Help with Diabetic Non-compliant Student

bergren · May 28, 2010

What do his parents say? What was the reaction of the primary care provider?

There is quite a bit in the literature aboutt working with adolescents with diabetes - have you been looking at that and the suggestions are not working?

This is an interesting article:

"Is non-compliance a dirty word?"

Non-compliance vs. diabetes self care: Are we still playing a blame game? - Diabetes Health

rn/writer, RN · May 28, 2010

Non-compliance presumes he has agreed to a treatment plan and is not following through. The fact the his doc or his parents have expectations for him doesn't mean he is at all invested in "their" plan.

I would start by just talking with him. See if you can get him to tell you what he understands about his condition (more user-friendly term than disease). Ask him about his goals for life--both short- and long-term. Ask how he felt (emotionally) after passing out in the bathroom. Certainly, if the goal is to be normal and blend in with the crowd, that would not qualify. And inquire just what it is that he thinks is being asked of him. Also, find out how well he understands things like A1c, carbs, glycemic index and some of the other terminology.

Get him talking about what holds him back from doing the things that will keep him healthy. If you can reach the anger and make a connection, you might have a chance to build some trust.

Without the trust, he won't have any reason to listen to anything you say.

Be willing to listen for a while before asking things of him. Present ideas and choices to him and respect his autonomy. Be different from the people who are hammering him to take care of himself.

If you can develop a genuine rapport, you can tell him that he matters to you and you would like to think he'll be around for a long time to come.

When you present information, put a positive spin on it. Instead of saying, "If you don't get your A1c down, you could go blind or lose your toes," say, "If you can keep your A1c below seven, there is a good chance that you won't lose your sight or have your toes amputated later in life." People tend to tune out threats. They absorb information better when it looks like there is something to be gained.

If there is something he's supposed to do and he's refusing, start small. Say, "I understand that you don't want to come in every day. How about twice a week. And for the first two weeks we can just talk." That may not seem like much, but it's more than he's doing now.

Find stories of famous young people who are successfully dealing with diabetes so he can see what good control looks like and what is possible if he achieves it.

Help him to graph his blood sugars and keep a record of success.

Point out that if he is willing to work with you, it might get his parents off his back.

Finally, whatever he decides, keep accepting him as a person. It really is his body and his battle. If he can see you as an ally who will not get disgusted or angry with him, you stand a good chance of helping him to do better.

Even as an adult, I struggle with doing all that I should. This has never been helped by overzealous practitioners who only want to harp on me about "compliance." The good ones met me where I was and have helped me to take baby steps. It takes time for a patient to own their condition. The most helpful things in this battle are connection and respect.

I hope he is receptive to you.

mustlovepoodles, RN · May 28, 2010

Non-compliance presumes he has agreed to a treatment plan and is not following through. The fact the his doc or his parents have expectations for him doesn't mean he is at all invested in "their" plan.
I would start by just talking with him. See if you can get him to tell you what he understands about his condition (more user-friendly term than disease). Ask him about his goals for life--both short- and long-term. Ask how he felt (emotionally) after passing out in the bathroom. Certainly, if the goal is to be normal and blend in with the crowd, that would not qualify. And inquire just what it is that he thinks is being asked of him. Also, find out how well he understands things like A1c, carbs, glycemic index and some of the other terminology.
Get him talking about what holds him back from doing the things that will keep him healthy. If you can reach the anger and make a connection, you might have a chance to build some trust.
Without the trust, he won't have any reason to listen to anything you say.
Be willing to listen for a while before asking things of him. Present ideas and choices to him and respect his autonomy. Be different from the people who are hammering him to take care of himself.
If you can develop a genuine rapport, you can tell him that he matters to you and you would like to think he'll be around for a long time to come.
When you present information, put a positive spin on it. Instead of saying, "If you don't get your A1c down, you could go blind or lose your toes," say, "If you can keep your A1c below seven, there is a good chance that you won't lose your sight or have your toes amputated later in life." People tend to tune out threats. They absorb information better when it looks like there is something to be gained.
If there is something he's supposed to do and he's refusing, start small. Say, "I understand that you don't want to come in every day. How about twice a week. And for the first two weeks we can just talk." That may not seem like much, but it's more than he's doing now.
Find stories of famous young people who are successfully dealing with diabetes so he can see what good control looks like and what is possible if he achieves it.
Help him to graph his blood sugars and keep a record of success.
Point out that if he is willing to work with you, it might get his parents off his back.
Finally, whatever he decides, keep accepting him as a person. It really is his body and his battle. If he can see you as an ally who will not get disgusted or angry with him, you stand a good chance of helping him to do better.
Even as an adult, I struggle with doing all that I should. This has never been helped by overzealous practitioners who only want to harp on me about "compliance." The good ones met me where I was and have helped me to take baby steps. It takes time for a patient to own their condition. The most helpful things in this battle are connection and respect.
I hope he is receptive to you.

I quoted you with the intention of snipping some of it before I reply, but your advice is just too good to shorten. I think I had this same student about 2 years ago in middle school. He just would not take care of his diabetes. He didn't care. Nothing that I could do or his mom could do made any difference at all. He had a probation officer specifically because he had been deemed an unruly child due in part to his non-compliance. He had even been sent away to a therapeutic school for a year, during which they tried to force compliance. He was released when even they got sick of his games. This student didn't want to have diabetes and he wasn't going to have any part of it. He went into DKA at least once a month in school. :eek: His doctor was just about finished with him, too.

I really felt sorry for my student. He had a very hard life. His dad was in prison, his mother had only been out of prison for about 3 months. He used his diabetes as a way to control his mother and get attention. I know that he was bringing in candy and other contraband but we could never catch him at it. Still, he'd come to the clinic with BS at 500 and vomiting, so I had to take it seriously. School system policy dictated that he had to go home for a BS of 500, and he knew just how far to take it so he could get what he wanted. He was constantly rewarded for his bad behavior. But my hands were really tied. All the talk in the world made not a difference in his thinking. He had decided not to have diabetes, I think.

I don't have any experience taking insulin, but I do have type 2 diabetes. I can understand how hard it is to stay compliant. Sometimes I fall off the wagon, too. My mother also has type 2 diabetes, but like my student, she had decided not to be diabetic. So she eats lots of carbs, very little protein or fiber, doesn't check her sugar(other than her fastings--about 126 :uhoh3: and her doctor is fine with that.) Mother has already lost the feeling in both feet--she waddles when she walks. The kicker is, my mother is an RN. She *knows* what to do and what the consequences will be. She just doesnt' want to deal with it. Just spending time with her is enough to keep me reasonably compliant!

OP, I hope you can make a difference with this student, but I wouldn't be surprised if he blows you off. It's very common for teens to not take diabetes seriously. I have a friend who was like that all through his 20s. He's in his early 30s now and on the waiting list for a pancreas-kidney transplant. He has been on dialysis for several years. He says he knew what he had to do, he just didn't want to do it. He wanted to be a normal kid. He didn't take it seriously until his kidney function hit 10%. :crying2:

rn/writer, RN · May 28, 2010

Let me add that no matter what happens, you might be planting seeds that will sprout years down the road. Maybe the most important thing for your student right now is a listening ear. Very often we don't exactly know what we're feeling (or we won't let it in) until we actually put the emotions and thoughts into words. He might be surprised at what's "in there."

Just being in his corner may be all that he'll allow at the moment. Or maybe he'll let you build on that. Either way, something good could come of your concern.

I wish both of you the best.

bergren · May 29, 2010

The research shows that the compliant teens with diabetes are depressed and the non compliant are not

Allie911 · May 29, 2010

Wow thanks for all the great advice. He struggles with his relationship with his dad and his mom isn't really in the picture anymore. I really believe he doesn't comply due to his relationship with his dad, it seems to be a power struggle. I've decided I need a counceling degree along with my nursing degree with this job )

katgross52 · Sep 28, 2011

If you find the answer to this question honey, please let me know!!!!! I have a 7th grade diabetic who is all of a sudden non compliant. She is coming to me before lunch checking her sugar and then we sit down together and she choses her foods. Together, we program her carbs into her insulin pump based on the foods she chose. We always choose foods that stay within her allotted 60 grams of carbs for meals. I hang around this school just so that she can check her sugar an hour and 1/2 later and it is always off the charts. Now, I find out that she is not eating what she chose and programmed into the machine. I have 4 schools and I cannot be this girls personal private duty nurse. The parent is exasperated and I'm at a loss. Any suggestions?

Jolie, BSN · Sep 29, 2011

While not ideal, what about calculating fast acting insulin coverage AFTER she eats, based upon what she has consumed?

rn/writer, RN · Sep 29, 2011

While not ideal, what about calculating fast acting insulin coverage AFTER she eats, based upon what she has consumed?

This is a good idea.

You guys might also see if there are phone apps for some of these kids that they could check into without attracting a lot of attention from their peers.

And pens, if they're covered, could make a big difference for kids who are now using needles and vials.

I would encourage you all to focus mainly on building connection with the kids. Ask them what it feels like to be diabetic and what part of their regimen they hate most. Forget the parents and the docs for the time being. Chances are they're doing more pushing than listening. Let the students teach you.

If the kids start liking coming to see you--having ONE person who is interested in what all this feels like to THEM--at some point you can tell them the truth--they aren't going to keep being able to coming in if the powers that be don't see anything being accomplished. Ask them to figure out a strategy--what's something you can do to help other people believe our time together is worthwhile?

It's a rare kid who can resist someone who is truly willing to give them an ear. But it has to be sincere. Your primary agenda has to be to build trust and connection. Only then will you have the street cred to finesse the rest.

I wonder if there's any possibility of starting a support group for some of the kids. Sometimes they listen to each other when they won't listen to anyone else.

Whatever happens, keep the door open. You never know when a kid will have a reality shock and need to talk.

Keep fighting the good fight. :up:

Arnu · Sep 29, 2011

Teen years are very hard. How long has this child has diabetes? Do his parents help him at all? For his doctor and parents to basically give up on him is sad and frustrating. This child doesn't need ultimatums, he doesn't need threats, he needs someone to understand. Threatening to suspend a child over not doing blood sugar checks is out of line. Is that even legal? In our district that never would happen.

I think you need to gain his trust and start with baby steps, no threats. He's a teenager, maybe he resents the fact that he has to go to the nurse in the first place? Maybe work out a plan with him stopping in the office in the middle of the day to let you know what his bg is. say before lunch, if he's checking else where he can peak his head in an say '135' or whatever he is. I'm sure he's holding some resentment. Diabetes is very difficult, most people don't understand that. Its constantly there.

Sitting down and having a heart to heart with any teen that is having a difficult time will go a long way. You're on there side, to help them, not to control them and certainty not to threaten them.

Good luck.

kids · Sep 29, 2011

My (now 31yo) daughter has been diabetic since she was 7.

What seemed to set off poor compliance in my daughter was the perceived loss of privacy and autonomy at school, that she enjoyed at home.

By middle school she was proficient at checking her sugar, calculating her coverage, doing injections and planning her meals (this back in the dark age of diabetic exchange diets, lol).

At home she was independent, she recorded her numbers on a pocket calendar and would let me know where she was on the scale in terms of coverage. At doctor visits the calendar came out for the doctor and they reviewed her numbers together.

At school her blood sugar was checked, she was told how much coverage she was getting, it was drawn up and injected by the nurse in the location of the nurse's choosing. The school nurse was resistive to any challenges to her methods and it made for a rough couple of years. Once my daughter made the move to high school and a nurse who was all about letting her be in control of her disease the compliance issues ended. The nurse only required that the pocket calendar be available in an emergency (as I did at home).

Opposite ends of the spectrum in terms of management and not an ideal method for every kid, just something that worked for mine and something to consider for others.