Driving independently has always been a rite of passage for adolescents of a certain age. The difficulty lies with the fact that a license to drive coincides with the adolescent invincibility and impulsiveness. It is known that teenagers are at the greatest risk for motor vehicle accidents due to this developmental stage. Add chronic illnesses, such as insulin dependant diabetes or seizure disorders, and the risk is incrementally higher due to the possibility of a seizure (due to hypoglycemia or epilepsy). So how does a healthcare provider deal with this common rite of passage in the life of a teenager or young adult?
There is no general consensus in making this decision. However, in terms of diabetes requiring insulin, the Maryland Motor Vehicle Administration (MVA) made an attempt to decrease the risk of hypoglycemia-induced motor vehicle accidents by requiring the signature of the healthcare provider treating those at risk for an accident due to underlying illnesses. About 10 years ago, the Maryland MVA, looking for a method to further decrease accidents, asked diabetes healthcare providers to sign a medical form and suggested that we pay attention to blood glucose monitoring (as well as diabetes control and Hb A1c) to determine fitness to drive. Many healthcare providers took this very seriously and would only sign the forms if there were evidence of checking blood sugars frequently (at least 4 times/day). And, if there was approval for the Learner's Permit, it was requested that the young adult check a blood sugar before driving and ensure that it was at least above 100 mg/dl or higher. In addition, it was strongly recommended that the driver carry rapid acting carbohydrate on his/her person at all times as well as storing a cache of carbs in the car.
I tend to use the "signing of the learner's permit" as a motivating force to attempt to get my recalcitrant teenagers to check blood sugars frequently. Therefore, it has been my policy to refrain from signing the learner's permit until I have physical meter evidence of sufficient blood glucose monitoring. What became of intense interest, especially to my psychology colleagues at Children's National, was the sustainability of blood glucose monitoring both before and after the learner's permit was signed.
We decided to perform an exploratory study (Monaghan M, Hoffman K, Cogen FR., License to drive: type 1 diabetes management and obtaining a learner's permit in Maryland and Virginia. Diabetes Spectrum 2013;26:194-199) . This study was the first to evaluate adolescent type 1 diabetes management behaviors in relation to obtaining a learner's permit. The approval of learner's permits and driver's licenses varies by state. As Virginia does not have a requirement for a physician signature, we had hypothesized that Maryland teenagers would have increased motivation to increase blood glucose monitoring. However, in this exploratory study, approximately half the teens were not "meeting the minimum standards for blood glucose monitoring frequency at the time of learner's permit acquisition." Thus our hypothesis was not supported. However, despite the disappointing results of this exploratory study, I still continue to try to motivate our young adults to increase blood glucose monitoring and stress the need for safety when getting ready to obtain a learner's permit. And, sometimes this requirement actually works
I have had several successes in adolescents who have maintained poor self care skills for many years and were desperate to obtain a Learner's Permit. I start warning these Maryland teens (and Virginia teens even without the need to sign a form) at least a year in advance of obtaining a permit and encouraging increased blood glucose monitoring. Much to their surprise, when actually adhering to the required glucose checks, they felt better and continued to perform these self-care skills. Sustainability after obtaining the Learner's Permit is another matter!
In summary, although our exploratory study did not support improved self blood glucose monitoring as a requirement to obtain a learner's permit; clearly, new motivational attempts need to be continued in an effort to improve adherence, especially in situations that might prove to be life-threatening such as driving.