Research article

Living with a child with Diabetes: Psychic Processes and Anxiety Work within the Family

NGUIMFACK Léonard1* and OLAMA EYENGA Claire Edwige

Department of psychology, University of Yaoundé, Cameroon

Submission: November 28, 2020;Published: December 11, 2020

*Corresponding author: Nguimfack Léonard, Associate Professor, Phd in Clinical psychology and psychopathology, Department of psychology, Faculty of Arts Letter, and Human Sciences, University of Yaoundé 1, Cameroon, BP: 8003 Yaoundé-Cameroun, Cameroon

How to cite this article:NGUIMFACK L,OLAMA E C E. Living with a child with Diabetes: Psychic Processes and Anxiety Work within the Family. Psychol Behav Sci Int J .2020; 16(1): 555928. DOI:10.19090/PBSIJ.2020.10.555928.

Abstract

Living with a child with diabetes is a very difficult matter with its lots of suffering. The child’s entry into a chronic disease as diabetes precipitates the whole family into an acute emotional crisis, especially anxiety triggered by the threat of losing the child and the questioning of fantasies of immortality. While for some families this anxiety is a source of withdrawal and abandonment of the child, for others it will be a libidinal investment motor leading to family adaptation. This suggests that these other families have succeed to carry out psychic elaboration work on their anxiety. The aim of this work is to understand the psychological functioning of the family in order to grasp the psychic processes implemented in the work of anxiety within families experiencing the child’s illness, more specifically diabetes. To achieve this, a qualitative study has been done. We used the clinical method that offers the possibility of access to the singularity of the family’s members and then, to the psychic processes implemented in the management of their situation. Data were collected through semi-structured interviews with 4 families met at the National Obesity Centre of Yaoundé Central Hospital. The data obtained have been analyzed through a thematic content analysis. The results reveal that families have mobilized several psychic and psychological processes (defense mechanisms and coping mechanisms) to do though work and adapted to the anxiety experienced. This result could contribute to the care of children with diabetes and their families.

Keywords: Anxiety; Diabetes; Subjective Experience; Psychic apparatus; Psychic processes; Family

Introduction

Diabetes is a serious chronic disease that occurs when the pancreas does not produce enough or when the body is unable to use the insulin it produces properly. Insulin is a hormone that regulates the concentration of sugar in the blood. Depending on whether blood sugar levels decrease, hypoglycemia and hyperglycemia are referred to as they decrease or increase .Hyperglycemia is a common effect of uncontrolled diabetes that leads after to severe damage to many organic systems, especially nerves and blood vessels. Today, many people have diabetes; its prevalence, which has long been dominant in wealthy countries, is steadily increasing everywhere, particularly now in middle-income countries. There are three forms of diabetes: type 1 diabetes, which is diabetes that more affects young people. It is due to the destruction of pancreatic cells producing insulin. Type 2 diabetes occurs mainly in overweight people after age 40. It is due to the body’s resistance to insulin, which can no longer get the sugar into the cells. Gestational diabetes, which is diabetes that occurs only during pregnancy. Women who suffer from it are subsequently at higher risk of diabetes. Any type of diabetes can cause complications in many parts of the body and increase the overall risk of premature death. Diabetes is therefore a major public health problem and is one of four priority noncommunicable diseases targeted by world leaders. There has been a steady increase in the number of diabetes cases and the prevalence of the disease in recent decades. Of course, the issue of diabetes concerns everybody, but what about the child who evolves in his primary environment with all the feelings that follow and continue? The issue of childhood diabetes is a concern for the rest of the family. The announcement of a chronic disease, such as diabetes, in children’s life, generates in the parents a set of emotions: anger, guilt, etc., which follow one another and intertwine. Very quickly a process of depression (driven directly by the announcement of the diagnosis of diabetes) will quickly be established, which would bring the construction of defense mechanisms and adaptation to this new situation [1]. In addition to the various emotional upheavals, family members of the diabetic child have other daily challenges: first seeking to accept the new situation and even adapting to it; having time for follow-up, financial challenges too are not often left out when we know that the treatment is expensive (although already free in Cameroon for children). All this feeds the experience of the surrounding environment with a heavy emotional and cognitive burden, experienced as a feeling of curse resulting in the disturbance of the psychic apparatus that must be constantly updated. Hence the need to take an interest in it in order to understand the uncomfortable experience and better prepare families for the management of this uncomfortable situation. This article is organized around the following topics: the problem, the methodology, the results, the theoretical approach and the discussion.

Problem

Diabetes is caused by a lack or failure to use a hormone called insulin. Diabetes is a disease that leads to lifelong treatment. As it increasingly occurs to children, his treatment includes insulin administration, blood glucose monitoring, physical activity and proper nutrition. Young children are increasingly at risk, in Cameroon 1 in 10 children dies from diabetes. This shows the place that diabetes has in our country. Work on childhood diabetes is increasingly focused on the life of the family. Indeed, the presence in the family of a diabetic child leads to the reorganization of life within it. A study conducted by Ricard [2] on psychological changes in parents of children with diabetes shows that suffering is observe in the parents. Manage that anxiety will be different from one family to another. According to Carreel [3], the disease is a threat to attachment that causes positive and negative changes within the family; considering this, questions arise about the organization of the system, their representations and their myths. They have to adapt and reorganize. When the environment of the diabetic child is mentioned, it concerns the effect of this environment on the evolution of the treatment of the child. The feeling (stress) of the family thus has an impact on the control of blood sugar, which will bring a good treatment of the child. And even good management of diabetes stress can influence marital relationships. Families with disadvantaged socio-economic status and lone-parent families were more likely to experience diabetesrelated stress and were therefore more likely to experience poorer glycemic control.

Sow, et al. [4] emphasize on family solidarity. Indeed, concerning health, the relationship of solidarity is established when the family realizes that one of the members must face an alteration of his health, whose care requires a collective investment. Molley-Massol [5] points out, however, that when an illness breaks into a family system, there is a trouble in that family. A new balance is to be found that depends on each family’s ability to adapt to change. When the family system is flexible and open, it is likely to promote adaptation to the illness of the patient and his loved ones by allowing them to speak freely and to share often painful emotions. For these families, the disease will most often be an opportunity to strengthen pre-existing bonds. For other family systems that are more rigid and closed, the onset of the disease results in dysfunctions in the family balance. Josse [6] notes that, even though the family continues to struggle and live despite the suffering caused by the child’s diabetes, it tries to repair their parental ideal by mobilizing (sometimes to the extreme) for the little patient. Thus, all the attention and energy are invested on the sick child; that helps to alleviate or control their feelings of guilt, depression and anxiety.

So, there will be a kind of fusion with the sick child; parents are increasingly motivated to support their child. This extreme investment in the sick child somehow relieves their suffering. They develop psychic processes that will enable them to live better with their child’s illness. This subjective experience and the process that promotes it is set up successively. Kaes [7] talks about the process of psychosis within the family group. Everything starts from the denial, the refusal of the situation (child’s illness); where the child’s family has often heard of diabetes but does not believe this is possible for their child; this one being healthy. It is fatality in the family; then you have to submit to the situation, which involves setting up psychic processes, researches about the disease and familiarizing it. This evokes a work of family thoughts on anxiety. Anxiety is the lack of representation, concerning the work of trauma or conflict. The threatening objects that cause the emergence of anxiety are internal and, paradoxically, without representation [8]. Or it could be misrepresentations, with unpleasant affects. And yet this subjective work could help people to feel better; and therefore, free themselves from anguish. Expressing feelings, placing words or giving meaning to these feelings may facilitate a decrease in anxiety due to the child’s illness. This anxiety due to the child’s illness being experienced differently by each member of the family, a mobilization will be carried out. The occurrence in a family of a disease that cannot be cured breaks the fluid experience of time. This situation of illness stops the movement of the chain, it will never be the same again.

As Nguimfack [9] says, the sick family member is not an isolated entity, he is part of a family environment in which he acts and is acted. Every time the family of this suffering member is touched by what he is experiencing, changes occur; the family tries to relieve itself or on the contrary, helps to maintain or amplify the ill-being. The family may feel helpless, being able only to witness the injuries shown by one of their own, they may feel guilty, or on the contrary be active in helping, caring and dealing with the medical people. The disease affects the entire functioning of the family through many difficulties: instability of glycemic balance, frequent anorexia during acute diseases, difficulty to describe the symptoms experienced in cases of hyperglycemia or hypoglycemia, need for increasing independence with age. In fact, in a serious situation within the family (which is a system), the whole family is called upon. Kaes [10] talks about group psychic apparatus where the formation, transformation and connection of psychic reality takes place between the subjects constituting the group. The same author adds that whenever a group is confronted with a crisis or serious danger situation, it tends to fit together by binding its members in the unfailing unity of a “body spirit”. But it is also possible that such a modality of apparatus is necessary for the survival of the group, the maintenance of the common ideal, the integrity of its psychic, social or territorial space. Group dependence is then a factor in this survival. Thus, the groupal psychic apparatus here will treat psychic reality, in representations. The family of the diabetic child, which is a group of people where each has a psychic functioning, a way of representing the disease will effect a psychic transformation in his mental apprehensions. It is an activity that takes place in the psyche, accompanied by fantasies (the imagination).These are an individual’s implicit common-sense personal beliefs about the disease [11]. These beliefs sometimes appear to be different from the scientific reality. The different members of the child’s family become a set that will deal with the disease. The experience of the entourage includes feelings of anguish, abatement, isolation and ambivalent aspects; revolt, shame, guilt, desire for death for oneself and for the child. Some parents may express different feelings such as hatred, guilt, mood instability (depression), resentment towards others, a decline in interest in the outside world to the point of death ideas, a source of rest. According to a study by Diabetes Analytics [12], on quality of life, diabetes generates anxiety, emotional distress (37%) and a feeling of burden (60%) and poses a threat to relational life, leisure and future plans. Other parents will experience this situation as a trauma through conflicting feelings. No matter how the situation is experienced, psychic changes always occur. The child’s diabetes will thus cause anxiety (related to death). This anxiety is a common experience with chronic diseases. The situation of diabetes that occurs in the child, being thus perceived as a danger, will lead to anxiety in the family members. This anxiety must find a way of flowing through elaboration. Psychic elaboration is a work of the psychic apparatus that consists of linking quantities of impulse energy to representations and establishing the representations of associative pathways between them [13].

The mere mention of the word ‘diabetes’ leads to changes in emotions, fantasies (imagination) arise around the word because of the objective reality of which it represents. This situation thus creates within the family a kind of insecurity that is expressed by difficulties in regulating emotions, failure in mentalization abilities [14]. The psychic apparatus fails to perform work on these thoughts that occur containing negative energy. However, the work of the psychic apparatus should be to link the amounts of impulse energy to representations and to establish between them the representations of associative pathways. Because of the too many unpleasant emotions and that psychic apparatus is unable to work on them, these unpleasant sensations will create anxiety whereas the role of the psychic apparatus is to create pleasure for the well-being of the individual by avoiding displeasure. In the situation of the child’s diabetes, the entourage would be overwhelmed by displeasure but with a propensity to regain pleasure. This implies on the part of the family an effort of psychic redevelopment still not easy to carry out in view of the experience of each other; and beliefs about the disease. Indeed diabetes, like any other chronic disease, is often considered in Africa to be linked to evil or mystical forces. However, the emotions that the individual or his family environment experience when facing a serious illness are articulated with their thoughts, their beliefs. However, if it is true that anxiety at first sight is normal due to the severity of the child’s illness, then this anxiety, if it persists could be a danger to family members of the diabetic child. How psychological processes contribute to the work of anxiety due to the child’s illness?

We understand the work of psychic elaboration of anxiety, which is nothing more than the work of anxiety aims to contain this anxiety by binding it in order to prevent accumulation from becoming pathogenic. Thus, the family psychic apparatus will make changes in its functioning by mobilizing processes. Hence this study focuses on the problem of the psychic processes and its role in the work of anxiety in families of diabetic children.

Method, Participants and Procedure

Method

This study on psychic processes and the work of anxiety in families of children with diabetes is a qualitative research. We used the clinical method, particularly the case study. It aims to understand the family mental functioning of the child with diabetes in order to understand the psychic processes that contribute to the work of anxiety in these families.

Participants

Participants are family members of children with diabetes. They were selected on the basis of the following criteria:

i. Having a clinically diagnosed child with diabetes in the family;

ii. Family members must share the sick child’s daily life (living under the same house);

iii. These people must be available to participate to the research;

iv. The child should not have another illness.

We have designated these families by pseudonyms (Penda’s family –Paulin-; Masso’s family –Evan-; Kiel’s family -Vanessaand Mbassi’s family –Arnaud-), to keep the anonymity of the participants.

Procedure

We conduct four (4) semi-structured interviews with the family’s members of diabetic children that we met in the diabetology department of the central hospital of Yaoundé in Cameroon. We used an interview guide based on the following themes:

i. Diabetes knowledge (before diagnosis and after diagnosis);

ii. The family experience of the disease on a daily basis (the stresses, the feelings, the difficulties, the anxiety, the gaze of others);

iii. The meaning given to diabetes and to the anxiety;

iv. The means used to elaborate and supported anxiety The entire interviews were conducted from a tape recorder; with a variable duration of 45 minutes to 1 hour per interview. We used content analysis for the results. The recorded interviews were transcribed on a computer using word software. The sentence fragments of the participants were selected to empirically base the analysis.

Results

The results are organized around four axes: the knowledges of the families on the child’s diabetes, the daily life of the family of the diabetic child, the manifestation of anxiety within the families and the management of anxiety by the families.

The Knowledges of the families on the child’s diabetes

If the child’s diabetes remains for many people unknown and even unacceptable because it would be a disease reserved for the elderly, however, for other families, it was with its occurrence that they had knowledge about it. As a result, most of our participants only learned that children could have diabetes only after diagnosis. We note this with the Penda family. The mother of the family let us know: « I didn’t even know that kids could have diabetes or else it is witchcraft …». In addition, within the same family, some had knowledge about diabetes before the child was diagnosed and others did not. We were able to note this difference in knowledge within the Kiel family where the mother claimed to have heard of diabetes in children but the aunt not really. Vanessa’s mother says: « I have often seen the children of some of my colleagues have diabetes, but I could not imagine that my daughter, my only one, my only child could have this too (accompanied by desires to cry) ».

For Vanessa’s aunt: « To say the truth I had never heard of diabetes in children, with elderly yes but not with children ». It emerged that it was only after the child was diagnosed with diabetes that those around him became truly aware of the disease. An open and declarative investigation has been launched from a secure platform [15]; it found that 52% of the child’s relatives would have liked to have received training; 32% actually had training in diagnosing and caring for a diabetic child. We understand here that after diagnosis, relatives will seek to have knowledge about the disease. Thus, in the Penda family, Paulin’s older brother claimed: « it’s from that moment I knew children too can get diabetes and that it’s due to insulin deficiency because I did the research on the internet ».

The child’s loved ones get involved in the disease by looking for information about diabetes. In the Masso family, Evan’s brother confirmed it to us: « I started looking for information about diabetes, medications, injections, how to inject and where? I found out on the internet, in the hospital, at friends’ homes ». In the Penda family, Paulin’s great-brother also told us: « I started looking for information on the internet about diabetes, how diabetes is caught and I discovered that for my little brother it is a disease due to a difficulty of the pancreas to produce insulin that is responsible for regulating blood sugar levels ». On a daily basis, relatives of the diabetic child learn about the disease, about scientific advances and it is in this search for knowledge that several parents have been able to benefit from the free childcare program set up by the program. « changing Diabetes in children ».

The daily life of the family of the diabetic child

In everyday life, relatives of the diabetic child are involved in monitoring the child’s treatment associated with blood glucose monitoring. Although the “Changing Diabetes in Children” program provides for moments of psychoeducation of children on the taking of their treatment, many parents have concerns about children taking insulin injections especially when they are too young. Vanessa’s mother, Mrs. Kiel, recounts: “My daughter who is too small can’t inject herself, I have to do it for her, and it’s painful every day, I can’t adapt”. Other older diabetic children self-inject. Some relatives of the child with diabetes have had to stop working in order to invest more in monitoring their child’s treatment. Ms. Kiel told us: “I took early retirement to take better care of my daughter. I couldn’t take anyone to do that. So my little sister is there to help me because her dad is almost always on the move. I bring her to the hospital for therapeutic education.”

The daily life of the family of the diabetic child is also full with several difficulties:

i. Difficulties with an uncertain future: For many parents, seeing their child with diabetes means an uncertain future, a death that can occur at any time. Some see no more interest in investing in their child’s education and sometimes the child even finds himself in a situation of recidivism, rebellion. Paulin’s mother recounts: “The child often refuses to take the drugs, it is when he himself already begins to feel bad that he is going to inject himself. He says we should leave him alone. He’s so rebelling. He got his CEP and I even wonder how he’s going to do for the future; or he has to learn a trade”.

ii. The financial difficulties: while treatment for children is free, parents continue to worry because it is a lifelong treatment. Evan’s father tells: “The government needs to think about the patient who will be over 21, since the program takes care of children up to the age of 21 and then? We who are in poor families, the child even does not succeed at school and yet he has to take the treatment every day”.

iii. Eating difficulties: The person with diabetes must have a well-established, balanced and regulated diet. And sometimes families are poor enough to be able to provide quality food for their children. Children with diabetes may also have strong appetite.

Evan’s father says: “He eats a lot and yet he’s not supposed to eat too much. If there is no one at home, he will eat more than he needs and what will follow is that he will urinate a lot and the blood sugar levels will rise”. We note here that parents who are caregivers must follow up rigorously and be always present especially when the child is smaller like Vanessa who is only 5 years old. His mom told us: “Vanessa is a baby, she is my baby. She doesn’t know anything, I have to feed her like she’s still 1 or 2 years old. She can’t go to a birthday party with her friends because she’s going to cry if they don’t give her candy like the others, I assure you it’s hard.”

iv. Difficulties related to the risk of complications of diabetes: the risk of complications of diabetes is high. All recommendations should be followed to the letter: annual examinations, treatment, regular physical activity and a balanced diet. This is not always the case, especially when parents, in addition to being caregivers, have to look for sources of funding. In the Mbassi family, Arnaud had to go into a coma several times because the grandparents sometimes being in their country occupations, Arnaud found himself alone at home all day. And also the living conditions in the village are not always the best as his grandparents told us. We see here that several complications are related to the situation of diabetes and this reinforces the busy experience of the environment of the diabetic child.

Manifestations of anxiety within the families

In the child’s diabetes situation, at the time of diagnosis, an anxiety is born that is spontaneous, involuntary, and automatic in the face of the danger (that is diabetes). This can be seen through bodily manifestations. If we stick to the manifestations of anguish as described by Freud; Vanessa’s mother says she felt dizzy when her daughter was diagnosed with diabetes. Arnaud’s grandmother: “When my husband explained the case to me at home, I may have done 2 days, I didn’t have an appetite, and it was like there was a lump in my throat.”

In chronic diseases and diabetes in particular, this anxiety cannot be transient because of the continual presence of what caused the anxiety. What will result from the distressed person’s behavior will be an attempt to escape or a denial. “As you can see, Vanessa’s dad isn’t here and he’s never been here since his daughter’s diagnosis, I think he’s running away from his responsibilities,” Vanessa’s mother told us. For her, her husband lets her carry the full weight of the disease and it is more difficult when it is a single parent who has to endure all the emotions. She thinks that when a child has this kind of problem, if both parents get involved, it would be less burdensome for them and it would help to be more positive, more pessimistic so it would help to reduce anxiety. Also, Vanessa’s mom went into a total denial “My daughter can’t have this disease!” She refuses to accept reality and continues to believe in the immortality of her daughter. For her, this can happen to others but not to her daughter because she is “an angel” who has done no harm to anyone .

The situation of diabetes removes this feeling of all power and imposes rather the feeling of helplessness in the face of the disease. Several family members of the child with diabetes have acknowledged that they cannot cope with the situation. Ms. Kiel said “If I could get that damn diabetes out, I would”. After diagnosis, the affect sometimes continues more in several forms. “I had no appetite and I lost a lot of weight,” Ms. Kiel said. For her, there was no more hope, nothing was more important to her. For her to eat or take care of her no longer matters, in short nothing matters more. Life would therefore stop, and all the energy is thus invested in the disease. For Ms. Kiel, the situation of diabetes is inevitable, “a cloud that will never disappear” according to her words.

The management of Anxiety by the families

The families developed many processes to manage anxiety due to the diabetes of his child.

Creative abilities

This processes plays a great role when managing anxiety in an individual or in a group of individuals. Creativity describes (generally) the ability of an individual or group to imagine or build and implement a new concept, a new object or to discover an original solution to a problem. The creative process is that of the symbolization of the repressed or cleaved lived experience, the transformation of a raw psychic material into a representation thus made usable for the psyche, under the primacy of the principle of pleasure. Otherwise, without symbolization of this raw material, the psyche is subject to the compulsion of repetition. It can be more precisely defined as “a psychological or psycho-sociological process by which an individual or group of individuals testifies to imagination and originality in the way of associating things, ideas, situations which changes, alters or transforms perception, use or materiality with a given audience. This refers to the development of new ideas about a situation as is the case in our study with the family members of the child with diabetes. The family sees, thinks of diabetes as something other than an incurable disease. It is a psychological work, and we talk of “brainstorming” technique of Osborn [16].

According to Roussillon [17], the subject’s subsequent creative activity will bear the trace of the specific characteristics of the primary relationship to the mother, both in terms of the successes and avatars of this creative activity, its inspiration, its points of stop and blindness. “The mother is the muse from which the creative thrust takes on sense, the one that, both from the outside and from the inside, constrains creative work, demands it by its separate existence.” But it also emphasizes the fact that “the hallucinatory satisfaction of the desire that presides over the creative process can only be sustained by its encounter with a reality that can be created, to the extent that it confirms the process itself.” In the event of a persistent failure of expected satisfaction, of disappointment, there is abandonment by the psyche of this attempt at satisfaction by means of hallucination and sidelined by the denial and cleavage of the experience in question.

Family members of a child with diabetes must create through processes, which will allow them to do work on anxiety. The constraint to create concerns the areas of primary traumas of the psyche, that is, those areas where the lived experience could not, at the time, be linked, symbolized, subjectively appropriate, as the psyche had been overwhelmed by the intensity of what was experienced. From there, the subject will try, especially through creation, to integrate into his psyche this un symbolized, cleavage experience, to secondly reappropriate what he had historically had to cut from himself in order to continue to survive [18]. This is the work that takes place after the diagnosis of the child because at first there is no connection between representation and the feeling, energy flows freely; however, this energy will be controlled. The child’s family thus builds through the processes put in place new ways of thinking and perception of the child’s illness. The child’s family members use their imagination to find new ways to understand the diabetes situation. For example, Paulin’s mother tells us that: “Listening to or singing religious music for me frees me from negative thoughts. When the anxiety wants to arise in me about my son’s illness, I just start singing or listening to religious music, which relaxes me and leads me to think of something else and then that feeling goes away even for two days.” We understand that music here is a source of managing anxiety. We also note the importance of creative ideas. However, creativity is attributed to cognitive processes, social environment and personality. The ability to create would therefore depend on the type of personality. This ability starts from recognizing the problem and then finding a solution to it.

Defence mechanisms

In interviews with family members of children with diabetes, sentences that referred to modes of protection and defence to the unpleasant feeling of anxiety emerged. So we were able to group them together:

i. Sublimation with Ms. Penda when she says “I spend time singing religious music and it takes negative thoughts away from me”;

ii. Reaction training with big-brother Masso “instead of feeling sorry for himself, it would be better to look for information about diabetes” ;

iii. The anxious anticipation with Father Masso “I am trying to see how to allow him to learn a training because I have no financial means, so in a few years he can be independent”;

iv. Compensation or activism with Mrs. Kiel “I play sports, which gives me energy and good humour; my husband is never there, I need to take refuge somewhere”;

v. Deplacement with grandmother Mbassi “it is even the witchcraft of the people of the village that bothers me more than the disease of the child”;

vi. The affiliation with Mrs. Penda “I have handed over my child’s situation to God”;

vii. The humour with Mr. Masso “sometimes as my child refuses to inject, I told him that there is still a lot of land in the village, if he dies we will bury him”.

Coping mechanisms

Coping refers to the responses, reactions that the individual will develop to control, reduce or simply tolerate the aversive situation. The results obtained in this study led us to group the different coping strategies found within families as follows:

i. Emotionally focused strategies

Coping can modulate emotion in a number of ways: A change in attention, either by diverting it from the source of stress (avoidance strategies), or by directing attention to it (vigilant strategies). Gross [19] developed an emotional regulation model by outlining the different modes we found in families of children with diabetes.

a. The change of the situation with Ms. Kiel “I told myself directly that it is jealousy. I’ve been cast a bad spell, my child is not sick”;

b. The watchful deployment with Ms. Penda “Anger was invading me... But it had to be pushed back so that I could take care of the other children as well.”

ii. Problem-centred strategies

Problem-centered coping is an active strategy coping or “vigilant” coping. Some families said they relied on the resources they used in past difficulties. This allowed them to reduce the degree of anxiety because it allowed them to know that if they were able to overcome the past difficulty, they would also overcome it. For other families, having knowledge about the disease and updating it allows them to live better with it. While it is true that the first idea about diabetes is that of death, causing upheaval, then the people concerned end up accepting and living with this situation thanks to information about the disease. Mr. Masso said: “At first we thought the child was going to die, but I saw my uncle who had grown old by being diabetic, that was at the time. Even today, a lot of progress is being made on diabetes, and that gives us hope. Since a diabetic can get married, have children normally like all the others, if he faithfully follows his treatment and diet.” As another strategy, vigilance, the child’s family here will not avoid the situation but will direct their attention to it “But we have to be strong and face this disease,” Vanessa’s aunt told us.

iii. Other problem-focused strategies include

a. planning solutions and resolutions with big brother Masso “... better to look for information about diabetes... and who knows maybe one day they can find the cure for diabetes”.;

b. Coping confrontation with Mrs. Kiel «I had to retire early».

iv. Strategies focused on social support

It is not easy to accept the disease in some families like Kiel’s. The father is almost never there because of his work and the mother had to be alone in this situation. “If my husband were there to support me in this situation I think I would have more strength and I would live it better.” Here the presence of the father of the sick child, or the unity of the family in this situation is what would help him. “However I have to be there for my daughter, I had to retire early and call on my little sister to help me, that’s what comforts me.” The fact that the whole family is going through this situation and being more close-knit here is a strategy to overcome the anxiety. We note here the importance of remaining united in difficult situations, which could allow survival as mentioned by Kaes [10].

Other families that are rooted in religion support their religious beliefs. These are words of comfort related to God’s promises and which family members firmly believe in. For example, the Koenig et al. [20] study showed the degree of increase in the health level of elderly people who regularly attended churches. It is in this vein that Ms. Penda tells us that what consoles her is that she knows that it is God who watches over her child and that it is he who decides on her life. She believes in it to the point where she added “God who is above science. He has helped me out of difficult situations in the past and I think he will do it again, he has often cured incurable diseases.” Here we see the effect that belief or thought has on emotions.

Similarly, Arnaud’s grandmother, a devout nun, says that she has entrusted her grandson to the Lord who will save him “I have put my trust in God and I believe he has the last word.” This thought makes her stronger and allows her to live better with the situation of her grandson, who has not easily accepted the diagnosis. All these processes are intended to enable a family psychic redevelopment. Psychic transformations will take place in the family of the sick child such as:

a. The liquidation of latent aggression where there is discharge of any aggression related to the child’s illness, this involves the lifting of suspicion of others regarding the child’s illness. We note this in Ms. Kiel’s words “... and stop blaming others”;

b. The lifting of denial, we must accept reality. Grandmother Mbassi says “Everyone one day will die ... diabetes is a disease like any other”.

Discussion

The upheaval of family balance

The child belongs to a system (family) where as long as he is at the child stage, is under the care or responsibility of his parents. Therefore, any situation he faces has an impact on the parents. In our study, the diagnosis of diabetes affects the parents who are the caregivers. Several psychic changes are observed in the mode of functioning of the patient’s family psychic system, linked to the family’s positive diagnosis of the disease [9]. It shows that loved ones are always involved in the history of the disease that upsets the family balance and the balance of power. So in our study, we have the disease that creates an imbalance within the family and represents a psychic trauma for the loved ones, depending on the bond that binds them to the patient (spouse, children, parents, etc.), their personalities, their history and the moment of life they are going through. The impact of the disease will depend on multiple factors:

i. The person with the disease: child, adolescent, father, mother, grandparents, or longer-married family;

ii. The age of each person concerned and the period of life they go through, their history, their past experiences. Has she ever been confronted with the disease, her own or that of a loved one?

iii. The bond between the patient and the loved one: a relative or friend, and the type of pre-existing relationship to the disease;

iv. The life-threatening prognosis;

v. The nature of the disease and the representations attached to it (chronic disease, progressive or not, painful or not, responsible in the long run for an inevitable degradation, genetic disease), with all the guilt it can generate;

vi. Family configuration: couple with or without children, single-parent family, blended family, etc.;

vii. The family’s social and relationship network;

viii. We understand through this study that regardless of the member affected within the family, the balance (both physical and psychic) will be disrupted.

ix. Socio-economic standard of living, employment status: period of unemployment or period of projects and achievements;

x. The family life cycle in which the disease is involved: young couple, period of relative tranquility in relation to family dynamics or on the contrary crisis period, divorce;

xi. Family beliefs about health, disease and the medical world in general.

xii. The child affected is the whole family and especially the parents who are the first to be affected already by psychological suffering but also by the various (financial) constraints related to the child’s situation. The younger the child is; the greater the suffering (the case of the Kiel family).

Anxiety and processes that come into play in his work Each individual reacts to the disease differently; according to Trudel et al. [21], there are determinants that influence responses to the disease:

i. Factors related to the individual: among other things the basic personality (maturity level, usual coping mechanisms); The stage of development, previous experience of the disease beliefs, i.e. knowledge of the disease in question; Assessing the situation The value placed on the organ or function attained; values of life;

ii. Factors related to the disease itself: This is the nature of the disease (gravity, symptoms it causes); the site of the disease; the course of the disease; predictable evolution; the possibilities and nature of treatment;

iii. Environmental factors: The quality of family relationships; the quality of other relationships with loved ones.

The psychic functioning of each human being involves the simultaneous and permanent playing of all levels of psychological organization, both primary and secondary [22]. In this mode of operation, the goal sought by the psychic apparatus is pleasure. The situation of displeasure that is diabetes is harmful and requires this constant search for psychic balance. This author speaks of the fact that the transformation of suffering passes through the psychic processes that promote the emergence and shaping of desires that have hitherto remained avoided, repressed or cleaved, and which, in the absence of a psychic instrument that can develop them, have not been able to participate in the return to balance. Anxiety has links with original fantasies that refer to unconscious guilt and sexuality in its oedipal form (castration anxiety and penetration anxiety). It can also take more disorganizing forms (separation anxiety and intrusion anxiety), whose extreme manifestations can then refer the subject to the pain of violence and despair (“primitive dissecting anxieties” in Winnicott [23]; “Unnamed Terror” at Bion [24]. Anxiety is already present from childhood and the subject who finds himself confronted with a serious situation is invaded by this feeling often linked to this archaic functioning. This is the case for family members of the diabetic child who will thus carry out work on this anxiety. This involves a passage of the free flow of energy where all emotions crossed the barrier of consciousness without being filtered (how the child functions); more controlled energy. There is a shift from the representation of things to that of words. This involves coping strategies.

Conclusion

This study, by its results, allows us to understand the great interest to be given to the patient’s entourage, which could lead to better care of the child. Its involvement allows us to understand the psychic functioning of family members with a sick child. Knowing how this works, this could help health professionals in better care of children with diabetes. And even at the level of the families themselves, much more for those close to them who often withdraw after the diagnosis of the child, this study allows us to see another aspect of chronic disease in general and diabetes in particular which is that of the possibility of having a sick child but of being able to continue to lead a balanced life and to continue to preserve family ties that it is not “the end of the world” as perceived by many family members with a diabetic child. This situation, instead of being fled, would help to build the resilience of each other and not even to push this difficult situation back into the psyche and that could resurface, but rather to do a job.

Conflict of Interest:

No conflict of interest.

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