It’s another edition of Thesis Thursday, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study. Last week, I posted the second section of Chapter 2: Literature Review which included a general overview of adolescent cognitive development. This week is the next section of Chapter 2: Literature Review, a general discussion of adolescent psychosocial development. This one is pretty lengthy…

Psychosocial

Erik Erikson’s theory of development is based on Freud’s theories of human development. Erikson expanded on Freud’s biological approach, taking into account the impact of society on development. Erikson developed “a set of eight psychosocial stages covering the lifespan, by studying the development of identity, and by developing methods that reach beyond the structural psychoanalytic setting used with adults” (Miller, 1993, p. 156). According to Miller (1993), “in the psychosocial view, physical maturation has personal and social repercussions. Maturation brings a new skill that opens up new possibilities for the child but also increases society’s demands on him” (p. 156).

Erikson’s first stage of development is Basic Trust versus Basic Mistrust, roughly the first year of life. Miller (1993) sums up the main task of this stage: “to acquire a favorable ratio of trust to mistrust” (p. 161). According to Erikson (1968),

a sense of basic trust … is a pervasive attitude toward oneself and the world derived from the experiences of the first year of life” (p. 96). “Babies develop trust in themselves from the feeling that others accept them and from increased familiarity with their bodily urges. (Miller, 1993, p. 161)

The bodily urges and physical experiences of an infant—sucking, biting, grasping— “are prototypes for the psychosocial modality of getting and giving” (Miller, 1993, p. 162). The baby’s primary focus is the mouth as a means of receiving, the oral stage from a psychoanalytic framework; from a more general standpoint it is the incorporative stage (Erikson, 1968, p. 98). The infant is taking nourishment orally, but he is also taking in with his other senses, learning and making sense of his environment visually, tactilely, aurally, odorously and kinesthetically.

It is necessary for some level of mistrust to be present “at all ages in order to detect impending danger or discomfort and to discriminate between honest and dishonest persons” (Miller, 1993, p. 162). An unhealthy ratio between trust and mistrust, with mistrust dominating, will result in a child or adult, who lacks self-confidence and is withdrawn and suspicious of others (Miller, 1993, p. 162), a barrier to forming and maintaining healthy relationships.

It is the relationship between mother (or primary caregiver) and infant which determines the developmental outcome of this stage, the extent to which an infant trusts or mistrusts his environment. “From the mother’s side of the interaction, there must also be trust—trust in herself as a parent and in the meaningfulness of her caretaking role” (Miller, 1993, p. 162).

Mothers create a sense of trust in their children by that kind of administration which in its quality combines sensitive care of the baby’s individual needs and a firm sense of personal trustworthiness within the trusted framework of the community’s life style. This forms the very basis in the child for a component of the sense of identity which will later combine a sense of being “all right,” of being oneself, and of becoming what other people trust one will become. (Erikson, 1968, p. 103)

Thus, the ratio of trust versus mistrust which develops in the infant serves as a structural basis for the formation of identity.

The second stage of development in Erikson’s theory is Autonomy versus Shame and Doubt, from about age two to age three, and corresponds with the psychoanalytic anal stage of development. “The psychosocial modality is holding on versus letting go, the counterpart to retention and elimination. This ambivalence pervades the child’s behavior and attitude” (Miller, 1993, p. 163). According to Erikson (1968),

the over-all significance of this second stage of early childhood lies in the rapid gains in muscular maturation, in verbalization, and in the discrimination and consequent ability—and doubly felt inability—to co-ordinate a number of highly conflicting action patterns characterized by the tendencies of ‘holding on’ and ‘letting go’. (p. 107)

Erikson (1968) characterizes this stage as a “battle for autonomy. For as he gets ready to stand on his feet more firmly, the infant also learns to delineate his world as ‘I’ and ‘you,’ and ‘me’ and ‘mine’” (p. 108).

Every mother knows how lovingly a child at this stage will snuggle close to her and how ruthlessly he will suddenly try to push her away. At the same time the child is apt both to hoard things and to discard them, to cling to treasured objects and to throw them out of the windows of houses and vehicles. (Erikson, 1968, p. 108-109)

The child’s ambivalence is reflected in the very meanings of his actions. “‘To hold’ can become a destructive and cruel retaining or restraining, and it can become a pattern of care: ‘to have and to hold.’ To ‘let go,’ too, can turn into an inimical letting loose of destructive forces, or it can become a relaxed ‘to let pass’ and ‘to let it be’ (Erikson, 1968, p. 109).

Autonomy develops as a result of a “supportive atmosphere in which the child can develop a sense of self control without a loss of self-esteem” (Miller, 1993, p. 162). The child’s parents and

his environment must … back him up in his wish to ‘stand on his own feet,’ while also protecting him against … that sense of having exposed himself prematurely and foolishly which we call shame or that secondary mistrust …, which we call doubt—doubt in himself and doubt in the firmness and perspicacity of his trainers. (Erikson, 1968, p. 110)

“Shame supposes that one is completely exposed and conscious of being looked at—in a word, self-conscious … Too much shaming does not result in a sense of propriety but in a secret determination to try to get away with things when unseen” (Erikson, 1968, p. 110). When shame prevails over the development of autonomy, it can result in an adolescent behaviorally “expressing the wish to ‘get away with’ things [yet] his precocious conscience does not let him really get away with anything, and he goes through his identity crisis habitually ashamed, apologetic, and afraid to be seen” (Erikson, 1968, p. 111).

“Doubt is the brother of shame. Whereas shame is dependent on the consciousness of being upright and exposed, doubt has much to do with a consciousness of having a front and a back—especially a ‘behind’” (Erikson, 1968, p. 112). Not only can the child not see, and initially not control this area of his body, but others show their dominance over it, threaten the child’s autonomy through their dominance, and then “designate as evil those products of the bowels which were felt to be all right when they were being passed” (Erikson, 1968, p. 112). The vestiges of doubt prevailing over autonomy are expressed by the adolescent “in a transitory total self-doubt, a feeling that all that is now ‘behind’ in time—the childhood family as well as the earlier manifestations of one’s personality—simply do not add up to the prerequisites for a new beginning” as an emerging adult (Erikson, 1968, p. 112).

This stage of development has particular ramifications for the psychosocial development of adolescents. “The first emancipation, namely, from the mother” is played out in the stage of autonomy (Erikson, 1968, p. 114).

There are clinical reasons … to believe that the adolescent turning away from the whole childhood milieu in many ways repeats this first emancipation. For this reason the most rebellious youths can also regress partially (and sometimes wholly) to a demanding and plaintive search for a guidance which their cynical independence seems to disavow. (Erikson, 1968, p. 114)

Erikson’s third stage of development is Initiative versus Guilt, roughly age four to five years. “The theme of this stage is children’s identification with their parents, who are perceived as big, powerful, and intrusive” (Miller, 1993, 164). Erikson moves beyond the Freudian Oedipus complex and concentration on the genitals to “emphasize the social components more than the sexual … Identification brings with it a conscience and a set of interests, attitudes, and sex-typed behaviors” (Miller, 1968, p. 164).

Miller identifies the basic psychosocial modality as “‘making,’ namely, intrusion, taking the initiative, forming and carrying out goals, and competing” (Miller, 1993, p. 164). From the child’s increased control of movement, more refined ability to communicate verbally and understand others, and the combination of movement and language leading to a more expansive imagination, emerges a sense of initiative, the “basis for a realistic sense of ambition and purpose” (Erikson, 1968, p. 115).

At the opposing end of the spectrum from initiative is guilt. “The child settles somewhere along a dimension ranging from successful initiative to overwhelming guilt due to an overly severe conscience that punishes sexual fantasies and immoral thoughts or behavior” (Miller, 1993, p. 164).

“The indispensable contribution of the initiative stage to later identity development, then, obviously is that of freeing the child’s initiative and sense of purpose for adult tasks which promise (but cannot guarantee) a fulfillment of one’s range of capacities” (Erikson, 1968, p. 122). Consistent with the structure of Erikson’s theory, this stage not only builds on the preceding stages and serves as a foundation for subsequent stages, but its themes and tasks will be revisited and reworked as they apply to future stages of development.

Erikson’s fourth stage of development is Industry versus Inferiority, about age six to puberty. During this stage, “the advancing child … ‘sublimates’—that is, applied to concrete pursuits and approved goals—the drives which have made him dream and play. He now learns to win recognition by producing things. He develops perseverance and adjusts himself to the inorganic laws of the tool world” (Erikson, 1968, p. 124). Most significantly, children in this stage enter school, “where they are exposed to the technology of their society” (Miller, 1993, p. 164).

Erikson (1968) defines industry:

While all children at times need to be left alone in solitary play or, later, in the company of books and radio, motion pictures and television, and while all children need their hours and days of make-believe in games, they all, sooner or later, become dissatisfied and disgruntled without a sense of being able to make things and make them well and even perfectly: it is this that I have called the sense of industry. (p. 123)

Children move beyond the realm of family into a new social realm that includes teachers, friends and friends’ parents. In looking to these other people and interacting with them, children learn to be members of society because school is its own sub-culture. “School skill seems to many to be a world all by itself, with its own goals and limitations, its achievements and disappointments” (Erikson, 1968, p. 123).

At risk during this stage is the development of a sense of inferiority.

This may be caused by an insufficient solution to the preceding conflict: the child may still want his mommy more than knowledge; he may still prefer to be the baby at home rather than the big child at school; he still compares himself with his father, and the comparison arouses a sense of guilt as well as a sense of inferiority. (Erikson, 1968, p. 124)

Furthermore, “school life may fail to sustain the promises of earlier stages in that nothing that he has learned to do well so far seems to count with his fellows or his teacher” (Erikson, 1968, p. 124).

Significant to the subsequent stage of development, puberty, there is

the danger threatening individual and society where the schoolchild begins to feel that the color of his skin, the background of his parents, or the fashion of the clothes rather than his wish and his will to learn will decide his worth as an apprentice, and thus his sense of identity —to which we must now turn. (Erikson, 1963, p. 260)

Erik Erikson defines the developmental period of adolescence as a crisis of identity versus identity confusion. Referring to the term, crisis, he states, “It is now being accepted as designating a necessary turning point, a crucial moment, when development must move one way or another, marshaling resources of growth, recovery, and further differentiation” (Erikson, 1968, p. 16). Specifically speaking to the idea of identity formation, Erikson (1968), states:

In psychological terms, identity formation employs a process of simultaneous reflection and observation, a process taking place on all levels of mental functioning, by which the individual judges himself in the light of what he perceives to be the way in which others judge him in comparison to themselves and to a typology significant to them; while he judges their way of judging him in the light of how he perceives himself in comparison to them and to types that have become relevant to him. (p. 22)

The basic task of Erikson’s developmental stage of adolescence “is to integrate the various identifications they bring from childhood into a more complex identity” (Miller, 1993, p. 165). The respective resolutions of the prior developmental stages combine with the rapid physiological changes of puberty and new social pressures and expectations to form a new identity “appropriate for the new needs, skills, and goals of adolescence” (Miller, 1993, p. 165).

An inadequately formed identity results in identity confusion “if adolescents cannot integrate their identifications, roles, or selves … The personality is fragmented, lacking a core” (Miller, 1993, p. 165). This can manifest itself in sexual identity confusion, delinquency, and psychosis, however it more commonly shows itself as an inability to achieve an occupational identity (Erikson, 1963, p. 262). “To keep themselves together they temporarily overidenitify, to the point of apparent complete loss of identity, with the heroes of cliques and crowds” (Erikson, 1963, p. 262).

Adolescents look to peers and society in their effort to understand who they are. “Adolescents not only help one another temporarily … by forming cliques and stereotyping themselves, their ideals, and their enemies; they also insistently test each other’s capacity for sustaining loyalties in the midst of inevitable conflicts of values” (Erikson, 1968, p. 133). In trying to differentiate who they see themselves as and who they do not want to be,

young people can become remarkably clannish, intolerant, and cruel in their exclusion of others who are ‘different,’ in skin color or cultural background, in tastes and gifts, and often in entirely petty [aspects] of dress and gesture arbitrarily selected as the signs of an in-grouper or out-grouper. It is important to understand … that such intolerance may be, for a while, a necessary defense against a sense of identity loss. (Erikson, 1968, p. 132)

Adolescents turn against their parents and other authoritative figures in an attempt to separate and define their identities, since childhood is a time of seeking to identity with caregivers.

In their search for a new sense of continuity and sameness, adolescents have to refight many of the battles of earlier years, even though to do so they must artificially appoint perfectly well-meaning people to play the roles of adversaries. (Erikson, 1963, p. 261)

In order to understand how adolescents with diabetes respond to the demands of their condition, it is necessary to have a knowledge base about the fundamental aspects of normal adolescent development. Physical maturation, the stage of puberty, cognitive development, Piaget’s formal operational stage, and psychosocial development, Erikson’s stage of identity versus identity confusion, all coincide to create the turmoil that characterizes adolescence.

Thanks for reading!
Check back next week for Diabetes: Introduction, Etiology, Pathophysiology, and Epidemiology & Statistics.

Today, I have a guest post from Haidee Merrit, author and illustrator of One Lump or Two?, a cartoon book about having diabetes. Haidee and I became virtually acquainted a few months ago, and I’m delighted to count her as one of my DOC friends. I love that she’s found a creative way to express her experience with diabetes, and she’s put it in a book to share with everyone. Both the diabetic in me and the fellow creative spirit in me want to support her efforts, so here’s Haidee!

In my naiveté, I really thought the hard work was done. I’m the artist and the patient: someone who leaves the marketing to the pros. I haven’t written in years and I really didn’t anticipate picking up the old pen (i.e. keyboard) and doing the dirty work.

I mean, didn’t I create this comic book to communicate without words? I’m tired of hearing myself talk about my health and I’m no fan of listening to others talk about theirs. In fact, I have moments of complete clarity while I make eye contact and nod to longwinded, animated and punctuated stories of other diabetics. I think, I must sound just like this. Admittedly, I am much more interested and entertained by my own stories than anyone else. I have a slight phobia of developing Munchausen’s or hypochondria, it’s true.

I started at what I thought was the top, the American Diabetes Association, Juvenile Diabetes Association, Boston’s Joslin, and all their many publications. People liked it, said they laughed, wanted one for their diabetic friend, but it was nothing that could be endorsed or sold by the professional medical community. And that’s when it became clear to me: I was trying to sell the book to the wrong audience. I was spinning my wheels marketing to the people who I thought could pass it on to the people who would most appreciate it. I was adding one additional step that was doing nothing more than crushing my ego and enthusiasm. It was so empowering to turn the table around and judge them. Do I even want their approval or their endorsements? To me, a very attractive thing about the book is that it’s deviant and secretive. Do I really want to cut and shape it to fit into the box? Answering ‘no’ of course, I’ve had to think about the book from an entirely different perspective. I’ve had to define for myself the purpose of the book and the desired outcome of my work. This is more thinking than I’ve done in years. (As an aside, anything stressful makes me crave sugar and I’ve gained 15 pounds.)

When it comes to communicating with others about diabetes, I wholeheartedly believe in the need for opening up new approaches and energies to dealing with the disease. I find that illustration works best for me. I believe cartoons can really reach people who are reluctant to embrace traditional supports and therapies. The art-therapy aspect of it is really amazing for me; it’s quite soothing to squirrel myself away and gnaw on these bitter nuts I’d been storing my whole life. So, not only are the cartoons a way for me to confront and accept things, but they have given me a way to tell other people about it. People ask questions after they read the book; it starts dialog. My book has a sense of honesty that is rare. Rare, approachable and necessary.

Motivation is not a bottomless well.

Thanks so much, Haidee!

Please support Haidee by adding her book to your collection of D books – or to give as a gift to a diabetic you know and love! Get One Lump Or Two: Things That Suck About Being Diabetic from Haidee’s website: www.HaideeMerritt.com

Group Shot (appropriated from Allison!)

On the Train to NYC

As has been reported elsewhere, Sunday was a big D meet-up in New York City. Jason and I set out at 8:30 to drive to the train station in Central New Jersey to catch a 9:36 train to New York. I am notoriously late for just about everything, which drives Jason nuts, so there was a tone of ‘aren’t-you-glad-I-insisted-we-leave-on-time?’ as we pulled up to an oddly long line of cars at the parking garage of the train station. While he waited in line, I jumped out to go get our tickets, and soon enough, it was apparent to me why there was such a ridiculous amount of people waiting for the train on a Sunday morning – the Phillies were playing the Yankees in New York.

We were the first people to get on the train, so we got comfy in our seats while the other bazillion people boarded and tried to find seats together. Our uneventful trip ended at Penn Station in New York just before 11AM. We made our way out, and I snapped a few pictures of the Phillies fans, just because I thought it was cool to see so many of them in NYC.

Phillies Fans Overtaking the NYC Subway

The agreed upon time to meet was 11:45, so we had plenty of time as we began to walk the twelve or so blocks towards Marseille, the restaurant that Allison, our party planner, chose for our gathering. The weather was beautiful, albeit just a bit warm as we walked up 7th Avenue. A few blocks short of our destination, I heard, “Lee Ann!” and there was Val, who had also arrived by train a little early.

Once we arrived at the restaurant, we stood outside, and the diabetics started to arrive. Tia, then Wendy, then Brenda and her SO, followed by Allison and her man, Erik, Erica, Cara and her friend, and as soon as we got seated, Amylia and Chuck. It was a sizable group considering a good many people had had to decline the invitation due to previous Memorial Day weekend obligations.

Allison caught me taking a candid shot

As seems to be the case with large groups of diabetics, there was plenty of conversation about pumps, CGM systems, insurance coverage, highs, lows, and a wealth of frustrations that only people who live it can truly understand. I was worried Jason would die of boredom, but he even chipped in his two cents a few times. Next time, I’ll have to make sure he’s sitting closer to the other type 3’s so he can also enjoy the experience of commiserating with people who “get it” – it being the never-ending nonsense that comes with trying to be there for a diabetic loved one.

The food was delicious. The multigrain waffles with strawberries sounded heavenly, but I was a little more carb-conservative with my asparagus-goat cheese omelet and bagel. A few people splurged though, opting for those waffles, and some French toast which made my BG jump just looking at it – a stack of thick slabs of bread coated in crushed cereal, topped with sautéed bananas and maple syrup. Jason and I had plans to go to a barbeque once we got home later that afternoon, so I knew there were far more carbs than I ordinarily consume in the near future – otherwise I would have been all about the waffles.

Drooling over Dessert

I also skipped dessert, but wasn’t shy about drooling over the desserts that were ordered. One of them looked like layers of chocolate, which I would have happily sampled, but lucky for me it was coffee-flavored and I don’t do coffee or coffee-flavored anything. As you can see, I snapped a picture of the dessert menu just because I’m weird like that.

Chuck impressed me with his dedication to working out. I hoped that a little of his enthusiasm for it would rub off on me by sitting next to him, but if it did, it’s having a delayed effect. Wendy shared her experience with Dexcom, which made me all the more anxious for the anticipated integrated Animas-Dexcom system so I can trade in my Minimed version. I was really happy to meet Tia, a fellow fruit-lover, who is studying to be an optometrist. Brenda explained to me how she’s been educating people locally about the DOC by speaking at health fairs and offering poster presentations.

I was bummed that I didn’t have more of an opportunity to chat with Cara because she had been sitting at the opposite end of the table, but we did get to talk for a few minutes and got a couple of pictures. She seriously couldn’t have been any nicer, and I’m hoping she makes her way to Philly sometime so we can spend more time together. Amylia and I had some time to chat, which was cool. She is super nice, definitely someone I could see myself hanging out with if we lived closer, but since we don’t, I was thrilled to at least get to meet her. Needless to say, I was delighted to see Erica, Val and Allison again.

After eating, we snapped lots of pictures before everyone was on their way. Jason and I headed to Penn Station with Val, Wendy, Brenda and Frank, although, I didn’t get to say a proper good-bye because we were hustling to catch our train since we still had to get to the barbeque.

A huge thanks to Allison for putting it all together. It was an awesome time – good food, seeing some “old” friends, and making some new ones. I couldn’t have asked for more!

Amylia and Me

Me and Cara

I haven’t had an encounter with The Fear in a while. I actually can’t recall the last time I had it or what might have triggered it. I do get pretty spooked before my bi-annual nephrologist appointments, but not to the extent that I used to get freaked, expecting to be told I’d slid a little closer to dialysis and the transplant list, nothing the gracious donation of an organ couldn’t fix. However, she’s assured me things are stable, and that based on her experience, she expects my kidneys to stay stable. While that hasn’t completely alleviated my pre-appointment anxiety, it’s made a big difference.

Monster Under My Bed (from: Cedric Hohnstadt Illustration)

The Fear, of course, is the shadow lurking in the corner, the monster under the bed, the boogeyman waiting to lunge out of the closet just when I’m feeling safe and secure in the bed of diabetes life, which is hardly the most comfy, pillowy mattress ever, but I’ve come to tolerate it enough to catch a decent night’s sleep on occasion. The Fear is what I feel when I think some complication of horrific magnitude has come to snatch me from safety and tote me off into scary uncertainty.

I used to live with The Fear because I didn’t understand that I had a choice. How much to teach kids about complications is fodder for another post, but I had learned about them as a kid at camp initially. I don’t know if the caveat that I could avoid them if I took care of myself was ever offered or not, but I, with my infinite child logic (see yesterday’s post…), took away the message that blindness, amputations, kidney failure, and premature death were essentially as much a part of diabetes as taking insulin and exchange diets. I was wrong about everything except the insulin, but for years, as certain as I know insulin stinks to high heaven, I was certain that I would be dead by age 30. That prophecy didn’t come to pass though. There was a point maybe in my mid-20’s, when I updated the prophecy to age 40, but as I stared down the barrel of my 30th birthday with my sexy new boyfriend, Jason, on my arm, it occurred to me that maybe I’d been mistaken to think such an early death was inevitable.

That’s about the time I got serious about getting myself together and figuring out how to manage my diabetes the way it was meant to be done. Of course, I’d been screwing with it – and dragging my poor body along for the ride – for so long, that it took me a couple more years to slay the demons who eventually had to concede that I was leaving them for good. Living without those demons has been an awesome experience thus far, but The Fear still stops in for a visit on occasion.

I like to have a treat at night, so around midnight last night, I broke open the cellophane wrapper of a 37g carb pastry. My BG was sitting at 105mg/dL, so I did a combo bolus to account for the fat and keep my BG from dropping before the sugar hit my bloodstream. At about 1AM, Jason went to brush his teeth, and I would’ve done the same, except I started to feel a low coming over me. The pastry carbs were MIA. I thought about a cup of milk, but opted for a sugar-free pudding instead because that’s the same number of carbs. In retrospect, maybe that wasn’t the best choice, but I knew I had pastry sugar waiting to charge through my system, so I didn’t feel the same sense of urgency that would have steered me towards the juice carton otherwise.

I ate my pudding and waited. At some point, I started to not feel so good, like kind of nauseous, an odd symptom I get with lows sometimes, so I checked my sugar. 61mg/dL. I really wanted to go to bed, but I needed my BG to not be low. It had been about two hours since I’d eaten the pastry, and maybe an hour since I’d eaten the pudding. Why the heck wasn’t my BG coming up? I was getting frustrated, especially since the nausea wasn’t lifting, so I got some cookies out of the cabinet. I didn’t measure or weigh or count. I wanted my BG to rise enough so I could go to sleep, so I just ate until all that remained were crumbs. I checked my BG. 55mg/dL.

Just Crumbs

That’s when The Fear arrived. I’d eaten all this carby food, and my BG had been hovering too low for almost two hours. I had bolused for the pastry, but never bolused for the pudding or the cookies, which had to have totaled at least 70g carbs. The only logical explanation was that my food wasn’t digesting. Gastroparesis ?? Could it be? There are times when I suspect I have some delayed digestion. Before meals, if my BG is low or within target range, I bolus after I eat more often than not, and I don’t typically get dramatic post-prandial spikes. I also use the combo bolus feature with almost every meal. If I took my entire bolus before I ate, I’m pretty sure I’d end up with a lot of post-meal lows. If I have slowed digestion, that doesn’t even really upset or worry me. What worries me is if it progresses to full-blown gastroparesis with the nausea, vomiting, weight and appetite issues – and the unpredictability of how to bolus for food if you don’t know if or when it’s going to be digested.

Although this one instance of carbs that aren’t kicking in is flimsy evidence, I do already have autonomic neuropathy. It’s affected my heart. I’ve had some unfortunate incidences of diabetic diarrhea. One of these days, I might cover that topic if I can figure out how to write about it without embarrassing myself or completely grossing you out. I’ve also had some sexual function/lady parts issues that I can only attribute to diabetes, yet another sensitive topic I’ve skirted. And these are issues that started close to 15 years ago, so would it be a surprise if my stomach also wasn’t functioning optimally, especially in light of having been bulimic for 18 years? Honestly, if last night was a sign of gastroparesis, it’s a wonder it hasn’t developed sooner.

By the time I went to bed, about 3AM, I wasn’t feeling low anymore, but I wasn’t sure how to bolus for the food I’d eaten over the course of the previous three hours. I told myself that perhaps I was just having one of those fluky nights when no matter what I do, I’m low. Even people without gastroparesis get days like that because sometimes diabetes just does it’s own inexplicable thing. If that were the case though, and I fully bolused for the carbs I had consumed, I might be facing some fierce early morning lows. I erred on the conservative side, assuming that at least some of the carbs were going to hit me eventually, and I took a small bolus of 1.5u. Then, I brushed my teeth, crossed my fingers, and got into bed.

The Next Morning

Naturally, I spent most of the morning being awoken by the CGM siren, periodically silencing it, and hoping it wasn’t bothering Jason too much. At 6:30AM I bolused 3.5u, hoping that would bring me down. Jason got up, got ready and left for work, and the siren was still blaring, kindly alerting me to the RISE RATE and the HIGH SG. I checked my CGM, and my BG was maxed out. Not good. Not good at all. I bolused 4u, and hoped that would do the trick and I could sleep in peace for just a little bit longer.

A few minutes before 10AM, the siren was still ringing out from under the covers. I looked at my CGM monitor, I looked at the clock, and decided that even if I tried to salvage any more sleep, it wouldn’t be peaceful. I felt like crap, I had a headache, and I felt like I’d licked the lint filter in the clothes dryer, so I trudged downstairs to see what my BG was, and take yet another bolus. 245mg/dL. Not horrific, but obviously not good. I tried not to think about what my BG had been 7.5u of insulin ago, while I programmed another 2.9u.

The Fear is gone, but I’m concerned. As I ate lunch a short time ago, I panicked for a moment, wondering if my food was going to digest. Was I over-reacting last night to assume this was a sign of gastroparesis? Do I wait and see if I have more incidents like this? Do I assume it’s just diabetes being diabetes, or do I follow-up and make sure it isn’t anything more foreboding? Maybe I was jumping to conclusions. Maybe I was being irrational because my BG was low. Having had diabetes for 31 years, and having already experienced problems as a consequence of not managing it well in the past, it’s hard to not let The Fear get the best of me sometimes. The Fear doesn’t need a reason to intrude though. If I listened to it every time it crawled out of the woodwork, I’d spend my life in and out of doctors’ offices and medical testing facilities, chasing every little hiccup and twitch like they were signs I was dying. I know I need to be cautious and proactive when it’s justified, but I also know I can’t let The Fear order me around. The problem is distinguishing when I should pay attention to it, and when I should know that The Fear is only trying to scare me.

It’s another edition of Thesis Thursday, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study. Last week, I posted the first section of Chapter 2: Literature Review which included the Overview, and sections on Health Psychology and Adolescent Physical Development. This week is the next section of Chapter 2: Literature Review, a general discussion of cognitive development in adolescence.

Cognitive

Strasburger and Brown (1998) state that Piaget’s theory of cognitive development is the most widely accepted. Piaget believed that an individual’s experience with objects and people results in general ways of understanding the world. “This understanding changes during development as thinking progresses through various stages from birth to maturity” (Miller, 1993, p. 30). “Each stage holds both the fruits of the past and the seeds of the future” (Miller, 1993, p. 42).

While this review of the literature is specifically about the adolescent stage of development, it is necessary to garner an understanding of the previous stages of cognitive development. Piaget is considered a structuralist, and was thus “concerned with relationships—between parts and the whole and between an earlier and a later stage (Miller, 1993, p. 37). The invariant stages “involve changes in the structure of thought” (Miller, 1993, p. 104), one stage building upon the previous stage(s). “Experience brings cognitive progress through assimilation and accommodation” (Miller, 1993, p. 105).

The first stage of Piaget’s theory of cognitive development is the sensorimotor period, roughly the first two years of life. “Infants understand the world in terms of their overt, physical actions… They move from simple reflexes through several steps to an organized set of schemes (organized behaviors)” (Miller, 1993, p. 42). The sensorimotor period is broken into six stages, the first of which is modification of reflexes, the first month of life (Miller, 1993, p. 43). “Behavior is characterized by inborn reflexes (i.e., rooting, sucking, grasping), which become more efficient and combine with each other to form primitive schemes (Pulaski, 1980, p. 214). The infant has “no awareness of self as such or of the distinction between self and the outer world” (Pulaski, 1980, p. 214).

The second stage of the sensorimotor period is primary circular reactions, one to four months (Miller, 1993, p. 44). “The baby discovers an interesting result from some behavior and then attempts to recapture the result” (Miller, 1993, p. 44). The infant is defining the limits of his own body, repeating movements to prolong interesting and pleasurable experiences, and combining movements “to form a more complex organization of behavior called prehension” (Pulaski, 1980, p. 214).

The next stage, characterizing infants, four to eight months, is secondary circular reactions (Miller, 1993, p. 45). “Secondary circular reactions are oriented to the external world” (Miller, 1993, p. 45), rather than to the infant’s body as in the primary circular reaction stage. “He uses habitual schemes in a ‘magical’ way, as if he considers his actions capable of causing unrelated external events to happen” (Pulaski, 1980, p. 214). Due to the integration of vision and grasping (Miller, 1993, p. 46), he can reach for objects that he sees, “but out of sight is out of mind” (Pulaski, 1980, p. 214). With the coordination of schemes, “the cognitive structures are becoming increasingly integrated and organized” (Miller, 1993, p. 46).

Coordination of secondary schemes, from eight to twelve months, is the fourth stage of the sensorimotor period (Miller, 1993, p. 46). This stage is characterized by the emergence of intentional behavior, the ability to recognize and reach for partly concealed objects, and the combining and coordination of familiar schemes to fit new situations (mobile schemes) (Pulaski, 1980, p. 215). Additionally, “the infant can now use objects as instruments to obtain a goal” (Miller, 1993, p. 46), and “his anticipatory behavior and his imitation of sounds and actions reveal the beginnings of memory and representation” (Pulaski, 1980, p. 215).

The stage from twelve to eighteen months is tertiary circular reactions (Miller, 1993, p. 47). During this stage of cognitive development, the infant can “deliberately vary an action in order to see how this variation affects the outcome”, and he can “exploit each object’s potential” (Miller, 1993, p. 47). The infant can “follow visible displacement of an object being hidden, and finds it where it was last seen… [and] he recognizes pictures of familiar persons or objects and can follow simple verbal directions” (Pulaski, 1980, p. 215).

The final stage of the sensorimotor period is invention of new means through mental combinations, approximately eighteen to twenty-four months (Miller, 1993, p. 48). “External mental exploration gives way to internal mental exploration… because the child can now use mental symbols to represent objects and events” Miller, 1993, p. 48). The child knows that objects exist even if he cannot see them, he begins to “use symbols in language and make-believe play, he remembers past events and imitates them at a later time, [and] he shows purpose, intention, and the beginnings of deductive reasoning, along with a primitive understanding of space, time and causality” (Pulaski, 1980, p. 215).

The second stage is the preoperational period, approximately age two to seven. Children no longer make simple perceptual and motor adjustments to objects and events. They can now use symbols (mental images, words, gestures) in an increasingly logical and organized fashion to represent objects and events (Miller, 1993, p. 42). The preoperational period is broken into two stages, the first of which is the preconceptual stage (two to four years old). The child’s thinking is still egocentric; he cannot conceive that another person has a different experience or view than his own. “He assumes that all natural objects are alive and have feelings and intention because he does” (Pulaski, 1980, p. 215). The second stage of the preoperational period is the prelogical or intuitive stage (four to seven years old).

Prelogical reasoning appears, based on perceptual appearances… Trial and error may lead to an intuitive discovery of correct relationships, but the child is unable to take into account more than one attribute at a time… Language is used in an egocentric way. (Pulaski, 1980, p. 216)

The concrete operational period, about age seven to eleven, is the third stage of development. “Children acquire certain logical structures that allow them to perform various mental operations, which are internalized actions that can be reversed” (Miller, 1993, p. 42). He can classify objects into groups, arrange them in a series, and he has also “achieved conservation, and recognizes that a cup of milk is the same amount, whether seen in a tall, narrow glass, or a short, wide one” (Pulaski, 1980, p. 216).

The final stage of Piaget’s theory of cognitive development is the formal operational period, approximately age eleven to fifteen. “Mental operations… can be applied to purely verbal or logical statements, to the possible as well as the real, to the future as well as the present” (Miller, 1993, p. 42). Formal operational thought enables an individual to “reason logically about abstract propositions, things or properties that he has never directly experienced… [He] is capable of deductive and inductive reasoning… His knowledge of the problem may be purely hypothetical, yet he is able to reason it through to a logical conclusion” (Pulaski, 1980, p. 216).

“The early and midteen years are characterized by the movement from concrete to abstract operations,” formal operational thought (Hofmann & Greydanus, 1989, p. 11). Concrete thinking is characterized by lack of the ability “to extract general principles from one experience and to apply them to a wholly new experience” (Hofmann & Greydanus, 1989, p. 11). “Moral concepts are limited to co-opting existing societal rules” (Hofmann & Greydanus, 1989, p. 11).

According to Strasburger and Brown (1998), formal operational thought, not fully achieved until age 15 or 16, is characterized by the abilty to generate abstractions, hypotheses, and all possibilities from a specific situation. They also characterize this stage of cognitive development with the ability to consider contrary-to-fact situations, approach problems in a systematic fashion, and use combinatory logic.

“Early in the development of formal operational thought, the adolescent has not yet achieved mastery” (Strasburger and Brown, 1998, p. 6). This manifests itself through egocentrism and apparent hypocrisy (“ the adolescent can conceptualize abstract rules but is unable to apply them consistently to himself or herself” [Strasburger and Brown, 1998, p. 6]). There’s also the personal fable, a belief that risks and consequences do not apply to him, which can lead to risk-taking behaviors, characteristic of adolescence (Strasburger and Brown, 1998).

“The abilty to consider abstract ideas, the future, and various possibilities is evident in adolescents’ social world” (Miller, 1993, p. 63). They consider and can experiment with various occupational and societal roles. They spend time thinking about and discussing societal, moral and political issues, and are able to see such issues from different perspectives. “However, there is still a lingering egocentrism. Adolescents are impressed with the power of thought and naively underestimate the practical problems involved in achieving an ideal future for themselves or for society” (Miller, 1993, p. 62).

Hofmann and Greydanus (1989) assert that not everyone even achieves formal operational thought; “thirty percent of the normal populace never become abstract thinkers” (p. 14). Furthermore, “persons who are capable of formal thought do not use it all the time… Judgement and rationality may succumb to irrationality stemming from stress and anxiety factors or chronic maladaptive patterns” (Hofmann and Greydanus, 1989, p. 14).

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