Conference Workgroup Reports

Workgroup 1 The goal for workgroup 1 was to address the psychosocial issues relevant for children and adolescents with type 1 diabetes, and to make recommendations regarding how to improve the psychosocial support available to children and families.

 

Mental Health Issues in Diabetes Conference

 

Summary of Workgroup 1 Discussions, Conclusions and Recommendations

Submitted by Jill Weissberg-Benchell, Ph.D., CDE Workshop Chair

 

The goal for workgroup 1 was to address the psychosocial issues relevant for children and adolescents with type 1 diabetes, and to make recommendations regarding how to improve the psychosocial support available to children and families.

  1. 1.     DEVELOPMENTAL CONSIDERATIONS

With respect to families with preschoolers, our team highlighted the following issues that a mental health provider should be familiar with and should offer anticipatory guidance to families about:

Fear of Hypoglycemia, and Struggles with Eating (timing, amount, predictability in intake). – given the fact that preschooler’s appetites vary greatly from day to day, it is difficult to predict how much and when a child will want to eat. One consequence of this is an increased risk of low blood sugars. The fact that preschoolers are less able to communicate how they feel to their parents also plays a role in this increased risk as well as a role in increased parent anxiety. 

With respect to families with elementary age children, our team highlighted the following issues that a mental health provider should be familiar with and should offer anticipatory guidance to families about:

Sharing the diagnosis with others, negotiating peer relationships, and preventing diabetes from interfering with daily activities. School-age children are beginning to expand their known-world and are also aware of how they are the same and different than their peers. In addition, this is the age where the concept of “fairness” is paramount, and diabetes is not fair.

With respect to families with adolescents, our team highlighted the following issues that a mental health provider should be familiar with and should offer anticipatory guidance to families about:

The increased influence of the peer group, the desire for independence while still needing supervision, the opportunities to engage in high risk behaviors, the increased risk for depressive symptoms, and the negative impact of family conflict. The rapid changes in adolescent physiology (hormones) and psychology (brain development) offer opportunities for both crisis and positive change. Teenagers are capable of engaging in good judgment and decision making, but that does not mean that they always engage in these skill sets.

 

 

  1. 2.     GUIDELINES

Out team pointed out that both ADA (American Diabetes Association) and ISPAD (International Society for Pediatric and Adolescent Diabetes) offer guidelines regarding the importance of psychosocial support embedded within a diabetes team. However, as far as we know, there are very few diabetes programs in the country that have fully-integrated mental health services. Some offer support only at diagnosis, some offer support only if families are already struggling, some offer support only during brief visits as part of diabetes clinic.

  1. 3.     RECOMMENDATIONS:

Our team offered a number of ideas regarding how to increase the availability of mental health services for families who have a child with diabetes. Some of these ideas are implementable immediately; others will take education, advocacy and systems changes.

Immediately Implementable:

  1. Psychosocial screening at diagnosis to help direct scare resources to families that need them most. Assessment of the marital relationship, family’s quality of life, communication and problem-solving skills, level of conflict, can all be easily assessed with validated questionnaires.
  2. Psychosocial screening annually that can include (based on developmental level) such areas as fear of hypoglycemia, parent stress, disordered eating behavior, depression.
  3. Set the stage for team’s expectations regarding family management and also regarding psychosocial functioning immediately, at diagnosis. Examples include statement that two caregivers should attend every single outpatient follow up clinic every time; diabetes must be as equally managed by adult caregivers as is possible, children need ongoing support and encouragement and should never be blamed for out of range numbers, tight control matters, technology can be helpful.
  4. Provide psychosocially-focused workshops for families annually that focus on the unique developmental needs of children in specific stages of life (e.g. supporting your preschooler; thriving through elementary school years; preparing for the middle school years; surviving high school; and preparing for life after high school).  

Requires Education, Advocacy, and Systems Changes:

  1. Insurance coverage for mental health services. Coverage for prevention services will be key (as opposed to coverage after a psychiatric diagnosis is made)
  2. Mandating mental health services as a requirement for obtaining and maintaining ADA certification
  3. Increasing the number of mental health professionals who are also Certified Diabetes Educators.
  4. Training programs specifically designed to train young professionals (nurses, psychologists, psychiatrists, social workers) in the interdisciplinary model where psychosocial care is an integrated part of overall diabetes care. Such programs can focus on both research and clinical training, as the most exceptional individuals are skilled at both.

 

  1. 4.     ACTION PLANS:

Based on the above-listed discussions, conclusions and recommendations, our workgroup made the following recommendations regarding action plans:

  1. We recommend that key diabetes-specific stake holders, including ADA, ISPAD and JDRF work together to integrate the existing standards of care from each entity and offer a consensus statement regarding the need for the integration of mental health care into diabetes teams.
  2. We recommend that key stake holders from both the diabetes world and the mental health world (e.g. American Diabetes Association, the American Psychological Association) work together to advocate for improved collaboration and cross-training of providers, work together to advocate for funding/reimbursement for mental health services, and work together to develop the necessary training for mental health providers to understand the unique aspects of life with diabetes.
  3. ADA certified diabetes programs must have a fully integrated mental health program in order to become and/or remain certified.
  4. We recommend that ADA and NIH as well as other stakeholders fund studies that assess different models for integrating psychological care into diabetes programs (e.g. telemedicine, on-line programs, primary prevention approaches, DKA prevention approaches, depression and eating disorder programs). The focus on psychosocial outcomes, metabolic outcomes and health care cost outcomes should all be included).
  5. We propose an intensive training model, sponsored by key stakeholders, for mental health providers that offers training in the key psychosocial issues for families living with diabetes, from both a developmental AND a family-systems perspective .
  6. We propose partnering with established mental health programs (e.g. United Health Services) to expand the accessibility of mental health services for individuals and families who would benefit from diabetes-trained providers within the community.

 

 

 

 

 

 

 

Workgroup 2 the needs of patients and caregivers in the care of diabetes, with a special focus on the period from late adolescence to adulthood.

Mental Health and Diabetes Work Group:

Co-chairs: Marian Rewers, Ken Gorfinkle

Participants: Lori Laffel, Lee Peebles, Howard Wolpert, M. Rubenstein, Tony Rogowski, Alyson Harder, Daniel Davidow, Karen Johnson, Martin Schappell, Aaron Kowalski

 

Our work group was tasked with addressing the needs of patients and caregivers in the care of diabetes, with a special focus on the period from late adolescence to  adulthood.  The work group was comprised of three distinct constituencies: Representing the private sector were medical professionals and hospital administrators whose focus is to run a large scale health system which provides quality care in a competitive health care market. Representing the patient/consumer point of view were active members of the JDRF and other community leaders whose lives are directly affected by diabetes and its care. The third group was comprised of medical and mental health professionals working within academic medical centers.

 

A number of central themes emerged:

 

Participants representing both the private sector and patient advocates clearly articulated a necessity to revamp the way mental health services are reimbursed by insurance companies.  Borrowing from commercial business models, the group strongly emphasized the need for identifying tangible outcomes by which to measure and evaluate treatment effectiveness.  Outcomes included patient satisfaction, protection of patient earnings, health maintenance and quality of life. 

 

Mediating steps were identified towards these outcomes:

  1. Recognition of age-specific goals in the context of chronic disease and patients’ potential to ‘bounce forward’
  2. Preventive mental health visits at a prescribed frequency after diagnosis
  3. Mental health intervention at key life-transition points, such as puberty, entry to college, marriage, pregnancy, and relocation.
  4. Advocacy is needed to protect against academic and employment discrimination.
  5. Involvement of the immediate family members of patients
  6. Education of primary and diabetes care providers
  7. Need for more outcomes research

 

Endocrinologists, nurses and mental health professionals were supportive of the above formulation, and then turned the focus on a need for diabetes treatment guidelines to better reflect the need for well-integrated behavioral health during all phases of care.  Specifically, the group described the enormous cost and health-saving potential of primary preventive behavioral intervention.  Research needs to further quantify the cost/benefit of preventing avoidable DKA admissions and long- term complications.  The group noted a gap in available mental health services for adults with diabetes in comparison to youth.  Also noted was a significant gap in “diabetes literacy” among mental health professionals in the community at large.

 

Medical professionals working in diabetes centers showed a strong consensus that mental health support for patients is best delivered on site, where the physicians, nurses and nutritionists have easy access to behavioral consultation.  Close collaboration between diabetes specialists and behavioral scientists will serve to boost effectiveness of both. 

 

Behavioral and mental health professionals working within diabetes care centers can identify a taxonomy for Diabetes Distress, and can begin to set out treatment guidelines for supporting patients as they find their health and wellbeing put at risk. 

 

■     New onset trauma

■     Honeymoon transition distress

■     Parent/child or family conflict

■     Fear of lows

■     Fear of high blood sugar and of complications

■     Separation anxiety in children

■     Defensive hyperglycemia in older patients

■     Diabetes-related disordered eating

■     Diabetes burn-out

■     Transition to emerging adulthood

■     Sexuality and intimacy

■     Pregnancy planning and management

■     School/employment/social stress around DM

■     Financial/insurance coverage challenges

■     Cultural barriers to accessing care

 

This taxonomy can be used to identify gaps in patient care, to develop structured interventions to minimize harm to patients, to create training standards for mental health workers in diabetes care, and finally to develop an action plan:

 

■     Develop a model for integrated care

■     Train mental health professionals in DM care

■     Conduct cost-effectiveness research on prevention

■     Lobby congress for ACA support

■     Raise public awareness.

 

 

Marian Rewers, MD, PhD                                         Kenneth Gorfinkle, Ph.D

Professor of Pediatrics and Medicine                     Assistant Clinical Professor

Clinical Director                                                           of Psychology in Psychiatry

Barbara Davis Center for Diabetes                         New York Presbyterian Hospital

University of Colorado School of Medicine             The Naomi Berrie Diabetes Center

           

Workgroup 3 Screening for Behavioral and Mental Health Issues

Mental Health Issues in Diabetes

Report for Working Group III

 

Screening for Behavioral and Mental Health Issues

 

First Principle: All care and assessment should be ongoing and incorporated into a Program of Planned Psycho-Behavioral Educational Anticipatory Guidance.

 

Second Principle: Counseling and psycho-behavioral education is most optimally delivered by a trained mental health professional. The professional should have experience in the management of diabetes or, at a minimum, experience in the care of serious chronic illness. Optimally the mental health professional should work in active collaboration with the diabetes team.

 

 

At initial diagnosis or transfer to a new care setting:  A patient and family assessment should be done to determine their Strengths and Challenges based on prior experience and coping mechanisms which were successful and/or not helpful in other challenging situations.  A complete behavioral family history is essential to optimal understanding of the strengths and risks of the patient and family. A behavioral family history from the spouse or partner is important in the adult patient.

 

Initial counseling should be completed at diabetes diagnosis to normalize the feelings of grief, loss, fear and anger surrounding the diagnosis. Families and patients should also be educated on warning signs and symptoms of excessive or prolonged feelings that may be helped by additional advice or therapy. In addition, anticipatory counseling should focus on the expected behavioral challenges associated with diabetes care including needle anxiety, fear associated with insulin injections and self-blood glucose monitoring, frustration with blood glucose values, fear of hypoglycemia, and fear of complications.

 

 

Within the initial 1-3 months after diagnosis: A repeat assessment to determine how the patient and family are coping with the diagnosis of diabetes and if there are diabetes specific behavioral issues that should be addressed. In addition to overall adjustment to their new diabetes diagnosis,  diabetes-specific issues may include needle anxiety or high and/or low blood glucose anxiety. These latter fears include fears of severe low blood glucose events and fears of death of the patient from both an acute low glucose event or from chronic high glucose levels resulting in long term complications. In addition to the extreme psychologic distress these anxieties cause, they are also major barriers to optimal diabetes management.

 

Within 9-12 months of diabetes diagnosis: After the mechanical tasks of diabetes care and decision-making around self-management have been mastered, a scheduled visit for anticipatory counseling on additional challenges of living with diabetes is essential to help to address the difficulties of living with a chronic disease. This visit is to:

1)   Increase awareness of how different family members may deal differently with both the day-to-day challenges of diabetes and the idea of the persistent presence of diabetes in the family.

2)   Review the importance of establishing/maintaining open, constructive communication between family members, including the patient, during childhood, adolescence and young adulthood.

3)   Educate patients and family as to the expected and unanticipated life events that will be challenges to diabetes management and may complicate family dynamics in unexpected ways due to the presence of diabetes.

4)   Remind patients and families that these challenging times are important times to prospectively ask for advice on how these events may affect their family and, for unexpected events, seek advice from the diabetes team so the team, including the mental health specialist, can provide advice and guidance on how these events might be handled so diabetes care and family cohesiveness is least disrupted.

 

Ongoing Care:  Routine visits with a behavioral specialist should occur at least annually and whenever behavioral or psychological concerns arise. These visits are part of the on-going Program of Planned Psycho-Behavioral Educational Anticipatory Guidance.

 

The purpose of these visits is to identify previously unrecognized psycho-behavioral issues or barriers to diabetes management and to provide prospective counseling regarding associated mental health issues might arise and behavioral challenges the patient and family may face based on age and diabetes duration.

 

There are social and demographic factors that have been associated with increased difficulty in managing diabetes. These might be considered alerts for more frequent behavioral assessments.

These include:

Children living in a single parent household

History of social services involvement

History of drug or alcohol abuse in the patient or a parent

History of antisocial behavior resulting in arrest

Financial insecurity as evidenced by lack of health insurance or government insurance

 

There are additional diabetes specific alerts to high risk for mental health disorders although there are also financial/societal causes of these signs.

These include:

DKA after the initial presentation

Persistently elevated HbA1c (generally considered to be > 9%)

Increased, persistent, or excessive low blood glucose levels

Frequent missed glucose checks and/or insulin doses

Unexpected weight change

Missed diabetes care appointments

 

 

Regular screening for common behavioral and mental health concerns will allow for early identification of behavioral and mental health issues and should be done in a time efficient manner for both patient and medical staff.

 

Conditions that should be screened for include: depression, anxiety including needle anxiety, fear of hypoglycemia, disordered eating including diabetes specific weight control behaviors, substance abuse/addiction, suicide and safety at home. There are also reports suggesting that screening for ADHD and executive functioning are helpful in individuals who are having difficulty with diabetes management.

Additional areas that may be beneficial to assess include DQoL and family QoL. Others might be shared diabetes responsibility? (Who is doing what?)

 

List possible screening tools

 

Children’s Depression Inventory (8-14 years)

Beck Depression Inventory (14-)

CED-D

(BRIEF) executive skills in everyday situations

http://www.phqscreeners.com/pdfs/08_PHQ-4/English.pdf

PHQ4 is a 4 item screening tool for both depression and anxiety. I don’t know if validated for both Pedi and Adult.

PHQ-9 has been validated in adults and children

Varney’s QOL scale is good, for parents and kids, but it’s long and hasn’t been used for screening.

 

MSCOFF: Screening for eating disorder behavior modified for DM. Not yet published but will be coming out in DM Care as a letter to editor, I believe.

1)   Do you  make yourself Sick because you feel uncomfortably full?

2)   Do you worry you have lost Control over how much you eat?

3)   Have you recently lost more than 14 lbs (One stone) in a 3-month period? [Clearly, the authors are from the UK].

4)   Do you believe yourself to be Fat when others say you are too thin?

5)   Would you say that Food dominates your life?

Item number 5 replaced with: Do you ever take less insulin than you should?

 

Many screening tools need to be adapted for diabetes to provide meaningful information.

The NIH Promis website has a number of validated and free questionnaires that might be considered.

 

Not validated but potentially clinically meaningful:

Do you take less insulin than you should?

Yes                  No

If yes, do you take less insulin because of:  (Please check more than one if they apply)

a)     Weight concerns

b)    Worry about hypoglycemia

c)     Difficulty paying for insulin/diabetes supplies

d)    Busy schedule

e)     Not remembering to take it

f)     Not being organized

 

Added by Alan Jacobson, MD -Psychiatrist:

There is value in using a simple and short three level assessment:

1.      Generic hrqol measure <1-5 items>- allows for comparison across populations

2.      Brief sxs survey- as a screening tool it need not be specific but have a high level sensitivity and utility to trigger further questions

3.      Something that is diabetes oriented – like the PAIZD, but that is 16 items as I recall and may be too long. Garry Welch has done a lot of work with it but don’t know if he ever came up with a brief version .

 

How we address the more complex and very important issues of family, social context and strengths is something that I will cogitate further. Take care.  My reference to the tool box comes from work we did years ago to develop material for diabetes care in primary care practices to be delivered by nurses and others in the practice.

 

 

 

Workgroup 4 Barriers of Intergrated Care

BARRIERS TO INTEGRATED CARE

  1. Limited reimbursement for psychologists, inappropriate CPT codes.
  2. Lack of control over clinic model and staffing- For ex., new funds are allocated to bring in more MDs to see patients, and not to provide behavioral health services.
  3. Incomplete integration of psychologists in diabetes teams.
  4. HIPAA- while not actually a barrier, since HIPAA allows communication between health care providers, it is often viewed as a barrier and used as a reason to not provide integrated care
  5. Poor communication between medical and psychosocial care providers

Conclusions: While barriers exist, there is a need for innovative approaches, perhaps utilizing new technologies, to provide services that will lead to decreased distress and improved quality of life. This could include peer-to-peer interventions, use of social media, and the psychologist as “leader” to develop and implement varying approaches and develop new paradigms to change existing care mechanisms.

Potential funders: NIH, ADA, JDRF, UHS, Kaiser Permanente, PCORI, Industry

INTEGRATED CARE RESEARCH

  1. Goal: To test integrated care team approaches (through RCTs) to improve mental health outcomes, medical outcomes (including adherence), cost and patient satisfaction of patients with T1D. We need to establish, through controlled clinical studies, that integrated care improves quality of life,  patient satisfaction, select medical outcomes, as well as provides    financial benefits.
  2. Should measure: behavioral outcomes (e.g., quality of life, patient satisfaction and prevention of depression) and behavioral mediators (e.g., self-efficacy), not just A1c/medical outcomes. The focus should be on “what patients care about.” Also, we should measure changes in healthcare costs related to behavioral interventions to demonstrate potential cost offset, though we shouldn’t focus on this since most medical outcomes are not held to that standard if they lead to better outcomes.
  3. Need more effective approaches to early detection and treatments for depression and other psychiatric disorders (e.g. eating disorders) in T1D patients.
  4. Need more studies of psychiatric patients who also have T1D, with valid, reliable and standardized measures. The few studies we have focus on, for ex., T1D patients who also have depression, but we should also look at depressed patients who also have T1D. These may not be the same patients.  Longitudinal studies are needed to determine to what extent integrated care team approaches prevents depression and suicide.
  5. Integrated care research studies should be a focus at national meetings, e.g. ADA, Endocrine Society.
  6. ADA should be a leader in identifying the key psychosocial issues to study, in providing education on the importance of behavioral/psychosocial issues in diabetes outcomes, and in funding true translational research.
  7.  NIH should increase their funding for integrated care and behavioral research so that it is a larger percentage of its grant portfolio.  Trans-NIH approaches are needed to support major outcome investigations of the role of integrated team approaches in diabetes care.
  8. Potential studies identified by the workgroup:
    1. Follow newly diagnosed T1D patients longitudinally. Provide an integrated care team intervention and test whether the intervention prevents poor quality of life and risk of depression and has a beneficial effect on medical outcomes.
    2. Examine how much integrated care costs and how much it saves in the long run.
    3. Focus on patients who are high utilizers of medical services (e.g., those who have had  frequent hospitalizations for DKA) and identify other vulnerable subgroups to develop an intervention unique to them (vs. intervention for all T1D patients to decrease their distress)
    4. Develop interventions that engage the family members, both to improve patient outcomes and to improve family members’ adaptation.
    5. Look at existing databases (e.g., EDIC) for potential data that’s already been gathered to analyze with these questions in mind.

 

 

Mental Health Issues in Diabetes Conference

 

Summary of Workgroup 1 Discussions, Conclusions and Recommendations

Submitted by Jill Weissberg-Benchell, Ph.D., CDE Workshop Chair

 

The goal for workgroup 1 was to address the psychosocial issues relevant for children and adolescents with type 1 diabetes, and to make recommendations regarding how to improve the psychosocial support available to children and families.

  1. 1.     DEVELOPMENTAL CONSIDERATIONS

With respect to families with preschoolers, our team highlighted the following issues that a mental health provider should be familiar with and should offer anticipatory guidance to families about:

Fear of Hypoglycemia, and Struggles with Eating (timing, amount, predictability in intake). – given the fact that preschooler’s appetites vary greatly from day to day, it is difficult to predict how much and when a child will want to eat. One consequence of this is an increased risk of low blood sugars. The fact that preschoolers are less able to communicate how they feel to their parents also plays a role in this increased risk as well as a role in increased parent anxiety. 

With respect to families with elementary age children, our team highlighted the following issues that a mental health provider should be familiar with and should offer anticipatory guidance to families about:

Sharing the diagnosis with others, negotiating peer relationships, and preventing diabetes from interfering with daily activities. School-age children are beginning to expand their known-world and are also aware of how they are the same and different than their peers. In addition, this is the age where the concept of “fairness” is paramount, and diabetes is not fair.

With respect to families with adolescents, our team highlighted the following issues that a mental health provider should be familiar with and should offer anticipatory guidance to families about:

The increased influence of the peer group, the desire for independence while still needing supervision, the opportunities to engage in high risk behaviors, the increased risk for depressive symptoms, and the negative impact of family conflict. The rapid changes in adolescent physiology (hormones) and psychology (brain development) offer opportunities for both crisis and positive change. Teenagers are capable of engaging in good judgment and decision making, but that does not mean that they always engage in these skill sets.

 

 

  1. 2.     GUIDELINES

Out team pointed out that both ADA (American Diabetes Association) and ISPAD (International Society for Pediatric and Adolescent Diabetes) offer guidelines regarding the importance of psychosocial support embedded within a diabetes team. However, as far as we know, there are very few diabetes programs in the country that have fully-integrated mental health services. Some offer support only at diagnosis, some offer support only if families are already struggling, some offer support only during brief visits as part of diabetes clinic.

  1. 3.     RECOMMENDATIONS:

Our team offered a number of ideas regarding how to increase the availability of mental health services for families who have a child with diabetes. Some of these ideas are implementable immediately; others will take education, advocacy and systems changes.

Immediately Implementable:

  1. Psychosocial screening at diagnosis to help direct scare resources to families that need them most. Assessment of the marital relationship, family’s quality of life, communication and problem-solving skills, level of conflict, can all be easily assessed with validated questionnaires.
  2. Psychosocial screening annually that can include (based on developmental level) such areas as fear of hypoglycemia, parent stress, disordered eating behavior, depression.
  3. Set the stage for team’s expectations regarding family management and also regarding psychosocial functioning immediately, at diagnosis. Examples include statement that two caregivers should attend every single outpatient follow up clinic every time; diabetes must be as equally managed by adult caregivers as is possible, children need ongoing support and encouragement and should never be blamed for out of range numbers, tight control matters, technology can be helpful.
  4. Provide psychosocially-focused workshops for families annually that focus on the unique developmental needs of children in specific stages of life (e.g. supporting your preschooler; thriving through elementary school years; preparing for the middle school years; surviving high school; and preparing for life after high school).  

Requires Education, Advocacy, and Systems Changes:

  1. Insurance coverage for mental health services. Coverage for prevention services will be key (as opposed to coverage after a psychiatric diagnosis is made)
  2. Mandating mental health services as a requirement for obtaining and maintaining ADA certification
  3. Increasing the number of mental health professionals who are also Certified Diabetes Educators.
  4. Training programs specifically designed to train young professionals (nurses, psychologists, psychiatrists, social workers) in the interdisciplinary model where psychosocial care is an integrated part of overall diabetes care. Such programs can focus on both research and clinical training, as the most exceptional individuals are skilled at both.

 

  1. 4.     ACTION PLANS:

Based on the above-listed discussions, conclusions and recommendations, our workgroup made the following recommendations regarding action plans:

  1. We recommend that key diabetes-specific stake holders, including ADA, ISPAD and JDRF work together to integrate the existing standards of care from each entity and offer a consensus statement regarding the need for the integration of mental health care into diabetes teams.
  2. We recommend that key stake holders from both the diabetes world and the mental health world (e.g. American Diabetes Association, the American Psychological Association) work together to advocate for improved collaboration and cross-training of providers, work together to advocate for funding/reimbursement for mental health services, and work together to develop the necessary training for mental health providers to understand the unique aspects of life with diabetes.
  3. ADA certified diabetes programs must have a fully integrated mental health program in order to become and/or remain certified.
  4. We recommend that ADA and NIH as well as other stakeholders fund studies that assess different models for integrating psychological care into diabetes programs (e.g. telemedicine, on-line programs, primary prevention approaches, DKA prevention approaches, depression and eating disorder programs). The focus on psychosocial outcomes, metabolic outcomes and health care cost outcomes should all be included).
  5. We propose an intensive training model, sponsored by key stakeholders, for mental health providers that offers training in the key psychosocial issues for families living with diabetes, from both a developmental AND a family-systems perspective .
  6. We propose partnering with established mental health programs (e.g. United Health Services) to expand the accessibility of mental health services for individuals and families who would benefit from diabetes-trained providers within the community.