again, like I have been saying is working as a team, treating it as diabetes is something they'll work together to overcome and also highlighting that having diabetes is not going to stop them from being able to live the life that they want to live. I think for parents also to build their knowledge of what are the signs to look out for in order to determine how to seek additional support. We have a really strong team here at CHOC in our endocrinology team, but also anywhere that kiddos might be seen for diabetes, really building that team and looking for that support. So, if they are noticing some of the signs, that I mentioned above or, additional signs could be, kiddos having increased A1cs often and missing clinic appointments or noticing that they're not following through in their diabetes cares. Then that might be the time to, Hey, I need additional support.

I need additional guidance, and in that case, asking their team for referrals for mental health support. It could be the endocrinology team, it could be pediatricians, but really, building that team. So I would say that that's a huge part, where they don't have to feel like they're alone or they have to navigate the stressors alone.

Host: Thank you for joining us again. And for more mental health and wellness tips and information, please visit choc.org/ mentalhealth. Thank you so much for listening to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County.

Together, we can keep kids happy and healthy. We'd like to invite our audience to download, subscribe, rate, and review Long Live Childhood on Apple podcast, iHeart, Spotify, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.