The role of observation within a project aiming at facilitating the transition of young patients with juvenile diabetes from paediatric to adults’ services

ABSTRACT

In recent years, the spread of juvenile diabetes has increased exponentially causing major psychological, economic and social costs and raising concern among health professionals and policy makers in relation to supporting these children and adolescent patients. The patients’ transition from Paediatric to Adult services is a critical moment with a high percentage of treatment drop-outs. This has been the focus of research carried out by a team of paediatricians, adult diabetologists, and child and adolescent psychotherapists in the Medical School of a large Italian city. This paper focuses on the role of psychoanalytical observation applied in work discussion seminars with the staff of Paediatric and Adult services in the hospital. The observations were conducted in the joint outpatient clinic, a new Service introduced experimentally to facilitate the transfer from Paediatric to Adult Dibetology Clinics. The seminars included the diabetologist for the last paediatric medical appointment and a paediatrician for the first young adult appointment. The paper discusses the methodology and the data gathered, focussing on the dynamics between the two doctors in the joint outpatient clinic, and on the impact of the social defences, which initially interfered with the joint work.

KEYWORDS:

• Diabetes
• transfer from children's to adult diabetic services
• psychoanalytical observation
• work discussion
• research
• social defences against anxiety

Acknowledgements

This paper is dedicated to the patients and medical teams who made these reflections possible. Their names do not appear for reasons of confidentiality but they are all present in our minds and memory. We also want to thank all the colleagues and students who contributed substantially to this work over time.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Simonetta M. G. Adamo, is a former Full Professor of Clinical Psychology at the University of Milan ‘Bicocca’. She is a Child and Adolescent Psychotherapist, a member of the Tavistock Society of Psychotherapists and of the Italian Society for Research in Paediatrics. She teaches at the Centro Studi Martha Harris, Florence and at the Centre d’ Etudes Martha Harris, Larmor Plage, France. Her main areas of research include psychoanalytic observation and its application in educational and hospital contexts, counselling young people, understanding imaginary friends, psychotherapy with Children with Autistic Spectrum conditions including Asperger's Syndrome. She lectures in several European countries and has published papers in International journals. She has edited books including La cura della relazione in oncologia pediatrica (Working on relationships in paediatric oncology), and, with Margaret Rustin, Young Child Observation. A Development in the Theory and Method of Infant Observation. She has also published, with Claudio Pignata, Sentinelle traditrici. Un approccio integrato alla cura delle patologie del sistema immunitario (Betraying sentinels. An integrated approach to the treatment of diseases of the immune system). Simonetta Adamo works in private practice in Naples. S.M.G. Adamo was in charge of the psychological interventions in the Project, as well as leading the groups with paediatricians and diabetologists, and acting as one of the observation and clinical intervention supervisors.

Francesca Racioppi is a Psychologist and a Psychoanalytic Psychotherapist trained in Italy and she holds an MA in Psychoanalytic Observational Studies. Her main interests are psychological disorders in young adults and adults and the use of psychoanalytical observation in research. She works for the World Health Organisation and clinically in private practice in Milan. F. Racioppi was the observer in the Joint Outpatient Clinic and conducted clinical interviews with the patients.

Gerarda Siani, is a Child and Adolescent Psychotherapist and a member of the Associazione Italiana di Psicoterapia Psicoanalitica Infantile (AIPPI). She holds an MA in Psychoanalytic Observational Studies, validated by the University of East London, the Tavistock Clinic and the Centro studi Martha Harris, Florence. She works at the General Hospital of Naples University ‘Federico II’, undertaking assessments and short term psychotherapy with children, adolescents and families. Her main interests are early childhood, language development and pathologies, the impact of physical illnesses on children and the problems of transgender adolescents. She has published many papers in Italian and international journals. G. Siani succeeded her in leading the groups with the diabetologists and the supervision groups.

Notes

1 Juvenile diabetes is the most frequent metabolic illness in childhood. In Italy, the rate is between 6 and 10 cases in 100,000 inhabitants per year, while in the United Kingdom 23 subjects in 100,000 are affected.

2 In the course of this long interval, several important changes in the Paediatric Service took place, such as the stable addition of a psychoanalytically oriented psychotherapist, E. Zeto, in the team, who contributed substantially to the transition project.

3 Quantitative research (Adamo, Siani, & Zito, 2011) looked at one hundred young diabetic people in treatment in the Paediatric Services. The tools which were used included:

• A personal-social record, drafted by us, for the measurement of descriptive variables;

• A Response Evaluation Measure-71 (REM-71) form for assessing the defensive attitudes of young adults;

• The Confidence in Diabetes Self-Care Scale (CIDS) for the measurement of therapeutic compliance;

• The Symptom Check List (SCL-90) in order to rule out the presence of severe forms of associated pathologies;

• Clinical interviews

4 For an initial analysis of the observations made in the JOC, see: Adamo, Siani, Racioppi and Zito (2013); Racioppi (2014).

5 This use of the observations is linked to the tradition initiated by Anna Freud, who found the stimulus to make changes in the organization of the nurseries that she set up in the observations made by the nursery teachers.

6 In his book ‘Organization in the mind’ (2005), David Armstrong describes his consultation work with what he defines ‘a community in transition’. It was a community which hosted children and adolescents with serious emotional problems. One of such problems within the community was the failed use of some buildings which had been specifically designed for late adolescents and young adults. The recurrent appearance, in the conversations with the managers and staff that had been interviewed, of the expression ‘letting go’, together with the analysis of other variables, leads the author to hypothesize the existence of the difficulty, on the part of the staff, of letting the children go and making space for their adolescence. Armstrong mentions how, over time, the young people sent to the community showed increasingly serious troubles, and how the task of the community, i.e. providing a strong experience of containment and a solid basis for preparing the separation of – and from – the children, had consequently become more and more arduous. Because of this, also the possibility of ‘letting the children go’ had been invested with a growing ambivalence on the part of the community's members.

7 The unambiguous attitude of the paediatrician is considered to be a crucial element for a good transition in the Parma's Protocol (Vanelli et al., 2004).