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The Glucose Control Resistance Scale (GCRS)

118 J Clin Res Pediatr Endocrinol 2019;11(2):118-124 DO I: 10.4274/jcrpe.galenos.2018.2018.0164 Maria-Eleni Nikita1, Helen M. Hendy2, Keith E. Williams3, Paul L. Mueller3 1University of Maryland School of Medicine, Maryland, United States 2Penn State University, Schuylkill Campus, Department of Psychology, Pennsylvania, United States 3Penn State Hershey Medical Center, Department of Pediatrics, Pennsylvania, United States ORI GI NAL AR TIC LE What is already known on this topic? What this study adds? Adolescents with diabetes have more problems with adherence than any other pediatric age group. Previous research has shown that multiple factors, including family conflict, disordered eating and anxiety, are related to adherence. The Glucose Control Resistance Scale (GCRS) is a measure of adolescent adherence to treatment that may allow diabetic care teams to better understand the origin of family conflict perceptions and the motivational beliefs that modify behavior and contribute to independent self-management and glucose control. Each question was designed to be meaningful in interventions by addressing common items of resistance to adherence and impulsive management decisions. The GCRS may be used by providers as an initial short screening survey on an annual or semi-annual basis. Address for Correspondence: Keith E. Williams PhD, Penn State Hershey Medical Center, Department of Pediatrics, Pennsylvania, United States Phone: +7175317117 E-mail: kwilliams2@hmc.psu.edu ORCID ID: orcid.org/0000-0002-6762-4585 ©Copyright 2019 by Turkish Pediatric Endocrinology and Diabetes Society The Journal of Clinical Research in Pediatric Endocrinology published by Galenos Publishing House. Conflict of interest: None declared Received: 12.07.2018 Accepted: 03.10.2018 tasks to adolescent psychological challenges. Combining attitudes of defiance or resistance with specific decisions on management can be useful in patient care because, for example, lack of motivation may influence compliance as much as the large number of burdensome management tasks. Challenges regarding diabetic management may be related to developmental changes. Adolescents are becoming more independent, yet often require parental intervention with diabetic care. In some cases. this leads to increased family conflict which has been found to be associated with poorer glycemic control as measured by higher hemoglobin A1c (HbA1c) levels (3,4,5). Increased sexual interest can influence both weight and body image concerns which have been found to result in higher HbA1c (6,7). Additionally, adolescents often report anxiety and self-doubt which have been associated with worse glucose control (3,8). Other beliefs prevalent in adolescents are a sense of physical “invincibility,” identifying with being independent, being in control and defying or being resistant to authority figures, usually the parents (9). These beliefs, combined with a physiologic lag in cognitive processing, can lead to difficulty with focusing on the future or with accepting the adverse consequences of poor metabolic control. These emotional beliefs may also lead to a feeling that there are no problems with resisting medically-recommended guidelines for glucose control. In many cases of uncontrolled diabetes, disordered beliefs in one of four areas of competence (family conflict, disordered eating, anxiety or resistance) are the cause of non-adherence to treatment recommendations (1,2,7). Commonly used screening tests of adherence measure management skills directly correlated with glucose control (10,11). These measures have largely removed psychological parameters from the management tasks, despite that the psychological factors may limit adherence and require intervention. Studies have explored issues related to motivation in adolescents with diabetes. For example, self-efficacy and outcome expectations were found to be related to diabetes self-management adherence and glycemic control (12). Motivation has also been integrated into treatment as a growing number of providers advocate the use of motivational interviewing (13). Some surveys contain distress items generated by the burden of management tasks, such as “feeling overwhelmed by my diabetes regime” (14). Other questionnaires list management tasks. However, intervention in one of these areas may not generalize to the other. Attention to both distress and task is needed for improvement of diabetic self-management. In our experience, discussing both distress and management in the diabetes outpatient visit with both the patient and their family is useful. This discussion can be initiated by exploring whether the patient not only values the required management tasks, but can also accomplish these tasks. This information can help the provider determine whether the adolescent understands these tasks and how the family can be sufficiently supportive to accomplish these tasks. The intervention process begins with identifying a distressing problem as the starting point from which to develop new problem-solving skills related to the specific stress in question. For example, “It’s too hard to calculate my insulin dose” would lead to exploring easier ways for the individual patient to determine a safe dose. The purpose of the present study was to develop a scale measuring resistance and impulsive decisions, thus enabling providers to be more effective in dealing with distress and fostering management tasks.