How Can We Help?
Adolescence – a nuanced approach
Compliance, concordance and life-styles
Adolescents have many issues to deal with – peer opinion, life goals, self-image, and sexuality to name just a few. Adding in issues of health complicates matters even more. The subliminal messages involved with taking medication include – ‘you aren’t as strong as your peers’ ‘you might die early’ and ‘ this illness means I’m of lower worth than my friends’. Dispelling concepts such as these can be just as difficult as getting individuals to acknowledge that they actual harbour such thoughts.
Most adults agree that trying to understand what’s going on in a teenager’s head is not easy, so it is not surprising that we often struggle to achieve congruence between what we think are worthwhile goals and what ‘they’ think. Why is good glucose control important ‘Because you will have fewer complications from diabetes in twenty years’ time’ is unappealing to someone whose worldview really doesn’t currently extend more than into the next few months. ‘Because adequate sugar control means you can spend more time hanging with your friends and less time feeling grim in a hospital bed’ may well have some slight impact.
Consider:
- A pill schedule that inevitably means you are in the company of your friends at pill time may be difficult for those without good psychological resources.
- Sacrificing some rigidity in pill taking may improve overall concordance by giving back some feelings of control.
- If you do see an opportunity to get friends involved, and your patient agrees, jump at it – teamwork can achieve a great deal in terms of compliance.
Diabetes in adolescence
Some cynics argue that the majority of teenage diabetics live in a state of permanent flux between ketoacidosis and hypoglycaemia, and that it is only the really erratic swings that we get to witness, when they result in hospitalisation. This perception is fuelled by the continual re-attendance of a small group of often notorious Type I teenagers who seem to be spending their lives in and out of emergency units and ICUs. Weather the storm and don’t give up on them – they often need you quite a lot more than you might think, and certainly a lot more than they would ever admit. Secondly, there is actually another cohort of impeccable teenage diabetics whom you hardly ever see because they are running their lives and their diabetes very successfully without your assistance.
Although twice daily short/intermediate acting combinations are very popular, individuals who struggle with regular meals may find such regimens problematic, and may be more comfortable on a basal bolus. If your patient can afford a cellphone he or she may well be able to afford a glucometer. Consider the possibility of getting test strips through the state, in which case ensure that the meter and the strips are compatible.
Diet. Try. This is influenced by peer pressure. Outside the situation of well-run diabetic clinics many young insulin dependent diabetics seem to manage on tiny doses of insulin and stay out of severe hyperglycaemia by regulating food intake. Some reach this state because they don’t have any food, and so insulin doses are adjusted downwards. Check weights and watch for trends – it may be necessary to improve both food intake and insulin dose. Obtain the contact details of local support groups.
Transition from paediatrics. This may also mark the transition from regular attendance with a parent to coming alone. Adult clinics are perceived as less friendly than are those for children, and young patients find themselves face to face with quite ill and sometimes rather daunting fellow patients (and even more daunting doctors). Try to smooth the transition by being approachable and not expecting too much in the beginning – adherence is trust-dependent, and this takes a while to develop afresh.
HIV in adolescence.
Issues are similar to those in adolescent diabetics, except that the process is further complicated by guilt/shame associated with acquiring the infection and very pervasive attitude of despair.
Strategies:
- Offer hope – short term (‘we can fix the TB’) as well as medium term (you can access ARVs as soon as need them’)
- Try to get both family members and friends involved, by inviting the patient to bring someone along for the next visit.
- Give concrete short-term goals and rewards – ‘take the 5 TB pills every day for another month and then we can change to only two per day’.
- Don’t initial expect perfect adherence or regular visits – this may take months.
- Talk about sex – it is happening anyway, and simple advice can sometimes help.