Recent information, as described in this issue, suggests that more effort, time, and precision on our part could benefit patients who have diabetes. At this point, there is more evidence of this for adolescents than for younger children. However, knowing how to best manage diabetes in teenage patients is not the whole story. The patient and the family must play the major role in diabetic management. So what we have is a teenager going through his or her normal development, which includes establishing independence from parents (and other authority figures, such as pediatricians) and shifting dependence to peers while indulging in the usual adolescent experimentation (taking risks). And we expect this same teen to be doing more to prevent diabetes (weight control and exercise for prevention of type II diabetes mellitus), to visit us at the earliest signs of diabetes, and to more precisely manage this disease by frequent home monitoring, dietary control, insulin adjustments, and lots of clinic visits. Because nothing happens unless the adolescent makes it happen, I asked Dr. Paul Robinson, Director of Adolescent Medicine at the University of Missouri's Children's Hospital in Columbia, to share his art of gaining cooperation from teenage patients. His reply follows.
When I was a pediatric resident 15 years ago, I helped take care of a young lady. Jenny was 16 years old and her diabetes was out of control. She was being hospitalized frequently (it seemed almost monthly) for diabetic ketoacidosis. When I asked why she was having so much trouble taking care of herself, she insisted that she was doing everything we asked and could not understand where these problems were coming from. She dutifully produced her diary showing excellent diabetic control. On the other hand, Jenny's mother rarely accompanied her to clinic and her father had not been involved in her life since she was 4, near the time her diabetes appeared. Mom had had several relationships with men since then, but none of them had lasted. Jenny had been involved in serial relationships herself. I asked about sexual abuse, but Jenny denied this. When I finished my residency, Jenny already had significant proteinuria. I wonder how she is doing now, but I am afraid I already know.
Compliance is always an issue when treating adolescents, and diabetic management is impossible without the full participation of these patients. How can the pediatrician maximize their active participation in their own care? Jenny's case demonstrates that strong family support and good parenting are fundamental ingrethents here. Does the pediatrician have any influence over this? Yes and no. Once things are to the point they were with Jenny, little can be done, although team care still offers the best source of help. However, every time we see any child, from infancy on, we can guide parenting.
Children of all ages and cultures thrive when parented by authoritative (as opposed to authoritarian) methods. Authoritative parents give their children unconditional love. They set reasonable limits and stick to them. They teach responsibility and allow intellectual freedom. Children raised in such homes learn how to take care of themselves because they are allowed to take progressively more of the responsibility and consequences for their behavior and mistakes. When struck by diabetes or another chronic disease, they are better prepared to cope. So, as clinicians, we should teach and encourage these principles as parenting skills. It is worth the effort. Even during the teenage years, and perhaps especially then, parenting instructions make a difference. Without family support, our ability to help adolescents is greatly reduced.
CONNECT WITH ADOLESCENTS
To care for teens and increase adherence, it is important to first connect with them. Don't take their independence (rebellion) too seriously or be too serious yourself. This does not mean talking or dressing as they do, but relaxed humor goes a long way and preaching usually goes nowhere. Adolescents can spot insincerity better than we think, so "faking it" does not work. We need to let them know that we care about them and that they, not their parents, are our main concern. This message can be lost when adolescents are seen only with their parents. Parents may be accustomed to giving their child's history because they have done so throughout his or her life. The clinician is tempted to allow this to continue because it is quicker and easier. Even if the clinician starts the interview by talking with the child, within several minutes most of the conversation often shifts to the adults in the room. The child is relegated to being a bystander rather than an active participant. In my opinion, this is a tremendous mistake and one that will lead to less patient compliance.
ENCOURAGE ADOLESCENTS TO TAKE AN ACTIVE ROLE
When I enter a room in which there is a parent and a teenager, I always greet the teenager first, before saying hello to the parent. If the teenager is a new patient, I explain up front that I intend to ask him or her the questions and that I would like the parent to answer only if the adolescent is unable to do so. The latter is generally necessary when we get to such things as birth history and family history. At some point, it is important to spend time alone with the teen, allowing him or her to express concerns without the parent present. This also allows better recognition of behavioral problems. I usually ask the teen whether the parent should be present for the physical examination. If there is time to spend alone with the teen before the parent returns to the room, I will sum up the findings and plans with him or her, repeating this when the parent returns. As a result, the adolescent hears things twice. Although this takes more time, it is worth it. If the parent is present during the "wrap-up," I will be talking to the teen. If the parent does ask questions, I try to address the answers to the teen. Although this may feel artificial at first, it becomes easier the more you do it, and parents and adolescents have said that they appreciate this. Regarding laboratory values, it is best to let the teen know the results before the parent, and, whenever possible, summary letters should be sent to the teen. This approach encourages the adolescent to be a part of the treatment team and the parent to let the teen take as much responsibility for care as possible.
In any relationship, there must be give and take so it is important to negotiate that which can be safely negotiated. This involves giving the adolescent options for treatment and allowing him or her to decide the course of action within parameters you and the parents can accept. Sometimes this negotiation takes the form of a contract, written or verbal. All of us are more likely to follow a treatment recommendation if we are involved in the decision.
These are my philosophies for helping the adolescent to become responsible for his or her care. The approach is not without anxiety for the pediatrician and the parent. Perfection is never possible, but I think you will get further with this than by working with parents in an authoritarian way.