Case 6.2 – T1D (Ongoing Management)

Key Components of Regular Assessment:

• Emotional well being
• Monitoring diabetes control and compliance with insulin injections
• Hypoglycaemic or hyperglycaemic episodes
• Exercise and diabetes
• Healthy eating
• Physical examination for complications of diabetes (including lipohypertrophy at injection sites, thyroid, coeliac disease as well as for neurological and vascular complications)

Key Issues to Explore with Nick (Adolescent-Specific Considerations):

Understanding Adolescent Development:

Adolescence is a time of major physical and psychological change and increasing independence. However, behaviour and degree of responsibility vary enormously during this period. Body image is very important and peer pressure can lead to denial, self neglect and risk taking behaviour.

Issues to Explore:

• Body image, in particular weight
• Smoking and alcohol (risk of hypos)
• Growth and puberty and changes in insulin requirements
• In girls, sexual activity, contraception, risk to foetus if poor diabetes control
• Driver's license (application needs endocrinologist approval – need HbA1C \<9%)

Common Adolescent Challenges with Diabetes:

• Poor or variable compliance with food, injections, and testing can become a problem
• Faking or fudging of blood glucose levels - not uncommon as the adolescent tries to 'satisfy' their parents and health professionals by having some reasonable readings in their book. Usually discovered when the blood glucose meter is downloaded or the HbA1c is out of keeping with the recorded blood glucose readings
• Insulin omission (forgetting or deliberate) - reasonably common at this age. This is obviously quite serious as it leads to poor control and risk of serious illness with diabetic ketoacidosis
• Resentment of routines - some adolescents begin to resent the daily requirements of diabetes management

Approach to Consultation with Adolescent Patients:

Key Principles:

• Adolescents should be increasingly taking over responsibility for their diabetes care but continue to need help and supervision
• Education should be directed primarily at the adolescent rather than the parents
• Additional education about alcohol, sexuality, drugs, smoking and complications is necessary
• Adolescents should increasingly recognise the importance of good blood glucose control to prevent complications and may be more willing to have multiple injections

Balancing Independence and Support:

Parents and adolescents need to continue working as a team with the diabetes through the teenage years. A more subtle "hands off" approach is needed than in childhood. Studies have shown that handing over total control too early and lack of involvement with diabetes by parents in the teenage years is associated with poorer control and other difficulties, including 'burnout' in adolescents. Clearly the degree of involvement will be differently negotiated for different families.

Role of the Diabetes Team:

The diabetes team are especially important in working with teenagers and may tend to be listened to more than 'nagging parents'. With greater maturity in later adolescence there is usually improved motivation, interest and compliance with the diabetes management. Some young people with diabetes sail through the teenage years with no major problems.

Understanding Trust Issues:

It can be a difficult time for families as questions over trust and honesty arise. Often these behaviours are limited to diabetes issues and reflect the significant additional stress that diabetes poses for teenagers.

Resources and Support for Teenagers with Diabetes:

• Diabetes centre
• Diabetes Australia
• Juvenile Diabetes Research Foundation Australia
• Diabetes Camps