Resolve ADHD to improve diabetes self-management
Many people with type 1 diabetes also live with attention-deficit/hyperactivity disorder. When they imagine ADHD, most people think of a child who can’t sit still in class. However, ADHD is often not accompanied by a hyperactive/impulsive presentation. Whether diagnosed or undiagnosed, ADHD impairs one’s ability to focus and to remember and retain information, which makes managing diabetes extremely difficult.
ADHD, particularly the subtype not associated with hyperactivity or impulsivity, is common in type 1 diabetes, and research suggests that many people who were diagnosed before age 17 years have some level of ADHD with predominantly inattentive presentation. Several studies show a correlation between the age at diagnosis and severity of inattentive symptoms, including a decrease in intelligence, attention, processing speed, long-term memory, executive function and self-monitoring.
Some research points directly to severe hypoglycemia, particularly in young children, as being the most plausible explanation for the neuropsychological deficits. Although more studies are needed to examine the effect of chronic hyperglycemia on children’s neurologic development, there are studies that show a negative effect on brain development from hyperglycemia and hypoglycemia.
Other studies have shown scarring of the brain’s frontal lobe and a significant reduction in gray matter in individuals who are diagnosed with diabetes during early development. Most patients who begin psychotherapy with me are struggling to manage their diabetes and tend to show deficits in all areas of mental acuity.
Self-deprecating thoughts, like “I’m useless,” cross some patients’ minds as they continually forget to do what seem like simple management tasks. At the end of a day, they may have done almost nothing to take care of their diabetes, not realizing the effect of ADHD.
ADHD is a psychiatric illness that causes constant distraction from doing what is needed to manage diabetes, but it can be quiet and even go unrecognized. After all, teasing out the cognitive impairments between high blood glucose and ADHD can be difficult. Many people living with ADHD are successful at work and at doing things they love.
Recognizing and understanding the influence of ADHD can limit its negative effects on diabetes self-management. ADHD with predominantly inattentive presentation is not a constant deficit of one’s ability to focus or pay attention. Attention manifests in two states: hyperfocus and hypofocus. During the hyperfocus mode, the patient experiences an intense form of mental concentration on a thought or behavior of interest. This includes daydreams, memories, work, hobbies, and other wants or desires. During the hypofocus mode, the patient experiences a severe lack of focus brought on by mental or physical exhaustion after a period of hyperfocus or avoidance of undesirable tasks. This includes facing painful realities, reading instructional manuals or performing any activity the patient doesn’t want to do. The inattentiveness found in ADHD presents as a type of avoidance that can be interpreted as procrastination.
The more emotional patients become about their diabetes, or in general, the stronger inattentiveness becomes. If patients come to accept their diabetes or reduce their anger and resentment about having the disease, inattentiveness can be reduced, improving active diabetes management.
However, a reduction of negative emotions will not resolve every aspect of ADHD that affects diabetes management. Some behavioral issues that stem from years of living in this pendulum of hyper- and hypofocus can be addressed with cognitive behavioral therapy. Other aspects of inattention are beyond patients’ control.
The primary sabotaging symptom of ADHD is constant forgetfulness, more appropriately described as “thought slippage.” With thought slippage, information is unable to stay in short-term memory. For example, a motivated patient thinks, “I need to check my blood sugar,” then a split second later he or she has forgotten to test. It is 30 minutes later, and the patient has the same thought and remembers the forgotten glucose check; then a split second later that thought is gone. It’s 3 hours later, and the patient still has not performed a blood glucose check and it is dinner time. Frustrated and annoyed at himself, the patient may or may not check his blood glucose before taking insulin.
During the hyperfocus state, people living with diabetes have a tendency to ignore or not notice what is happening in their environment or with their body, and they can miss symptoms of hypoglycemia. Their pump or continuous glucose monitoring alarms may go off, but until they have completed the task they’re hyperfocused on, they will take no action to resolve the alarms. Such a heightened state of focus causes patients to avoid the rest of the world around them.
After patients with ADHD are diagnosed and treated to resolve the attention issues, they can be expected to improve in all of the above areas of functioning, including diabetes management. Medication can help remove some blocks that interfere with diabetes management, but patients still have work to do. Once on medication, patients still need to understand the emotional issues that trigger symptoms of ADHD and adjust their focus toward diabetes management.
Based on current research and clinical observation, there is no doubt that ADHD with predominantly inattentive presentation and early-onset type 1 diabetes are comorbid issues. It is important to identify ADHD early on to prevent long-term complications in patients with diabetes. Once a patient receives the correct ADHD treatment, it is important to follow up with psychotherapy and diabetes self-management education. In many cases, the cognitive issues need to be addressed before education and management can take hold.
- Katon WJ, et al. Ann Fam Med. 2013;doi:10.1370/afm.1501.
- Northam EA, et al. Diabetes Care. 2001;24:1541-1546.
- Perantie DC, et al. Diabetes. 2011;doi:10.2337/db11-0589.
- For more information:
- Eliot LeBow, LCSW, CDE, is a diabetes-focused psychotherapist, presenter, author and founder of DiabeticTalks and Diabetes-Focused Psychotherapy. His private practice is in New York City and is also available via Skype. LeBow, who has been living with type 1 diabetes since 1977, treats the many diverse cognitive, behavioral and emotional needs of people living with diabetes. He can be reached at: firstname.lastname@example.org.
Disclosure: LeBow reports no relevant financial disclosures.