Challenges in Diabetes Management Beyond Insulin
When I arrived back home from Diabetes Camp, I faced a typical week of patient visits. I generally see about 50 patients of all ages per week in different outpatient sites. The flavor of each site is different depending on variable circumstances: age of patient, home and school situation, financial concerns, and adherence issues. Each visit is fraught with unique concerns and issues. It is my belief that to have a successful follow-up visit with a family and person with diabetes, it is important for the diabetes healthcare provider to discover the "hidden agenda" (if there is, indeed, one). It is key to determine and define the barriers (or successes) that present in the visit and explain the glycemic status over the last 3 to 4 months. Therefore, I view each visit as a means to determine what is actually going on within the child and family situation.
Typical Themes (often age-group dependant):
- Toddlers: Adult caregivers clearly dictate diabetes care in this age group; however, the child often has the last word due to behavior. Parents and family members are often overwhelmed not only with normative age related issues; but now have diabetes care added to the daily routine. Needle phobia, acting out, and temper tantrums are common in these toddlers. Parents/caregivers are often overwhelmed by the need to become the pancreas for their children and most often manage extremely well. However, this constant vigilance takes its toll: sleepless nights checking 3 am blood sugars due to realistic parental concerns of hypoglycemia, anxiety about marked fluctuation of blood sugars that cannot be controlled due to toddler eating behavior, etc. Ideal insulin management would include giving insulin before meals (basal/bolus insulin regimens), however, if the child does not eat all his/her meals that certainly would not be a good idea. In summary, the caregivers of these children suffer from altruistic intent: they are just trying to provide the best possible care for their beloved child.
- Elementary Aged Children: These children are generally a joy! They often out-shine their older siblings in their desire to do their best! These children aim to please and therefore are more adherent to not only general rules, but also diabetes management. Parents describe these children as excellent patients and often praise them constantly. Keep in mind that this behavior is age-appropriate. The desire to please caregivers/teachers is strong and will often last until puberty. The challenge with this particular age group is to determine just how much of self-care skills should be delegated safely to the child. This depends on the child's comfort and willingness to perform different tasks and clearly should be individualized. More specific examples will be provided in Part 2 next week.
- Adolescents (up to 18ish): By far, healthcare professionals find this group the most challenging (and some feel the most rewarding...if you can find how they tick.)This group is reminiscent of the toddler group: increased risk-taking, challenging authority. However, this impulsive risk-taking group is in more potential danger due to identification with the peer group and an inability to understand the consequences for a potential action. Add this normative adolescent behavior to the need for adherence to diabetes self-care skills and you have a potential for major problems. (This is a generalization. Not all teens behave in this manner). Herein lies all the potential issues that both parents and caregivers must face. Most teens want to identify with the peer group. Therefore, previously adhered to self-care tasks may become more odious to the teen as they do not want to appear different. Goodbye testing 4 to 8 times a day! Independence also plays a role. Teens are given more freedom and have the means to obtain food (and alcohol illegally) and may not adhere to their insulin regimens and thus omit insulin (due to the desire to be like their peers, desire to forget they have diabetes secondary to appropriate diabetes burnout, and other psychosocial issues. Because they know that they will need to provide blood sugars at their diabetes interim visit, they may devise intricate means to do so (forgetting the blood glucose meter, fabricating written records of blood sugars, using control solution, sampling sibling, friend or other liquids to obtain blood sugars, etc.) I am STILL learning about the degree to which these teens will try to bamboozle me! These visits are often filled with drama and may become exhausting! However, once the diabetes healthcare provider forges a relationship with the teen and hones in on what actually matters to him, there is often a major change in adherence and often an epiphany ensues!
NEXT week: Suggested solutions (that may or may not work).