Transitioning Your Teen Jamie R Wood MD Associate

Transitioning Your Teen Jamie R. Wood, MD Associate Professor of Pediatrics Medical Director, Clinical Diabetes Programs Center for Endocrinology, Diabetes, and Metabolism Children’s Hospital Los Angeles

Outline • Definition of Transition • Guiding Principles of Transition • Transition Milestones: • Transition from middle school to high school • Transition from high school to college • Transition from college to adult independence

Definition of Transition • The movement, passage, or change from one position, state, stage, subject, or concept to another

Guiding Principles of Transition • Gradual • Two steps forward, one step back, two steps forward… • “Diabetes is a team sport” • The expectation should never be total independence • Importance of rehearsal and trial and error with a safety net • Every person living with diabetes is different and will transition at their own pace • A parent of a child with type 1 diabetes never “lets go”, nor should they

Diabetes Management Skills • Check finger stick BG • Change pump infusion set • Give insulin injection with pen or syringe • Manage sick days • Refill prescriptions • Make doctor appointments • Understand diabetes and alcohol • Get in touch with diabetes team • Insert/calibrate/use CGM • Understand diabetes and driving • • Count carbohydrates Calculate insulin dose based on carbs and BG Treat hypoglycemia and hyperglycemia Manage diabetes and exercise

Transition milestones: middle school • Checking BG independently • Counting carbohydrates/calculating insulin doses (often still with supervision) • Giving own injections/boluses • Independent outings with friends, sleepovers • Changing pump infusion set/CGM (often still with supervision)

Transition milestones: High School • Independent management at school • Driver’s license • Dating • First Exposure to Alcohol and Drugs • Sick day management with supervision • Managing diabetes and exercise with supervision

Issues During High School § Make sure student with diabetes is on a flexible insulin regimen: § Insulin pump therapy § Basal bolus therapy with multiple daily injections (MDI) with insulin pens § Continuous Glucose Monitors § If not: § Make an appointment with your diabetes team to discuss changing to a flexible insulin regimen § Allow enough time for student with diabetes to adjust and become comfortable and independent with new regimen

Insulin Pens

Insulin Pumps

CGMs

Issues During High School § During high school allow the teenager to gradually become more independent with their diabetes selfmanagement: § Are they doing their own injections? § Can they do their infusion set changes independently? § Do they have a system to keep track of when to do site changes? § Can they count carbohydrates independently? § If not directly supervised, do they forget meal boluses or blood glucose checks? § Do they know what to do when they are sick?

Issues During High School § First step is to have teenager assume responsibility for diabetes management with direct adult supervision: § During meals have teenager count the carbohydrates independently and determine meal-time bolus and then double check with adult § Have teenager do site changes independently with adult watching

Issues During High School § Second step is to give teenager more independence with indirect adult supervision § Do as many “trial runs” as possible prior to college when there is still a safety net § Allow overnight sleepovers, sleep away camps § Allow teenager to manage diabetes, but review meter/pump to make sure that teenager is staying on track § If blood glucose monitoring declines, glucose average increases, or boluses are being missed, then increase supervision and try again § Talk through different scenarios – what would you do if…. ?

Issues to Address Beginning of Senior Year § Make an appointment with your diabetes team to discuss college transition: § Will your doctor remain the same for college? § What type of college setting would be best? § Close to home vs. far from home? § Living at home vs. living in dorm? § How will you communicate with diabetes team? § Email? Phone calls? Faxing logbooks? Download devices remotely? Who will make the call? § How does the parent know communication is occurring?

Issues to Address End of Senior Year § § Prescriptions § Mail order with supplies shipped directly to student every three months § Transfer prescriptions to local pharmacy on campus § Whose responsibility will this be? Appointments § Make appointments far in advance when you know student will be home (winter break, spring break, summer vacation) § Who will be responsible for making appointments? § If moving far from home consider having the name and number of a local diabetes clinic on hand

Issues to Address End of Senior Year § Housing: § Dorm vs. apartment, roommates vs. single § Important to try and normalize college experience § § Having a roommate to help respond to emergencies may be safer § Consider a suite with private bedrooms but shared living space § Single room or apartment if privacy is important to student § Kitchen to prepare own meals Request/purchase mini-refrigerator for room

Issues to Address End of Senior Year § Develop a communication plan § Frequent phone calls, emails, text messages will help reassure both student and parent § Discuss frequency of communication and who will initiate § Teach student to download pump to website, so that parent/diabetes team can review from home § Review health insurance plan § Can student stay on parent’s insurance plan through college? § Does student health plan offered through university cover diabetes supplies?

Diabetes and Driving • Driving Rules: • Medical alert bracelet, window decal, or wallet card • Check BG before you turn car ignition on • Keep rapid acting carbs in car to treat lows • Check BG at least every 1 -2 hours on longer trips • Pull over to check BG or treat low

Dating with Diabetes § Who to tell about your diabetes and when to tell them are your decisions § Eating on a date – will it be easier to stick to your meal plan if your date knows about your diabetes? § What happens if you get low while with your date? § How will you check your blood glucose and bolus while on a date? § Will the date involve physical activity like hiking or walking? Be prepared with extra snacks. § Most people figure out that discussing your diabetes before hand avoids awkward moments later

Alcohol § “All young adults face challenges and have to make decisions about dating, driving, and alcohol. Teens with diabetes face the same choices as their friends. But having diabetes complicates the choices you make. ” § http: //www. diabetes. org/for-parents-and-kids/forteens. jsp

Alcohol (1) § Drinking is illegal until your are 21! § Metabolism of alcohol uses the liver enzyme that is also responsible for maintaining blood glucose overnight or raising blood glucose during hypoglycemia § Alcohol can be dangerous for a person with diabetes for various reasons: § Alcohol can cause hypoglycemia § Alcohol can impair your ability to recognize hypoglycemia/hyperglycemia § Alcohol can impair your judgment and ability to make good decisions

Alcohol (2) § If student makes the choice to consume alcohol, they need to know how to do it safely: § Check glucose very frequently § Moderation (1 -2 drink maximum) § Avoid sugary drinks and hard liquor § Always eat before, during, and after drinking § Do NOT cover carbohydrates in alcohol with insulin § Wear your medical I. D.

Tips for Parties • Go with friends who know you have diabetes and know what to do in case of an emergency • Rehearse a couple of lines to politely say “No thanks” to a drink offer • Have confidence that most friends will respect your decision to not drink • Offer to be the designated driver or sober monitor • Carry a half-full “drink” around with you to avoid being asked if you want another – nobody needs to know it is only diet coke • Alternate alcoholic drinks with non-alcoholic drinks or water

A Few Words About Recreational Drugs • JUST SAY NO! Extremely dangerous even without diabetes • Gateway drugs – use of one (e. g. marijuana) often leads to use of more dangerous and addictive drugs • Dangerously impair your ability to feel lows • Dangerously impair your ability to make good decisions • Will often result in forgetting to take your insulin resulting in DKA (diabetic ketoacidosis) and in overeating (highs)

Transition Milestones: College • Independently manages diabetes, but knows how to call for help and seek advise • Has a method to keep track of numbers (BGs, carbs, insulin doses) • Download pump/CGM to parent(s) or diabetes team for review • Established agreed upon communication plan with parents • Can independently manage sick days and exercise

College § “The task of letting go is a major developmental milestone for both the child and family members, especially parents. This transition is exceedingly tough and emotionally stressful. It is hard enough to send your child to a new environment away from the nest, but it is even harder to leave your child with diabetes in the midst of a bustling college dormitory!” § Dr. Fran Cogen, My. Diabetes. Central. com

What You Need to do Before Classes Start (1) § Find Your Campus Health Center § Ask what resources are available for students with diabetes § Ask if you can empty your sharps container at the health center § Ask about prescriptions and pharmacy locations § Ask about support groups on campus or in area § Find the Dining Halls/Cafeterias § Is nutritional information available or can it be provided? § Ask for the weekly menu so you can plan ahead

What You Need to do Before Classes Start (2) § Form a relationship with your school’s Office of Disability Services or Office of Student Services §They will help you avoid academic problems arising from your diabetes (high or low blood glucoses, ketones, doctor’s appointments) § Universities are legally required to make reasonable accommodations for students with diabetes (Section 504 of the 1973 Rehabilitation Act and 1990 Americans with Disabilities Act) § Contact office to see what they require – many will ask for a letter from your doctor stating that you have diabetes

What You Need to do Before Classes Start (3) § What accommodations should I ask for? §Option to reschedule exams for episodes of hypoglycemia or hyperglycemia §Extra time to complete exam to allow for blood glucose monitoring, eating a snack §Excused absences for sick days or medical appointments §Allowances to bring food/water into class

What You Need to do Before Classes Start (4) § Prepare backpack with diabetes supplies to carry to class (glucose source must always be with you!) § Pack a sick-day kit for dorm room § Obtain a medical alert bracelet and wear it § Go through checklist of diabetes supplies § Put together emergency contact information: § Phone number for RA, health center, doctor, pharmacy, parents § List of medications and allergies § Copy of insurance card

Who Needs To Know You Have Diabetes? § Your Housing Resident Advisor and Resident Coordinator § Your Roommates/Friends § The University Health Center and Office of Student Services § Professors § What do they need to know? § Diabetes overview § Signs/symptoms of hypo and hyperglycemia § How to administer glucagon § When to call for help and who to call

Teaching Glucagon • Save expired glucagon kits for teaching/demonstration • Download app:

How To Break The News § It is hard to explain diabetes to a person without diabetes § Assure the person that you have control of your diabetes and the information you are sharing is for emergencies only § Show the person: § § How to use Glucagon - this can be overwhelming to a stranger of diabetes, try to answer their questions and concerns § How you use your glucose meter § Your pump and how it works It may be easiest to tell your roommate about diabetes through a written letter

Thank you!!! Questions? ? ?