Newly diagnosed diabetic

Flare, ASN, BSN · Aug 26, 2012

You've tried putting him in control - it sounds like that hasn't been effective, so now it's time to give him the hard line. Yes, he's going to have to check in with you throughout the day. Since he's proved himself as untrustworthy, then he's got the consequence that he gets escorted through the lunchline - and maybe even monitored to eat. It's sad that it sounds like his parents aren't involved in this process - as that is votal in him being consistent with his care. Don't sugar coat anything (ha ha... i made a pun!) he has to be aware of the seriousness of neglecting his care and his diabetes. A meeting with your principal to inform them what's going on, this may push the parents to get a bit more involved. I think that a meeting with a guidance counselor and a phone call to his doctor is also in order.

100kids, BSN, RN · Sep 4, 2012

Hope this is going well for you. I had a tough pre-teen diabetic last year and he made me work for my money everyday!

mustlovepoodles, RN · Sep 4, 2012

It's going...okay....I can't seem to get through to him the importance of carrying his diabetes kit bag with him at all times. I can't tell you how many times he has come to the clinic to check blood sugar *without* his meter. :uhoh3: Despite the fact that I send him right back to class to get it, he continues to "forget." I tried instituting a reward system for him, but unless it is attached to food he simply doesn't care. The latest struggle has been keeping juice in his kit bag--he drank it on the bus going home--"I was thirsty." Smiling, giggling. He told me his doctor told him "it's not my fault! I'm just like this!!" :banghead:

I have gotten the cafeteria on board. I work with the child to choose his lunch, then he takes the written menu to the cafeteria ladies who are on notice to give him NOTHING but what is on the menu. No snacks without mom's permission. But he keeps trying every adult who goes in there, especially those who don't know him and his situation.:flamesonb

blondy2061h, MSN, RN · Sep 4, 2012

How's he doing academically? The whole going to your office, forgetting his meter, going back, forgetting it again, makes me wonder of he's avoiding class. Or maybe attention seeking? Has he seen a counselor? A diagnosis like this can be upsetting.

rn/writer, RN · Sep 4, 2012

Please, forgive me if I sound critical. That is not my intention. I just can't help but notice that this is typical behavior in newly diagnosed diabetics everywhere, no matter which type and no matter how old. They hate that they have all these new restrictions along with a ton of people telling them what to do and when to do it. And so they rebel. Preteens are already primed for the adolescent launch into resistance, but anyone confronted with a host of expectations and limitations is going to feel a huge amount of anger and frustration over what feels like an ambush.

What do they do with the emotions? A few bite the (low-carb) bullet and settle down. But most go through a period of turmoil and acting out before they are ready to look at what comes next.

Part of this acting out includes casting the caretakers in the role of the disease. The patient, in effect, hands a tug-of-war rope to the parent, doctor, nurse or educator and yanks on it as hard as he can. It makes him feel powerful and in control. Unfortunately, the logical reaction is for the caretakers to pull back to get the patient into "compliance." Which invites more pulling from the patient. And so on, ad nauseum.

This goes on until someone gives up (or the rope breaks!). Many times, the conflict drags on for years with no one really winning.

What's a concerned school nurse to do?

The first thing you can do is acknowledge, both to yourself and to the kid, that you can't make him do anything he doesn't want to do. That isn't giving up. It's putting an uncomfortable reality on the table for all to see. Why would you do this? Because it's the truth. But more important, because it's a highly effective way of setting down your end of the tug-of-war rope. You are telling this child that much of the power to live better lies within him and you will not agree to turn his life into a wrestling match.

Next, you apologize for trying to control his life and sending him to the lunch ladies with a list you drew up. You own the fact that you (again, this isn't meant to be critical--it's what we're taught to do, however erroneously) didn't give him time to get used to the idea of being diabetic and come up with questions on his own. Suggest that things might have gone better if you'd let him tell you about his life and what is important to him before telling him what to do.

By this time, he'll probably be in shock and wondering what the catch is.

As well he should.

The catch is that he is really the one in charge. Ask him how that feels. Expect a pretty positive reaction. Then you can gently (oh, so gently) explain that this means his is also the one responsible for whatever happens. Tell him he will have lots of help and support, so he doesn't have to feel too scared of such a big job. But it really is his job.

I'd encourage you to set up times to meet with him. More often at the beginning. Get to know him. Kids really gravitate toward people who are willing to listen to them. If you catch yourself jumping in with critical messages, stop and apologize for interrupting. Learn the currency of his life to find out what motivates him. Ask him questions about his hopes and dreams and goals. Ask him to think about any problems diabetes is causing him now or might cause him in the near future. (Preteens generally think a couple of weeks ahead, but they can stretch to consider high school. Adulthood is somewhere "out there" and not relevant.) Let him mull this over for the next meeting. Shake his hand and thank him for talking with you. The concept here is that if you don't establish connection and build trust he won't listen to you or look to you for guidance.

At the next meeting, kick around topics like the things he hates most about being diabetic or stuff he's afraid other kids will notice. Meet him where he is and let him know you're an ally, not an enemy. Ask about his symptoms in a non-threatening way. Does he mind them. Has he ever been teased or treated differently because of them? If so, you could assist him with making his own list for the lunch ladies. Or you could make suggestions for choices that might lessen his symptoms.

Provide him with websites for young people that lay out the nuts and bolts of the disease and how it affects kids in user-friendly ways. This kind of resource should pique his curiosity and let him know he's not alone. He needs access to lots of information. You can also give him age-appropriate written info--thinkg like ways that uncontrolled diabetes can mess up his teen years. No driver's license in some states if he has a history of diabetic seizures. Problems with playing sports. Weird breath. Seizure-related incontinence (gasp!). Things that would get a kid's attention.

Now that the kid himself is coming up with questions and feeling the need, let him know that you have ways to help him step up and take action. The glucometer, is no longer a control device used by the people who are trying to boss him around. It is now a highly useful weapon in the fight against humiliation and a way for him to assess the effects of diet and activities.

Anytime he says no to something you offer, say, "Okay. I just want you to know that [whatever] is available. If you ever think it would be helpful, let me know." No judgment. No coercion. No shaming.

Let him feel his own need and formulate his own questions. If you don't think he will do this, trust that his body will keep giving him reminders. If this gradual approach is too scary to consider, think about what he will be doing if he's in open rebellion. The biggest difference will be that your door is open and he doesn't have to feel ashamed or whipped to come to you. You want to plant the message in his brain that you are someone he can turn to when his body starts acting up or he runs into problems.

This is one time when uninvolved parents can be a blessing. Many parents of newly diagnosed kids ramp up the helicoptering to a breathtaking degree. They become hypercontrolling and a little hysterical in a way that really messes the kids up. Of course, you take charge with little kids. But when a child reaches the age where they fight back, you have to work within their autonomy and not just shut them down. Uninvolved parents will probably not have a cow over a more laid-back approach, and that give you-and the boy--some breathing room.

Here is a link to an article I wrote about newly diagnosed diabetics. It focuses mainly on Type 2 patients, but much of it applies to the Type 1 folks, as well.

https://allnurses.com/general-nursing-discussion/those-darn-diabetics-640099.html

Forcing the issue might get you some good results in the short term, but I can just about guarantee long-term disaster--lots of cheating, risk taking, and denial. Combining honest (non-emotional) information with respect will allow this boy to become far more invested in his own treatment than all the coercion in the world. Why? Because it will come from the inside and not depend on the overseeing presence and threat of caretakers. He will be his own best advocate in the long run.

blondy2061h, MSN, RN · Sep 4, 2012

It's also important to note that most type 1 diabetics are no longer prescribed a restricted diet, at least no long term. They're prescribed insulin in varying amounts to match their carbohydrate intake. He may be on a restricted diet now until things get under control, but maybe he can take encouragement in knowing that it doesn't have to be long term.

mustlovepoodles, RN · Sep 4, 2012

At the moment his doctor has limited him to 60gm carbs per meal. I do not choose his food for him; he does. I give him the daily menu choices. He can choose between 2 entrees or a big lunch salad, fresh fruits and veggies, canned fruits, white or choc milk, or fruit juice. What I do is put several combinations together so he can see what 60 carbs buys him. For instance, he had a breakthrough last week when he discovered he could have 1 grilled cheese sandwich + 1 juice(his favorite choice) for 60gms OOOORRR he could eat grilled chicken fingers, corn, peaches, a plum AND 1/2 carton of white milk for 60gms. :yelclap: When he saw how much food he could get by making other choices, he "got it." Now he looks at it like a puzzle and he's switching things around so he can get the most food without going over the carb budget.

I will continue to have him carry his menu to the cafeteria until he gets a little more secure about it, maybe another month. Everything is still so new to him, I really believe he needs a moderate level of assistance and some structure. I have talked with his mom about all this, and she is on board. Apparently he's doing pretty well at home. I have to give the child some credit--diabetes is a sucky thing to have,especially when you're only 10 yrs old.

rn/writer, RN · Sep 4, 2012

Great to hear that he's looking at the dietary choices like a puzzle. It sounded like you were making the choices for him, and that usually doesn't go down too well.

It is amazing to see what you can "buy" with good carbs compared to the little bit bad carbs will get you. That's an excellent and very visual tool.

country mom · Sep 6, 2012

I work mostly with adult type 2's and learning carb counting is a challenge for them- I can't imagine being 10 and trying to learn it. Thank goodness this child has a school nurse there to help him.

mustlovepoodles, RN · Sep 6, 2012

Isn't that the truth! Yesterday I had a pleasant heart-to-heart with my student. Nothing scary, no confronting. Just "Gee, you know? You have kept your blood sugar in a pretty good place the last 4 weeks. And I think you are making some good food choices. Has it been hard, finding out you have diabetes?" And that unleashed a torrent of words, mostly relief I think, that someone is listening to him rather than correcting him for everything. He is really getting the concept of the carb budget. He says he wants to give his bus driver some juice boxes so he won't be tempted to drink them on the way home (he has some glucose tabs which he doesnt like much.) Yesterday he chose a good lunch. But when he went to the cafeteria he chose some additional food. The manager sent him to me with his tray in hand. I spotted his extra 16gms fruit. Once I explained that he could have the fruit, but he would need to take additional insulin he was stunned. And then a light bulb went off in his head. :idea: In the end he elected to save one of his fruits for a snack later rather than get another shot.

So it's going pretty well this week. No hiding food. He's starting to come on board. Now, if I can just get him to take his diabetes kit with him everywhere he goes.

100kids, BSN, RN · Sep 7, 2012

That's great! Huge progress. I think sometimes it's hard because the kids are unsure, the parents are unsure and everyone needs to figure it all out. Sounds like you really made an impact.