Development and Diabetes Technology
My most recent blog discussed the artificial pancreas in the camp setting. The preliminary results were extremely encouraging! The campers were required to wear both the insulin pump and the continuous glucose sensor on their person. That works for motivated parents and their equally motivated and willing children, but what about toddlers, children, and adolescents who may not be so enthusiastic about being attached to a device? We are all aware of the evidence-based literature that clearly supports the combination of insulin pump therapy in association with continuous glucose sensor. There is less hypoglycemia and tighter control, which results in the improvement of glycemic status. But what happens when the toddler, child, or adolescent does not care about evidence-based literature?
Developmental readiness and age-appropriate behavior will always potentially undermine well-intended therapy or technology. Each developmental stage poses different minefields. Take for example, one of my 7-year-old patients who decided on her own how to manage her continuous glucose monitor. Our creative child had just come back from lunch and received her bolus insulin (she is on basal/bolus therapy and receives a long-acting basal insulin plus rapid acting insulin for meals) and asked permission to go the restroom. Nothing unusual there. The child was later picked up by her Mom who noted that she was missing her CGMS sensor. An investigation was initiated and after a school search, it was determined that the sensor had been flushed down the toilet! She chose her unique method to inform her family and her diabetes healthcare team that though everyone else may have thought that the CGMS was a grand idea, she was having none of it. She demonstrated age-appropriate behavior that made it clear that she simply was not ready to apply the technology.
This is not the first school-aged child to flush expensive devices down the toilet. Another 8-year old ripped out his pump and tried to flush it down the toilet. These age-appropriate actions denote concrete manifestations of internal conflict. Families and healthcare providers must be aware of the behavior of the child and not just pay attention to his/her words. It is important to remember that school-age children in the latency period have a desire to please authority figures. Therefore, they may say what we want to hear to gain approval but behave in a different manner.
What about those rebellious adolescents? These kids will just tell you outright "I am not going to wear anything that is attached to my body!" My advice is to heed what they are telling you, as teens will find varied ways to sabotage the caregiver desire to be progressive and helpful. They will simply not put on the devices after purchase, will break them (even though they know the pump company will send another pump), scratch the screen of the pump so one can't even see anything, conveniently lose the device (after several losses, family and healthcare providers eventually get the message), and just about devise any method to avoid wearing the sensor or pump.
My advice: let the school-aged child or adolescent tell you that they are interested in the technology. Wait until they are developmentally, emotionally, and mentally prepared to incorporate the device into their lifestyle. Sadly, I have noted that many teens who have started insulin pump therapy or continuous glucose sensors at young ages decide to abandon the technology when they are older. This is an unfortunate occurrence as we so want the children and adolescents to adopt the new technology and own it!
Knickers update: We are nearing the finish line! Knickers was accepted as a therapy dog by Therapy Dogs, Inc. We can now send our paperwork to Children's National Medical Center for processing and eventual clearance so Knickers and I can attend the outpatient sites!