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Special Challenges Of The Teen Years

Published:
25-April-2005

By H. Peter Chase, M.D.

  • Struggle for independence
  • Growth and body changes
  • Identity
  • Peer relationships, alcohol, drugs, tobacco
  • Sexuality
  • Consistency (exercise, eating, emotions, and lifestyle)

Struggle For Independence

Parents often despair at the thought of their "angelic" child becoming an adolescent. The teen years have been defined as the period in life when one varies between wanting to be a child and wanting to be an adult. These feelings vary from second to second, minute to minute, hour to hour, day to day, week to week, and year to year. The "child" part of the adolescent wants to be completely dependent on parents and other adults. The emerging "adult" wants to be an entirely independent person. There are many shades between these two extremes that may linger into later life. Hopefully, the variation becomes less with increasing age.

In the past, we believed that children with diabetes should assume their own management at a certain age and they would suddenly become independent. We now know that independence is not age specific and is a gradual process. We think of diabetes as a family disease that requires a great deal of parent-child partnership to achieve good blood sugar control and healthy independence. Parent partnership (involvement) with the teen can be accomplished in a variety of ways: drawing up and giving injections; keeping a log book to record blood sugars and note trends and problems; faxing blood sugars to the diabetes care team; helping with weekend dosing when teens may want to sleep in and could use some help with shots and a quick breakfast. These not only help the teenager, but also keep the parent "in the loop" and aware of what is going on with management.

The "child vs. adult" struggle can greatly influence diabetes management during the adolescent years. A teenager may want entire responsibility for diabetes management at one time, faithfully checking blood sugars, watching food intake, and taking the responsibility for injections. At another time, blood sugars will not be checked unless the parent is there to help, injections may be forgotten, or sugar may be consumed in large quantities. Parents can lessen the effects of this variable attitude toward the diabetes care by remaining involved and offering to share these responsibilities with their "child-adult". A supportive adult who is readily available, but not overbearing or constantly nagging, can be a help to any person with diabetes, regardless of age.

Diabetes care is usually NOT the top priority for a teenager. Their main priorities may be their peers, schoolwork, sports, a car, a job, etc. (in varying orders of importance for different teens). Thus, the parents may need to help in keeping focus on the tasks necessary for good sugar control.

If the teenager's actions (or lack of them) result in possible serious dangers to his/her health, then the parents have no choice but to step back in for a time. This is particularly true when insulin shots are being missed. Hopefully the next attempt at taking on increased responsibilities will be more successful. Sometimes professional counseling is necessary. However, the majority of teenagers gradually assume adult independence by themselves. In contrast to the parents' worst fears, they do grow up! In fact, a teenager with diabetes may assume adult responsibilities earlier than other teenagers.

The task of how to help children grow to be independent young adults is a challenge for most families. Diabetes complicates that task somewhat. It is normal for parents of children with diabetes to feel anxious about normal separations such as overnights, camp, and school trips. Keep in mind that with good preparation and supervision, these separation experiences are an important part of growing up.

Growth And Body Changes

The adolescent growth spurt and the development of adult sexual characteristics result in many body changes, probably more than occur at any other single time of life.

Growth Hormones

The gain in height is a result in increased hormone levels (growth hormone, testosterone, and estrogen). Growth hormone partially blocks insulin activity. As a result, insulin requirements increase dramatically and are usually the highest per pound body weight that they will ever be. The insulin requirement usually decreases when growth is completed. If blood sugar control is good during puberty, full growth is usually reached. Research has shown that better growth (to full adult potential) is more likely with good sugar control.

Sex Hormones

Female sexual development includes breast and hair development, widening of the hips, and the onset of menstrual cycles. These pubertal changes may be slightly delayed in girls with diabetes. Blood sugars may increase during menstruation, and many girls will increase the Humalog or short-acting insulin during this time.

Body Image

Teenagers are often very concerned about "body image". It is fortunate that diabetes does not usually result in visible body alterations. Wearing an insulin pump may change this, and is part of the reason why pumps should not be "pushed" on a person until they are ready. However, having diabetes may make teens "feel" different from their peers. The refusal to wear an identification bracelet or necklace, to wear an insulin pump, or to refrain from eating high sugar foods may relate to not wanting to feel different from their peers.

Identity

Who am I?

Teens are searching for the answer to the question, "Who am I"? It is important to emphasize the positives about whom they are at this stage of their lives, and who secondarily happens to have diabetes. The diabetes should not come first. Positive reinforcement should be given when a good attitude toward living with diabetes is demonstrated. Compliments are important. For example. "Good job on getting your blood tests done even with the stress of finals" (even though the stress and not exercising may have resulted in high sugar values). In contrast, it might be necessary for parents to "bite the bullet" and not respond when stress results in blood sugar testing not being done. A cheerful offer to record results or give injections during busy times can be rewarding for both the teen and the parent.

Risk Taking

The in-the-middle age range of teenage years, 15-17 is usually the most difficult time of the teenage years. The teen often sees himself/herself as "invincible". Risk-taking and experimentation tend to occur more frequently. These may include risks involving diabetes such as eating high sugar foods, not doing blood sugars, or even missing shots. Regular (or more frequent) clinic visits and HbA1c tests at this time may help return the teen to reality. Parents need to let the teen know that they trust their child to act maturely. Patience on the part of the care providers and from the parents is a real virtue at this time.

Peer Relationships

Peer relationships are very important to teenagers, often more so than relationships with parents. Early in adolescence, close friends are usually of the same sex. In later adolescence this often changes. Being like their peers is very important, having diabetes and being different can be a problem. Some teenagers are comfortable doing blood tests or giving themselves injections in front of their friends. Others, particularly if acceptance of the diabetes has been a struggle, will absolutely refuse to let anyone other than the closest friend know that they have diabetes. The willingness or refusal to wear an ID necklace or bracelet may reflect the teen's own acceptance of diabetes.

Much of a teen's identity relates to conforming with their peer group. Peer groups can be important in helping the teen make decisions about the use of drugs, alcohol, or tobacco. If the peer group rejects or accepts these, the teen with diabetes will probably do likewise. Because smoking and chewing tobacco age the blood vessels and lead to a greater likelihood of diabetic kidney disease and later of heart attacks, tobacco use is particularly harmful to the individual with diabetes. Alcohol consumption can result in delayed severe insulin reactions. Drugs that alter awareness of time have their greatest effects on diabetes by interfering with consistency in eating and insulin injections.

Participation in a support group for teenagers with diabetes can be a help. A support group can be both a social and a discussion group. It may help the teenagers share their feelings with others who also have diabetes. They soon realize that others have many of the same feelings that they do, and that they are quite normal in spite of having diabetes.

Research has shown that the teen with diabetes who involves his/her peers by sharing knowledge about diabetes is more likely to achieve better sugar control. You may want to encourage a teen to bring a friend to a clinic visit to continue to learn how they can support their friend with diabetes.

Sexuality

Teenagers with diabetes run the same risks as non-diabetic teens of contracting diseases such as AIDS, herpes, chlamydia, and other sexually transmitted diseases. Pregnancy in adolescent girls with diabetes has added risks compared to non-diabetics. If a woman with diabetes is in excellent sugar control prior to becoming pregnant, there will not be an increased risk for miscarriages or birth defects in the baby. However, if she is in poor sugar control, particularly in the early part of a pregnancy, the baby will be at increased risk for birth defects. The only sure way to absolutely prevent a sexually transmitted disease or pregnancy is to abstain from sex. If a male or female believes they cannot cause or become pregnant due to diabetes, they are absolutely wrong. The stress of the teen years may be heightened by conflicts about emerging sexuality.

Consistency (Exercise, Eating, Emotions, And Lifestyle)

If everything could be the same everyday, blood glucose control would be much easier. Unfortunately, there is no such thing as consistency in many teenagers' lives. Bedtime may be at 10:00p.m. on school nights, but then at midnight or later on weekends. Many teens like to sleep late on weekends. Parents should set an absolute limit of 9:00a.m. as the time when the insulin must be taken with at least a glass of juice. The teenager can then go back to sleep for an hour. If the teen sleeps later than 9:00a.m. without juice or food intake, the insulin taken the previous evening may lead to hypoglycemia. Likewise, taking the insulin later than usual results in an overlap with the evening insulin and a greater likelihood of low blood sugar. Once again, supportive adults must be available to make this plan work.

Consistent exercise is often a problem. Seasonal sports, such as football or soccer, call for heavy exercise for a few months, but may be followed by weeks or months of little activity. Blood sugars will vary and the insulin dose and eating plan may need frequent adjustments for changes in activity level. It is good to have a back-up activity such as walking, jogging, or aerobics so that there is some exercise everyday.

Rapid mood swings are more common during adolescence. Mood swings may change the blood adrenaline level, affecting blood sugars. Adrenaline causes the blood sugar to rise. In general, normal adolescent mood changes should not affect overall glucose control significantly. However, adolescence is frequently an age when other conditions may emerge. Mood disorders and anxiety disorders are common, though they are often unrecognized conditions. If your teenager shows unusual changes that are concerning you, please talk to your health care team. Such changes include frequent irritability or anger, a drop in grades or school performance, loss of interest in activities that were previously enjoyable, suspected substance abuse, changes in sleep habits, loss of appetite, hanging out with a different group of friends, or dropping friends altogether. These may be symptomatic of an underlying mood disorder.

Teenagers' eating habits may be affected by their emotions. Teenagers are notorious for rather unusual eating habits and this poses a challenge for teens with diabetes who might not want to see themselves as different. Parents should be suspicious of eating disorders if their teen overeats, doesn't exercise and still doesn't gain weight. Weight loss without dieting or heavy exercise should also alert the parents to possible missed injections. More parental supervision and possibly professional help is then necessary,

The teen years are stressful for everyone. However, they can be the happiest years of an individual's life. The teen with diabetes has extra stresses, but with a supportive family, these stresses can be managed. Diabetes is a partnership between the parents and the teenager. It is often important for the parents to be patient and to remember that they too, were once an adolescent. Parents must find ways to stay involved in the diabetes management, but not to be too overbearing. Diabetes is a disease of compromise, as parents, teens, and care providers must often compromise as to the level of care agreed upon. Parents must be available to help and to be supportive, but still let the teenager gain independence. The good news is, they do grow up!

By H. Peter Chase, M.D.
Barbara Davis Center for Childhood Diabetes
Department of Pediatrics