pink panther - diabetes management - chapter 18

TOPICS:PsychosocialAdjustmentGoal Setting andProblem SolvingTEACHING OBJECTIVES: 1. Present the importance of long-

term family support andinvolvement in the diabetesmanagement.

2. Define age-appropriate skillsand tasks.

LEARNING OBJECTIVES:Learners (parents, child, relative orself) will be able to:1. Outline family support roles for

diabetes management.2. Identify at least one age-

appropriate sign of readinessfor learning diabetesskills/tasks.

Chapter 18

Responsibilitiesof Children atDifferent AgesINTRODUCTION

Daily diabetes care has grown more complex in recent years.In addition to the usual family responsibilities, it is not unusualfor families to:

4 do four or more blood sugars per day

4 give three or more shots each day

4 use an insulin pump

4 juggle sports and exercise

4 count carbohydrates or follow other food plans

Good sugar control requires the active involvement ofparents for many years. The myth that children should beencouraged to do all of their own diabetes care at an early ageno longer applies. Diabetes is a family disease.

Children of different ages are able to do different tasks andto accept different responsibilities. It is important not toexpect more from children than they are able to do. If they areunable to do the tasks, they may develop a sense of failure andlater poor self-esteem resulting in poor self-care. Familymembers need to watch for signs that the child needs moreassistance, especially during times of high blood sugars.

The ability to do certain tasks may vary from day to day andparents must be available to help as needed. The childrenshould be encouraged to gradually assume care for themselvesas they are able. The ability to successfully live independently,both in everyday life and with diabetes care, is the eventual goalfor all of our children.

193

194 Chapter 18 Responsibilities of Children at Different Ages

The purpose of this chapter is to reviewnormal child development and how it relatesto diabetes care. Although parts of this chaptermay not be important for each reader, sectionsmay be helpful to some families. It must beremembered that all children develop atdifferent rates (and our own children are alwaysthe most advanced).

Age alone, as a guideline, does not tell uswhen an individual child is ready to assumetasks. There is no such thing as a magic agewhen the diabetes suddenly becomes theresponsibility of the child or teenager. Bepatient! Independence takes a long time. Thesuggestions below may vary for any given childor family. Diabetes is a family disease andthe family must work together. Familymembers need to help each other. Sharing taskswill help prevent the diabetes care frombecoming the responsibility of just one person.

CHILD UNDER THREEYEARS

Traits and Responsibilities Not Relatedto Diabetes

This is a time of rapid development of asmall, wondrous creature who eats, sleeps, cries,soils diapers and starts to learn about the world.

Motor and brain development are the most rapidof any time in life:

4 sitting (6-8 months)

4 crawling (6-12 months)

4 walking (12-18 months)

4 language development

These developments open up a whole newworld.

Chapter 18 Responsibilities of Children at Different Ages 195

Accidents are the infants major danger.They must be protected from:

4 stairs where they might fall

4 poisons and medicines they might swallow(from cupboards, garages and purses)

4 auto accidents

4 other dangers (including coffee tables withsharp edges)

All infants with or without diabetes needlove. Parents and care providers need to cuddleand hold infants frequently throughout the day.This is particularly true after shots and bloodsugar tests, as infants do not understand parentscausing pain. Parents must remember that thetesting and shots are essential to their infants lifeand they must move beyond feelings of guilt (asdiscussed in Chapter 10). Much of the fussingaround blood sugar tests and shots is due to theinterruption in the childs activity rather thanpain. Infants develop trust during this periodand combining the diabetes care with love willhelp to make the diabetes care a part of normallife. Young adults often look back withappreciation to their parents for the shots andcare they gave them when they were young.

Responsibilities Related to Diabetes

Although babies and toddlers are not able todo any of their own self-care, the following aresome special suggestions that may help parents.

4 Blood sugar testing:

l Toes are used more frequently as a sitefor doing the testing.

l The BD Ultrafine lancets are smaller andmay hurt less.

More frequent blood sugar testing is usuallydone (see Chapters 6 and 7) because the babiesand toddlers cannot tell if their blood sugars are low.

The parents may learn to recognize a cry,crankiness or body movements that are differentthan usual and that indicate a need to do ablood sugar level. Teething can be a difficulttime when more blood sugars are needed to

separate a low blood sugar from normalfussiness. The temptation to let an infant naplonger than usual is offset by the possibility ofhypoglycemia.

4 Blood sugar levels:

l The blood sugar level to aim for is alsohigher (80-200 mg/dl [4.5-11.1mmol/L]; see Chapter 7) as severe lowsmay be more dangerous to the infantsrapidly developing brain.

l Low blood sugars can be treated withless carbohydrate than for an older child(usually 5-10g due to smaller body size).This amount is found in 1/4 cup ofmilk, orange or apple juice or 2-3 oz ofsugar pop (soda), although the amountneeded may vary from infant to infant.

l Infants who suck on a bottle of milk orjuice frequently during the day or nightwill tend to have higher blood sugarlevels. Overnight sucking on a bottle canalso lead to dental decay.

4 Shots:

l Shots are sometimes given while theinfant is sleeping (if he/she tends to getvery upset). If the child squirms orawakens at the time of the shot, the dad(or mom) should reassure the child. Astatement such as, It is just daddy (ormommy) giving you your insulin maybe all that is needed.

l The bottom (buttock) is used morefrequently as a place to give the shot.

l Eating is often variable and parents canwait to give the shot until they see what iseaten. This is easiest to do when therapid-acting Humalog/NovoLog/Apidrainsulin is being used. The dose of insulincan then be reduced if intake is low.

The amount of time taken to eat a mealshould be the same for all the children,with or without diabetes. Specialtreatment can result in eating problems.It is important for the parents to stay incontrol.


Table 1Age-Related Responsibilities and Traits

Non-diabetes-related Diabetes-related

Age below l developing gross motor l parents must do all care 3 years skills l acceptance of diabetes care as part

l developing speech skills of normal lifel learning to trust l often give shots after seeing whatl responding to love is eaten

Age 3-7 years l imaginative/concrete l parent does all tasksthinkers l gradually learns to cooperate

l cannot think abstractly for blood sugar tests and insulin shotsl self-centered l inconsistent with food choices may

still need to give shots after mealsl gradually learns to recognize

hypoglycemial undeveloped concept of timel adult needs to do all insulin pump

management

Age 8-12 years l concrete thinkers l can learn to test blood sugarsl more logical and l at age 10 or 11, can draw up and

understanding give shots on occasion, althoughl more curious they still need supervision l more social l can make own food choices; can learnl more responsible initial carb-counting

l do not appreciate that doing somethingnow (e.g., good diabetes control) helps to prevent later problems (e.g., diabetes complications)

l can recognize and treat hypoglycemial by 11 or 12 years, can be responsible

for remembering snacks, but may still need assistance of alarm watches or parent reminders

l can do own insulin pump boluses, butneeds adult help to remember

Age 13-18 years l more independent l capable of doing the majority ofl behavior varies shots or insulin pump managementl body image important and blood sugar tests, but still l away from home more needs parental involvement andl more responsible review to make decisions about dosagel abstract thinking l knows which foods to eat; can dol able to understand the carbohydrate counting

importance of doing l gradually recognizes the importancesomething now to of good sugar control to prevent laterprevent problems in complicationsthe future l may be more willing to inject multiple

shots per day


l The amount of rapid-acting insulin is keptlow due to body size and due to anapparent increased sensitivity to rapid-acting insulin. With the insulin syringescurrently available, it is not usuallynecessary to dilute insulins. Most parentslearn how to judge 1/2 unit dosagesusing the 0.3cc (30 unit) insulin syringes.The Precision Sure Dose 0.3cc syringeshave markings for half-unit measurements(Chapter 9). Similarly, the BD Pen Mini

can deliver half-unit increments.

It is important for parents of infants withdiabetes to incorporate the diabetes into theireveryday lives. Children learn throughimitation. If parents have adjusted to thediabetes and can view their child with the samepositive feelings they had prior to the diagnosisof diabetes, it will help the child to grow upfeeling positive and psychologically healthy. Asummary of non-diabetes and diabetes traits foreach age group is shown in Table 1.

AGES 3-7 YEARS


4 They think concretely.

Concrete thinking means things are eitherblack or white, right or wrong, good or bad.They do not think abstractly. For example,they are unable to realize that Having a shotof insulin will help me to stay healthy.Instead, a shot may be considered apunishment for doing something wrong.Parents need to repeat over and over that thechild hasnt done anything wrong and to tryto describe in the childs language why pokesand shots are important.

4 They start to see themselves as separateindividuals from their parents.

Children gradually become very curious inthis period. They often want to know howthings work. They can annoy parents withthe simple words how and why.

4 Children of this age are very self-centered.

They may progress from playing with a toyalone to gradually learning to share a toy orto share the love of their parents. Primaryattachments are to parents and family.Interest in other relationships, such as schoolpeers, begins at six to seven years of age.

4 Age responsibilities in children 5-7 years oldbegin to increase dramatically.

They can help pick up their toys, make theirbed or put their dirty clothes in the hamperwhen guided by the parent. They are capableof fixing simple foods, such as cereal or asandwich, but still do not understand simpledangers such as putting a knife in a toaster orbeing careful around boiling water. Theymust have much parental supervision.

4 Children 5-7 years old are learning to read,opening a whole new world.

They are discovering many new things,asking lots of questions and practicing newskills. They feel more independent and, insome ways, they are. Usually they arecooperative and love to be helpful.However, they still require a good deal ofadult supervision.


4 The parents must do all diabetes related tasks.

Fine motor coordination (the coordinationof the fingers when handling small items) isnot yet fully developed. They cannot dotasks such as accurately drawing insulin intoa syringe. This is also true when a child ofthis age is using an insulin pump. The adultmust always be available to do all of thepump management.

4 They can gradually learn to cooperate withtheir parents (e.g., sitting still for bloodsugar tests and insulin shots)

4 They can help by choosing or cleaning a fingerfor a blood test or by choosing the site for theinsulin shot.

4 Children as young as three or four cansometimes recognize low blood sugars.

They can tell parents when they are hungry.


Their complaints may be vague or seemstrange to us (Mommy, my tummy ticklesor Daddy, I dont feel good.) However,these clues can be very helpful to parents.Helping children verbalize the bodysensations of low blood sugars is animportant task for family members.

4 If a shot (e.g., Lantus) is going to be givenafter the child is asleep, this should bediscussed between the child and parents.Some children will say fine. Others wantcontrol and will ask to have the shot givenbefore they go to sleep.

4 By age 5-7 years, recognizing low blood sugarsis more completely developed, particularly ifthe parents have encouraged it.

4 Children of ages 4-7 years may have someconcept of which foods they can eat.

They can be taught to ask, Does it havesugar in it? or Do you have a diet pop?They cannot be expected to always or evenvery often make the right choices over theones that look or taste good. They willprobably choose foods that are similar towhat friends or family are eating. They canbe expected to have some temper tantrumsat being limited in high-sugar food.

There is not much concept of time at thisage. An adult will need to make sure that asnack is taken at a specific time. Sometimesa watch that beeps at a set time can be usedas a reminder for a snack.

4 They usually have no objection to wearing adiabetes ID bracelet or necklace.

It is good to get children into the habit ofwearing the ID when they are young. Thismay help them to do this as they get older.

It is important for parents of children in thisage group (as in all age groups) to keep apositive attitude. Remember the bloodsugar tests and insulin shots help to keep thechild healthy. Playing games arounddiabetes chores and gradually getting thechild to help (even in little ways) may bebeneficial. One fun game is to use quartersor stickers to reward the child for guessing

the blood sugar number while the metercounts down. Whoever is closest wins. Itwill help the child to learn to tell when theyare high or low. Hugs and kisses willreassure the child that the parents lovecontinues. To be able to keep a positiveattitude, parents need their own support fortheir worries and hard work. Friends,family, diabetes support groups or othersources of support can be extremely helpful.

AGES 8-12 YEARS


4 Children of this age continue to think inconcrete ways.

They can gradually think more objectively andunderstand another persons point of view.

4 Fairness and meeting their needs are veryimportant.

4 Children at these ages are more social andpeers begin to play a more important role intheir lives.

They usually begin to spend nights atfriends houses. They have more peeractivities than do younger children.Becoming involved in some team sports canhelp them to stay involved as they get older.This is a great age to do classroomeducation about diabetes. The more peersunderstand, the less likely they will tease.They can soon become a real support toyour child. Peer support is important,especially later during adolescence.

4 Children can be helpful by learning to take onincreased responsibilities.

They may help with doing dishes, feedingpets, cleaning their own room and otherrooms or taking out the garbage. Specialrewards, such as stars on a calendar, may behelpful in encouraging certain activities.

4 They are capable of more complex foodpreparation and can better understand safetyand danger issues.



4 Some children begin to do their own bloodsugar testing at ages 8-10.

4 At about this age some children wish to beginto give some of their own insulin shots.

The ability to accurately draw up the insulinis a bit slower in developing, but it is usuallypresent at 10 or 11 years of age. Thecoordination needed between seeingsomething and using the fingers tosuccessfully do the job (eye-handcoordination, fine motor skills) developsduring this age. This is an exciting time towatch a child develop. Adult supervision isessential for all of these important tasks.

The child can get burned out if:

l they begin any of these tasks at tooyoung an age

l they have too much responsibilitywithout the parent being available totake over when needed

They will be more likely to rebel during theteen years by missing shots or not testingblood sugar levels. In addition, they mayhave difficulty requesting their parents helpwhen needed if they are expected toperform self-care tasks alone. Parents muststay involved in diabetes management withthis age group!

4 Children of this age sometimes feel that lifeisnt fair, particularly as it pertains todiabetes.

It is helpful to just listen to them if theyexpress such feelings.

4 Children may be able to give their own shotswhen staying at a friends house.

As the children are usually very active whenstaying at a friends, we often suggestreducing or omitting the dose of rapid-acting insulin and reducing the dose of theevening long-acting insulin by 10-20percent. The parent can draw up the shotahead of time and put it in a small box,

toothbrush holder or other container andleave it at the friends home. They mayeven place it in the Inject-Ease. They mayask the friends parent to supervise the shot.It is important to remember to roll a syringecontaining NPH insulin between the handsto re-mix it prior to giving the shot.

It is also essential that the friends parents beinformed about hypoglycemia. The handoutsin the school or baby-sitters sections(Chapters 23 and 24) may be helpful.

4 Children of this age can eat lunch at schooland make choices to avoid high sugar foods.

Some will begin to learn to countcarbohydrates.

4 They can gradually learn to recognize andtreat their own hypoglycemic reactions.

4 They are also more aware of time and canlearn to be responsible for eating a snack at aset time.

4 Insulin pumps are sometimes considered by thefamily in this age group.

It is important for the family to meet withall team members (Chapter 26). This helpsto determine who is truly ready to startusing the pump.

4 Sports can be very important at this age.

A child who learns to enjoy athletics isstarting a healthy pattern for their life aswell as for controlling diabetes.

Parents of the child in this age range must bepatient in teaching the child about diabetesand how to do diabetes-related tasks. Theparents must still be very involved insupervision of the diabetes care. They mustalso be secure enough to let the child begin toassume some responsibilities on his/her roadto becoming an independent person.

Diabetes camp, group ski trips, hikes orother events allow the children to receiveinvaluable support from each other and torealize that they are not the only person inthe world with diabetes.


AGES 13-18 YEARS


4 Teens gradually develop independence and asense of their own identity.

As noted in Chapter 19, Special Challengesof the Teen Years, this age group variesgreatly between wanting independenceversus needing dependence. Somerebellious behavior may be demonstratedtoward parents as teens grow into separateindividuals.

4 Skills increase greatly in this age group.

Automobiles can be driven legally andpower lawn mowers can (hopefully) beused. Teenagers may take jobs to earn theirown money. Activities, in general, aregreatly increased.

4 Body image becomes a major concern.

Teenagers worry about how others viewthem. The slightest pimple may become acatastrophe. Early in this period, friends ofthe same sex are very important, whereaslater, interest in the opposite sex usuallybegins.

4 More time is spent with friends.

4 The older teen is away from the home moreand stays out later with friends.

4 Experimentation with alcohol at some point iscommon.


4 Teens gradually take over more of theirdiabetes care.

Parents still need to be available to assistwith giving a shot from time to time. Theyneed to take over the diabetes care for aperiod of time if the youth seems burnedout. Teens generally do better if they getextra help, particularly with insulin dosage.

As noted in Chapter 19, A SUPPORTIVEADULT CAN BE AN ASSET FOR A

PERSON WITH DIABETES,REGARDLESS OF AGE. Even parents ofolder teens still need to help with makingsure adequate diabetes supplies are available(and paying for them) and making sure thatclinic appointments are made and kept everythree months.

Parents should come to the clinic, althoughthe staff may request to see a teenindividually to discuss issues that may bedifficult to talk about with parents present.

4 Many teens dislike the chore of writing bloodsugar results in a log book.

If the parents agree to do this at the end ofeach day (with the teenagers OK), it is away for the parents to keep tabs on thediabetes. Having values written down (andoften faxed to the diabetes care provider) isimportant in looking at trends and knowingwhen changes in insulin dosages need to bemade.

4 Experimentation with alcohol will likely upsetthe diabetes control (see Chapter 11) and cancause severe hypoglycemia.

4 Experimentation with street drugs upsetsschedules and diabetes as well. The use ofdrugs can result in:

l increased appetite and higher bloodsugars

l loss of incentive for good diabetesmanagement

l eating meals irregularly

4 Good peer support can help the continuationof:

l an exercise regimen

l a healthy diet

l a consistent lifestyle

l not using tobacco products (an addedrisk for diabetic kidney disease and forlater heart attacks). Most people whoare going to use tobacco will begin priorto age 20 years. Usually, if the peer


group does not smoke or chew, theyouth will make a similar choice.

Identification with peers is so important inthis age group that their support (or lack ofit) may greatly affect the teens diabetesmanagement.

4 A belief in God and church, synagogue ormosque activities may help guide the teen.

4 Continued involvement with parents canprovide stability, limits, love and support.

4 Grandparents can be a tremendous help atany age (see Chapter 24).

Again, support from peers (with or withoutdiabetes) is very important in this age group(see Chapter 19, Special Challenges of theTeen Years).

4 There is often a feeling of invincibility or itcant happen to me.

Regular clinic visits at this age may help theteen realize that diabetes care andresponsibility are important. Teens withdiabetes are faced with more difficult tasksand more serious life issues than their peers.Teens with diabetes often seem to matureearlier than teens without diabetes. Theylearn at an earlier age when they have to beserious in life and when they can have fun.

4 Insulin pump use is often considered in thisage group (Chapter 26).

Transition to a pump is more successfulif this is the teens choice. If the parentspush for an insulin pump, but the teen isnot ready, there is a lower chance forsuccess. It is important to have the help ofthe entire diabetes team when making thisdecision. Readiness for the pump can beassessed together. This age group is oftenquicker than parents in learning the use of

Table 2Average Ages for Diabetes-Related Skills

Age of Mastery (in years)__________________________________________________Skill Recommended by the Survey of

American Diabetes Association Care Providers

A. Hypoglycemia1. Recognizes and reports 8-10 4-92. Able to treat 10-12 6-103. Anticipates/prevents 14-16 9-13

B. Blood glucose testing 8-10 7-11

C. Insulin injection1. Gives to self (at least sometimes) 8-112. Draws two insulins 12-14 8-123. Able to adjust doses 14-16 12-16

D. Diet1. Identifies appropriate 10-12 10-13

pre-exercise snack2. States role of diet in care 14-16 9-153. Able to alter food in relation 14-16 10-15

to blood glucose level

Abstracted from a survey done by Drs. T. Wysocki, P. Meinhold, D.J. Cox and W.L. Clarke at Ohio State University and theUniversity of Virginia (Diabetes Care 11:65-68, 1990).


the pump (a mini-computer). Glucosecontrol can improve ONLY if meal bolusesare remembered. This activity can oftenrequire adult help.

The parents role for the teenager is to beavailable to help when either forward orbackward steps toward adult maturity are taken.Providing support, stability, limits and love areessential at this difficult age (as at all ages).

Age alone should not be the primaryfactor in deciding that a person shouldassume responsibility for diabetes self-management. Parents who offer continuedassistance and who share the responsibilitieswith the teen will generally have a teen in betterdiabetes control.

The average ages for mastering tasks asrecommended by the American DiabetesAssociation and by a survey of care providersare shown in Table 2.

DEFINITIONSEye-hand coordination: The ability to use thehands to finely adjust what is seen with the eyes.This ability usually develops around the age of 10.

Fine motor control: The ability to carefullymove the fingers with precision (e.g., drawinginsulin to an exact line on a syringe). Thisability usually develops around age 10 or 11.

Self-esteem: How a person feels abouthimself/herself.

QUESTIONS AND ANSWERSFROM NEWSNOTES

It seems like every time our eight-year-old son stays at his friendshouse or has his friend stay

overnight at our house he has low bloodsugar the next morning. Should we bemaking changes?

Overnights are an important socialand developmental step in our society.It is important that children with

diabetes be able to participate just like any otherchild. Overnights are also a step in developingindependence and are sometimes the first nightspent away from the parents. It is important forthe child to be safe in relationship to thediabetes. The children usually run and play abit harder with their friend on overnights.They also stay up a bit later than normal anduse more energy. It is generally wise to reducethe insulin dose, both the rapid-acting (20-50percent) and the long-acting (10-20 percent)insulins, on these nights.

A good bedtime snack is also advisable.Remember the pizza factor, that pizza tendsto keep a blood sugar up better than most otherfoods. If there is a frozen pizza in the freezer, itmay be a good night to use it. It is also wise toawaken the child at a reasonable time in themorning and to get a glass of juice or milkdown sooner rather than later.

Do remember that if the child is able to doa shot but is not yet old enough to draw it up,the morning NPH and rapid-acting insulin canbe pre-drawn. The syringe can be put into alittle box or toothbrush holder and just rolledto mix the next morning. Think aboutreducing the dose again for the morning shot ifit is likely that the two friends will be playingtogether much of the next day.

Q

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pink panther - diabetes management - chapter 18

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