The diagnosis of diabetes can cause any number of feelings in each family member as well as in the family as a group. These feelings often follow a similar pattern, sometimes referred to as the grief process. The student may deny the disease or feel very sad. Anger is very common as is fear and guilt. Adaptation to the condition is aided by talking and sharing feelings. School nurses and teachers are in a position to listen and provide support.

School Age: Ages 6-11

Developmental Issues

  • Diagnosis at this age: kids readily assume that sexual or aggressive feelings and thoughts brought this on.
  • Fear of dying (“di” in “diabetes”) intensifies — feel helpless in the face of death
  • Fear of complications from advertising
  • Feelings of powerlessness, external locus of control.
  • Belief in their parents as a source of security erode.
    • may rage at parents for not protecting them
    • fear that parents will not tolerate the illness (confirmed when parental bereavement is observed or overheard)
  • Fear that parents will be burdened financially by the treatment plan.
  • Fear that they will lose family position or not be able to positively contribute.
  • Waning dependency on parents
  • Fear of being “different”
  • Can perform most self-care
  • “Cheating” (food and blood sugar results) not uncommon
  • Regression: bedwetting, tantrums, school phobias
  • Eager to learn
  • Begins to understand “consequences”
  • Tests independent decision-making
  • Most time spent away from home

Problems with Diabetes

  • To protect her/himself, the child may try to hide his differences and ignore diabetes by bedwetting, eating “forbidden” candy at school, refusing to eat snacks/lunches, ignoring early signs of low blood sugar, refusing to wear Identification, etc.
  • Such efforts at “not having diabetes” often cause the opposite effect: high or low blood sugars, more adult concerns, and more (rather than less) attention.
  • School personnel may not understand diabetes and its demands: aspects of diabetes that can embarrass the child may annoy the teacher or be perceived as a means of self-attention or avoiding work; excess school absences, school failure, and lowered self-esteem are potential consequences.
  • Family gives up more control without assurances that those who have responsibility will be conscientious and concerned; the family becomes a nuisance — especially if a problem — real or perceived occurs.

Prevention

  • Emphasize positive aspects of the differences between the child and peers: can eat snacks when others can’t — special privilege not to be abused.
  • Provide an opportunity to discuss diabetes as a school project — invite diabetes team; peer and teacher acceptance and support is addressed as a positive open approach to diabetes rather than something that is kept secret and embarrassing.
  • Tell classmates that diabetes is not contagious and does not come from eating too much candy.
  • Clarify the child’s — and peers’ — fears, fantasies, perceptions and attitudes as they occur so that maximum cooperation takes place.
  • Allow the child to express feelings of control over the body and pride in doing those special things to stay “in control.”
  • Encourage and reinforce openness and honesty through family therapy, acknowledgment of the difficulties involved with diabetes, and the use of nonjudgmental parenting/counseling to stop attitudes of dishonesty and sneaking.
  • Discourage teachers from using foods as rewards for good behavior or learning.
  • Address positive ways to resist societal and peer pressure.
Teens: Ages 12-18

Developmental Issues

  • Erratic growth; puberty
  • Glucose control may be erratic
  • Concerned about body image
  • Greatly influenced by friends
  • May challenge authority
  • Development of self-esteem
  • Begins to understand abstract concepts
  • Concerned with physical appearance
  • Clearer sense of self (can set goals)
  • Increased autonomy
  • Risk – taking behaviors
  • Many social activities

Problems with Diabetes

    • Massive denial is frequently manifested as omitted insulin injections, forgotten snacks, breakfast not being eaten, food binges (especially in girls), and behaviors that suggest rejection of the notion of “being different.”
    • Diabetes is difficult to incorporate into the adolescent’s self-identity.
    • Social non-acceptance of self-monitoring of blood glucose (SMBG) or being reliant on needles (like a drug addict) bring additional pressures to deny diabetes.
    • Confusion of feelings during this period of physical change prevents open communication with parents and other adults.
    • Anger, inappropriate sexual behavior, escapism, suicidal gestures, and depression are part of an attempt to gain self-control.
    • Substance abuse let the adolescent demonstrate self-determination even though it compromises physical and emotional health.
    • Growth spurts disrupt control and accentuate differences and moodiness, making it difficult to know what’s causing what.
    • High blood sugars can delay puberty.
    • In girls high blood sugars may alter menses, and cause chronic vaginal infections.
    • Isolation from group activities (e.g., sports) can lead to peer separation and lack of social involvement.
    • Sexual identity can be confused and misunderstood.
    • Family confusions and frustrations with normal and abnormal adolescent rebellion may lead to loss of family support and disruption of communication patterns.
    • Eating disorders become a potential means of coping. Manifestations:
      • Bulimia (especially in girls)
      • Low body weight; fear of being fat
      • Excessive exercise
      • Abuse of laxatives
      • Binge eating
      • Self-induced vomiting
      • Insulin omission

Prevention

  • Encourage family therapy to avoid and limit denial and to work through problems of appropriate control and limit setting.
  • Inform parents that they have rights and power over teenagers.
  • Instruct teenagers that they should earn privileges based on responsibility for their own behavior.
  • Encourage parents to enforce the rules.
  • Encourage participation in leadership training to teach assertiveness skills so that teen learn how to say “no” and to develop pride and self-control.
  • Develop alternate behaviors to “acting out” that rely on negotiating skills and other social skills to use in the face of peer and societal demands.
  • Encourage verbalization of feelings to avoid psychosomatic patterns and somatic symptoms such as hysteria and hypochondria.
  • Encourage teens to bring peers to clinic and to extend themselves to others as a means of developing a positive social identity.
  • Respond directly to sexual needs by providing accurate information.
  • Fully explore the meaning of insulin use, independence, food habits to help resolve emotional problems.
  • Address issues of substance abuse in a nonjudgmental manner.