Diabetes Distress in Adolescents and Young Adults Living With Type 1 Diabetes

Abstract

Key Messages•Diabetes distress is a normal aspect of living with diabetes and can fluctuate over time.•Adolescence and young adulthood can be challenging life periods, and this age group may require extra support.•The management of distress needs to be acknowledged and addressed within the mainstream of person-centred, comprehensive youth diabetes care. •Diabetes distress is a normal aspect of living with diabetes and can fluctuate over time.•Adolescence and young adulthood can be challenging life periods, and this age group may require extra support.•The management of distress needs to be acknowledged and addressed within the mainstream of person-centred, comprehensive youth diabetes care. The self-management of type 1 diabetes (T1D) represents an additional challenge to the usual developmental tasks of adolescence and young adulthood. In our current work, D1 Now (1Walsh D.M. Hynes L. O'Hara M.C. McSharry J. Dinneen S.F. Byrne M. Embedding a user-centred approach in the development of complex behaviour change intervention to improve outcomes for young adults living with type 1 diabetes: The D1 Now Study.HRB Open Res. 2018; 1: 8Crossref PubMed Google Scholar), we are developing and piloting an intervention to improve outcomes in young adults (18 to 25 years) living with T1D in Ireland. Part of this work involves screening young adults for diabetes distress with the Diabetes Distress Scale (2Polonsky W.H. Fisher L. Earles J. et al.Assessing psychosocial distress in diabetes: Development of the diabetes distress scale.Diabetes Care. 2005; 28: 626-631Crossref PubMed Scopus (691) Google Scholar), and this has led to conversations with clinical diabetes staff around recognizing, managing and supporting young people with elevated levels of diabetes distress. The aim of this paper is to provide an overview on the prevalence and sources of diabetes distress in adolescents and young adults and to discuss the issues around screening and managing distress in the diabetes clinic. Diabetes distress (hereafter referred to as distress) can be conceptualized as the negative emotional burden of living with diabetes (3Polonsky W.H. Anderson B.J. Lohrer P.A. et al.Assessment of diabetes-related distress.Diabetes Care. 1995; 18: 754-760Crossref PubMed Scopus (825) Google Scholar). Much of the research on the emotional side of diabetes to date has focused on depression. However, although rates of depression are higher in individuals with diabetes than the general population (4Anderson R.J. Freedland K.E. Clouse R.E. Lustman P.J. The prevalence of comorbid depression in adults with diabetes.Diabetes Care. 2001; 24: 1069-1078Crossref PubMed Scopus (2758) Google Scholar), it is increasingly clear that distress is a distinct emotional construct rooted in the worries, fears and concerns of individuals contending with a chronic condition (5Fisher L. Gonzalez J.S. Polonsky W.H. The confusing tale of depression and distress in patients with diabetes: A call for greater clarity and precision.Diabet Med. 2014; 31: 764-772Crossref PubMed Scopus (235) Google Scholar). It is not a psychiatric disorder, although, if left untreated, its persistent and pervasive nature can result in more generalized negative affect (6Skinner T.C. Joensen L. Parkin T. Twenty-five years of diabetes distress research.Diabet Med. 2020; 37: 393-400PubMed Google Scholar). Traditionally seen as a complication of diabetes, Gonzalez and colleagues postulated that distress is more appropriately viewed as the emotional aspect of living with this demanding condition (7Gonzalez J.S. Fisher L. Polonsky W.H. Depression in diabetes: Have we been missing something important?.Diabetes Care. 2011; 34: 236-239Crossref PubMed Scopus (160) Google Scholar). The same authors suggested that distress exists on a single continuous dimension that is characterized by content and severity (5Fisher L. Gonzalez J.S. Polonsky W.H. The confusing tale of depression and distress in patients with diabetes: A call for greater clarity and precision.Diabet Med. 2014; 31: 764-772Crossref PubMed Scopus (235) Google Scholar). The content can be made up of distress in relation to diabetes and self-management (e.g. fear of hypos) but also distress related to other life stressors (e.g. family, finances) and distress from other causes (e.g. life history, genetics). It is important not to lose sight of the nondiabetes-related causes of distress because these can often impact on self-management and diabetes-related difficulties. The severity of distress can fluctuate throughout the lifespan (5Fisher L. Gonzalez J.S. Polonsky W.H. The confusing tale of depression and distress in patients with diabetes: A call for greater clarity and precision.Diabet Med. 2014; 31: 764-772Crossref PubMed Scopus (235) Google Scholar). It is estimated that about one-third of adults with T1D are living with elevated levels of distress at any one time (8Sturt J. Dennick K. Hessler D. Hunter B.M. Oliver J. Fisher L. Effective interventions for reducing diabetes distress: Systematic review and meta-analysis.Int Diabetes Nurs. 2015; 12: 40-55Crossref Google Scholar). This one-third figure is also reflected in the rates of distress seen in adolescents living with T1D (9Hagger V. Hendrieckx C. Sturt J. Skinner T.C. Speight J. Diabetes distress among adolescents with type 1 diabetes: A systematic review.Curr Diab Rep. 2016; 16: 9Crossref PubMed Scopus (104) Google Scholar). Although no meta-analytic work has been done on the rates of distress within the young adult population, 2 studies have estimated the prevalence to be 28% and 32%, respectively (10Lašaitė L. Dobrovolskienė R. Danytė E. et al.Diabetes distress in males and females with type 1 diabetes in adolescence and emerging adulthood.J Diabetes Complications. 2016; 30: 1500-1505Crossref PubMed Scopus (21) Google Scholar,11Hislop A.L. Fegan P.G. Schlaeppi M.J. Duck M. Yeap B.B. Prevalence and associations of psychological distress in young adults with Type 1 diabetes.Diabet Med. 2008; 25: 91-96Crossref PubMed Scopus (90) Google Scholar). Higher levels of distress are significantly associated with poorer self-management behaviours, such as less physical activity, poorer diet and insulin restriction (12Sturt J. Dennick K. Due-Christensen M. McCarthy K. The detection and management of diabetes distress in people with type 1 diabetes.Curr Diab Rep. 2015; 15: 101Crossref PubMed Scopus (50) Google Scholar). Higher levels of distress have also been consistently shown to be associated with poorer clinic outcomes, in particular, glycemic control (12Sturt J. Dennick K. Due-Christensen M. McCarthy K. The detection and management of diabetes distress in people with type 1 diabetes.Curr Diab Rep. 2015; 15: 101Crossref PubMed Scopus (50) Google Scholar,13Law G.U. Walsh J. Queralt V. Nouwen A. Adolescent and parent diabetes distress in type 1 diabetes: The role of self-efficacy, perceived consequences, family responsibility and adolescent–parent discrepancies.J Psychosom Res. 2013; 74: 334-339Crossref PubMed Scopus (36) Google Scholar). It can also be a contributing factor to recurrent diabetic ketoacidosis, which tends to be most commonly seen in young women (see Garrett and colleagues for a recent review of the recurrent diabetic ketoacidosis literature) (14Garrett C.J. Choudhary P. Amiel S.A. Fonagy P. Ismail K. Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: Contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention.Diabet Med. 2019; 36: 1329-1335Crossref PubMed Scopus (13) Google Scholar). Most distress research to date has been done with people living with type 2 diabetes (12Sturt J. Dennick K. Due-Christensen M. McCarthy K. The detection and management of diabetes distress in people with type 1 diabetes.Curr Diab Rep. 2015; 15: 101Crossref PubMed Scopus (50) Google Scholar), who can have very different experiences and challenges to people living with T1D. However, some work has been done to investigate what exactly are the contributing factors to distress in adults living with T1D. Fisher and colleagues used an exploratory factor analysis to identify 7 sources of distress for people living with T1D (15Fisher L. Mullan J.T. Arean P. Glasgow R.E. Hessler D. Masharani U. Understanding the sources of diabetes distress in adults with type 1 diabetes.J Diabetes Complications. 2015; 29: 572-577Crossref PubMed Scopus (140) Google Scholar). These included a sense of powerlessness, negative social perceptions, physician-caused distress, relationships, fear of hypoglycemia, self-management and eating distress. These sources of distress form the subscales of one the first distress scales for adults with T1D, the Diabetes Distress Scale---Type 1 (DDS-T1) (15Fisher L. Mullan J.T. Arean P. Glasgow R.E. Hessler D. Masharani U. Understanding the sources of diabetes distress in adults with type 1 diabetes.J Diabetes Complications. 2015; 29: 572-577Crossref PubMed Scopus (140) Google Scholar). Looking more specifically at younger people living with T1D, Balfe and colleagues conducted qualitative interviews with 35 young adults (aged 23 to 30 years) living with T1D in Ireland (16Balfe M. Doyle F. Smith D. et al.What's distressing about having type 1 diabetes? A qualitative study of young adults' perspectives.BMC Endocr Disord. 2013; 13: 25Crossref PubMed Scopus (63) Google Scholar). They reported that distress is most commonly triggered by self-consciousness, fear of being mistaken as having type 2 diabetes, day-to-day management struggles, difficulties with the health-care system, concerns about complications and the future and apprehension about pregnancy. The young adults felt that talking to diabetes health-care professionals about distress reduced its impact and should be a part of standard care. There has been little qualitative research done with adolescents with T1D about their experiences of distress. It is worth noting that distress levels are often found to be higher in females than males (10Lašaitė L. Dobrovolskienė R. Danytė E. et al.Diabetes distress in males and females with type 1 diabetes in adolescence and emerging adulthood.J Diabetes Complications. 2016; 30: 1500-1505Crossref PubMed Scopus (21) Google Scholar,12Sturt J. Dennick K. Due-Christensen M. McCarthy K. The detection and management of diabetes distress in people with type 1 diabetes.Curr Diab Rep. 2015; 15: 101Crossref PubMed Scopus (50) Google Scholar,15Fisher L. Mullan J.T. Arean P. Glasgow R.E. Hessler D. Masharani U. Understanding the sources of diabetes distress in adults with type 1 diabetes.J Diabetes Complications. 2015; 29: 572-577Crossref PubMed Scopus (140) Google Scholar); however, it is unclear whether that is due to a true increased rate or a reflection of different coping strategies (e.g. females are more likely to talk about and seek support for distress) that could underlie gender-specific differences (10Lašaitė L. Dobrovolskienė R. Danytė E. et al.Diabetes distress in males and females with type 1 diabetes in adolescence and emerging adulthood.J Diabetes Complications. 2016; 30: 1500-1505Crossref PubMed Scopus (21) Google Scholar). As high levels of distress can be quite a debilitating burden for adolescents and young adults and as it is also likely to impact on other outcomes, such as self-management and glycemic control, several interventions have been developed for its reduction. A recent systematic review and meta-analysis of interventions targeting distress among adults with T1D included 41 randomized, controlled trials and concluded that there is sufficient evidence to support the use of psychoeducational interventions to reduce distress (8Sturt J. Dennick K. Hessler D. Hunter B.M. Oliver J. Fisher L. Effective interventions for reducing diabetes distress: Systematic review and meta-analysis.Int Diabetes Nurs. 2015; 12: 40-55Crossref Google Scholar). That review showed that psychoeducation focusing on diabetes and mood or targeting motivation, delivered in any format, was significantly associated with reduced distress at follow up. There is less evidence around interventions for distress specifically targeting adolescents or young adults. A recent systematic review of interventions targeting distress among adolescents identified only 4 randomized, controlled trials, precluding meta-analysis (9Hagger V. Hendrieckx C. Sturt J. Skinner T.C. Speight J. Diabetes distress among adolescents with type 1 diabetes: A systematic review.Curr Diab Rep. 2016; 16: 9Crossref PubMed Scopus (104) Google Scholar). In a narrative synthesis of intervention effectiveness, the authors concluded that there is some evidence that psychoeducational interventions, including cognitive restructuring, goal-setting and problem-solving, can reduce distress. It seems that interventions that have been developed based on theory and have a well-defined rationale for why they work are more likely to be effective (17Hampson S.E. Skinner T.C. Hart J.O. et al.Behavioral interventions for adolescents with type 1 diabetes: How effective are they?.Diabetes Care. 2000; 23: 1416-1422Crossref PubMed Scopus (109) Google Scholar). That review highlighted that, although interventions appear to show some promise for reducing distress in the short term, there is limited evidence about how to sustain these benefits in the longer term, or what may be needed for ongoing support for young people to reduce and prevent further distress (9Hagger V. Hendrieckx C. Sturt J. Skinner T.C. Speight J. Diabetes distress among adolescents with type 1 diabetes: A systematic review.Curr Diab Rep. 2016; 16: 9Crossref PubMed Scopus (104) Google Scholar). Preliminary findings from a study published since the publication of that review indicate that intervening with a psychoeducational intervention may be effective in preventing the development of distress in adolescents (18Hood K.K. Iturralde E. Rausch J. Weissberg-Benchell J. Preventing diabetes distress in adolescents with type 1 diabetes: Results 1 year after participation in the STePS program.Diabetes Care. 2018; 41: 1623-1630Crossref PubMed Scopus (24) Google Scholar). The review also highlighted that the few intervention studies conducted so far have been carried out largely in the United States, with relatively socioeconomically advantaged populations. Interventions are needed to target young people from more socioeconomically and ethnically diverse backgrounds. Several tools have been developed to measure distress. Two that are widely used to assess distress are the Problem Areas in Diabetes scale (PAID) and the Diabetes Distress Scale (DDS) (2Polonsky W.H. Fisher L. Earles J. et al.Assessing psychosocial distress in diabetes: Development of the diabetes distress scale.Diabetes Care. 2005; 28: 626-631Crossref PubMed Scopus (691) Google Scholar,3Polonsky W.H. Anderson B.J. Lohrer P.A. et al.Assessment of diabetes-related distress.Diabetes Care. 1995; 18: 754-760Crossref PubMed Scopus (825) Google Scholar). The PAID is a 20-item scale of diabetes-specific emotional distress that measures a wide range of feelings related to living with diabetes and its treatment, including guilt, anger, depressed mood, worry and fear. It is scored from 0 to 100, with higher scores indicating greater distress. A score of >40 is considered the threshold for elevated distress among adults (19Welch G.W. Jacobson A.M. Polonsky W.H. The Problem Areas in Diabetes Scale: An evaluation of its clinical utility.Diabetes Care. 1997; 20: 760-766Crossref PubMed Scopus (441) Google Scholar). In more recent years, the PAID has been adapted for adolescents (age 11 to 19 years old) with T1D. The PAID-Teen scale has 26 items that are rated on a 6-point scale (20Weissberg-Benchell J. Antisdel-Lomaglio J. Diabetes-specific emotional distress among adolescents: Feasibility, reliability, and validity of the problem areas in diabetes-teen version.Pediatr Diabetes. 2011; 12: 341-344Crossref PubMed Scopus (76) Google Scholar). It includes reference to unique developmental stressors, such as parents and friends. It is scored from 26 to 156 with a score >70 indicating moderate distress and a score >90 indicating high distress (21Hagger V. Hendrieckx C. Cameron F. Pouwer F. Skinner T.C. Speight J. Cut points for identifying clinically significant diabetes distress in adolescents with type 1 diabetes using the PAID-T: Results from Diabetes MILES Youth–Australia.Diabetes Care. 2017; 40: 1462-1468Crossref PubMed Scopus (10) Google Scholar). The PAID has not been adapted for young adults. The DDS is a 17-item scale that captures 4 dimensions of distress: emotional burden, regimen distress, interpersonal distress and physician distress (2Polonsky W.H. Fisher L. Earles J. et al.Assessing psychosocial distress in diabetes: Development of the diabetes distress scale.Diabetes Care. 2005; 28: 626-631Crossref PubMed Scopus (691) Google Scholar). It yields a total distress score as well as the 4 subscale scores. A mean item score of ≥3 on either the total score or any of the subscale scores is considered the cutoff for distress worthy of clinical attention (2Polonsky W.H. Fisher L. Earles J. et al.Assessing psychosocial distress in diabetes: Development of the diabetes distress scale.Diabetes Care. 2005; 28: 626-631Crossref PubMed Scopus (691) Google Scholar). Although the DDS has not been adapted for any specific age group, it has been adapted for T1D specifically. The DDS-T1 has 28 items rated on a 6-point scale (15Fisher L. Mullan J.T. Arean P. Glasgow R.E. Hessler D. Masharani U. Understanding the sources of diabetes distress in adults with type 1 diabetes.J Diabetes Complications. 2015; 29: 572-577Crossref PubMed Scopus (140) Google Scholar). It has 7 T1D-specific subscales, which have been mentioned previously. The DDS-T1 uses the same scoring system and cutoff points as the DDS. Both the PAID and the DDS are available in short form. Both versions of the PAID and the DDS report good psychometric properties and have been translated into various languages for widespread use. Although both scales measure the same construct, it has been noted that they bear significant differences (22Fenwick E.K. Rees G. Holmes-Truscott E. Brown J.L. Pouwer F. Speight J. What is the best measure for assessing diabetes distress? A comparison of the Problem Areas in Diabetes and Diabetes Distress Scale: Results from Diabetes MILES–Australia.J Health Psychol. 2018; 23: 667-680Crossref PubMed Scopus (19) Google Scholar,23Schmitt A. Reimer A. Kulzer B. Haak T. Ehrmann D. Hermanns N. How to assess diabetes distress: Comparison of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS).Diabet Med. 2016; 33: 835-843Crossref PubMed Scopus (50) Google Scholar). A comparison study conducted in Germany found that the PAID has a stronger focus on emotional concerns, diet and complications, which are closely associated with quality of life and depressive outcomes, whereas the DDS is more reflective of self-management and physician-related distress, which may explain its consistent associations with self-care and glycemic control outcomes (23Schmitt A. Reimer A. Kulzer B. Haak T. Ehrmann D. Hermanns N. How to assess diabetes distress: Comparison of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS).Diabet Med. 2016; 33: 835-843Crossref PubMed Scopus (50) Google Scholar). In summary, both scales have good psychometric properties and a justified decision should be made on which to use based on the clinical/scientific purpose (23Schmitt A. Reimer A. Kulzer B. Haak T. Ehrmann D. Hermanns N. How to assess diabetes distress: Comparison of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS).Diabet Med. 2016; 33: 835-843Crossref PubMed Scopus (50) Google Scholar). Regularly screening for distress using these scales can provide a pathway to acknowledge and deal with distress in the clinic, and its importance has been recognized in international guidelines (24Delamater A.M. de Wit M. McDarby V. et al.ISPAD Clinical Practice Consensus Guidelines 2018: Psychological care of children and adolescents with type 1 diabetes.Pediatr Diabetes. 2018; 19: 237-249Crossref PubMed Scopus (83) Google Scholar,25Young-Hyman D. De Groot M. Hill-Briggs F. Gonzalez J.S. Hood K. Peyrot M. Psychosocial care for people with diabetes: A position statement of the American Diabetes Association.Diabetes Care. 2016; 39: 2126-2140Crossref PubMed Scopus (356) Google Scholar). However, the value of labelling and measuring distress is controversial. Fears exist that using scales may "overpathologize" the emotional side of living with diabetes. Some health-care professionals fear that by labelling distress and providing a "number" for it, we are opening a "Pandora's Box," which may be difficult to close (7Gonzalez J.S. Fisher L. Polonsky W.H. Depression in diabetes: Have we been missing something important?.Diabetes Care. 2011; 34: 236-239Crossref PubMed Scopus (160) Google Scholar). Sturt and colleagues acknowledged that, unless local psychological care services and care pathways for distress exist, health-care professionals may be reluctant to uncover distress (12Sturt J. Dennick K. Due-Christensen M. McCarthy K. The detection and management of diabetes distress in people with type 1 diabetes.Curr Diab Rep. 2015; 15: 101Crossref PubMed Scopus (50) Google Scholar). Diabetes health-care professionals have identified barriers to addressing psychosocial concerns with patients, which include lack of time, privacy and knowledge (26Mosely K. Aslam A. Speight J. Overcoming barriers to diabetes care: Perceived communication issues of healthcare professionals attending a pilot Diabetes UK training programme.Diabetes Res Clin Pract. 2010; 87: e11-e14Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar). In addition, internationally >50% of diabetes teams would like to receive more training in this area (27Holt R.I. Nicolucci A. Kovacs Burns K. et al.Diabetes Attitudes, Wishes and Needs second study (DAWN2TM): Cross-national comparisons on barriers and resources for optimal care—healthcare professional perspective.Diabet Med. 2013; 30: 789-798Crossref PubMed Scopus (104) Google Scholar). It cannot be denied, however, that distress is a common component of the experience of diabetes and support cannot wait until the appropriate care pathways and training are in place. Gonzalez and colleagues (7Gonzalez J.S. Fisher L. Polonsky W.H. Depression in diabetes: Have we been missing something important?.Diabetes Care. 2011; 34: 236-239Crossref PubMed Scopus (160) Google Scholar) argued that validated measures do not need to be used and that ongoing clinical conversations and support within the clinic that include discussions about the emotional aspects of living with diabetes may be of the most benefit. They posited that, as the "emotional" and "physical" aspects of living with T1D are inextricably linked, the management of distress should happen within the diabetes service. As highlighted in the Balfe et al study, young people living with diabetes feel that talking to their health-care professionals reduces the impact of distress and were keen to see it as part of standard care (16Balfe M. Doyle F. Smith D. et al.What's distressing about having type 1 diabetes? A qualitative study of young adults' perspectives.BMC Endocr Disord. 2013; 13: 25Crossref PubMed Scopus (63) Google Scholar). This is in line with the American Diabetes that the aim of diabetes care is to health outcomes and health related quality of D. De Groot M. Hill-Briggs F. Gonzalez J.S. Hood K. Peyrot M. Psychosocial care for people with diabetes: A position statement of the American Diabetes Association.Diabetes Care. 2016; 39: 2126-2140Crossref PubMed Scopus (356) Google Scholar). In adolescents and young adults who have high levels of distress can be by diabetes health services communication that about emotional aspects of living with diabetes and provide and psychoeducation for self-management of diabetes. communication involves use of reflective and The used around diabetes is it should be and such as that by the UK Health report Health and Scholar). the of distress can young people and can be (7Gonzalez J.S. Fisher L. Polonsky W.H. Depression in diabetes: Have we been missing something important?.Diabetes Care. 2011; 34: 236-239Crossref PubMed Scopus (160) Google Scholar). It also the experience of distress as one that on a and that may fluctuate over time (5Fisher L. Gonzalez J.S. Polonsky W.H. The confusing tale of depression and distress in patients with diabetes: A call for greater clarity and precision.Diabet Med. 2014; 31: 764-772Crossref PubMed Scopus (235) Google Scholar). the young is distress, a to psychological services may be the aspect of diabetes that the young is distressing can be addressed of within the clinic, such as to and of to that can improve self-management (e.g. continuous or insulin (16Balfe M. Doyle F. Smith D. et al.What's distressing about having type 1 diabetes? A qualitative study of young adults' perspectives.BMC Endocr Disord. 2013; 13: 25Crossref PubMed Scopus (63) Google Scholar). This approach of communication and of for self-management to the young and staff within the diabetes clinic. This of the young people can with their diabetes care cannot be L. Byrne M. D. Dinneen S.F. O'Hara a A qualitative of clinic among young adults with type 1 Health Psychol. 2015; 20: PubMed Scopus Google Scholar). It can often the and that on the diabetes have identified as they lack issues of distress. The to to to and are for good diabetes care. As there has been relatively little research on distress in adolescents and young adults living with T1D, there are several that need to be we need more prevalence of elevated distress in these to an international also need qualitative of the of distress because it is likely that this age group may experience some unique As mentioned there is some evidence to that psychoeducational may reduce distress (8Sturt J. Dennick K. Hessler D. Hunter B.M. Oliver J. Fisher L. Effective interventions for reducing diabetes distress: Systematic review and meta-analysis.Int Diabetes Nurs. 2015; 12: 40-55Crossref Google V. Hendrieckx C. Sturt J. Skinner T.C. Speight J. Diabetes distress among adolescents with type 1 diabetes: A systematic review.Curr Diab Rep. 2016; 16: 9Crossref PubMed Scopus (104) Google Scholar). However, as out by Skinner and we do not how it is for diabetes to these and (6Skinner T.C. Joensen L. Parkin T. Twenty-five years of diabetes distress research.Diabet Med. 2020; 37: 393-400PubMed Google Scholar). are a and work is on the and of psychoeducational (6Skinner T.C. Joensen L. Parkin T. Twenty-five years of diabetes distress research.Diabet Med. 2020; 37: 393-400PubMed Google Scholar). However, with distress in clinical care is and its perceived barriers need to be from the of A should be to how we can and support diabetes so that addressing distress a standard component of care for adolescents and young adults with T1D. This work was by a Health and The no role in the or of this of and this and made to its the and it was by and authors of the published and authors have to be for aspects of this