TOPICS:

Chapter 18

Responsibilities
of Children at
Different Ages

Psychosocial
Adjustment
Goal Setting and
Problem Solving
TEACHING OBJECTIVES:
1. Present the importance of longterm family support and
involvement in the diabetes
management.
2. Define age-appropriate skills
and tasks.

INTRODUCTION
Daily diabetes care has grown more complex in recent years.
In addition to the usual family responsibilities, it is not unusual
for families to:
do four or more blood sugars per day
give three or more shots each day

LEARNING OBJECTIVES:
Learners (parents, child, relative or
self) will be able to:
1. Outline family support roles for
diabetes management.
2. Identify at least one ageappropriate sign of readiness
for learning diabetes
skills/tasks.

use an insulin pump

juggle sports and exercise
count carbohydrates or follow other food plans
Good sugar control requires the active involvement of
parents for many years. The myth that children should be
encouraged to do all of their own diabetes care at an early age
no longer applies. Diabetes is a family disease.
Children of different ages are able to do different tasks and
to accept different responsibilities. It is important not to
expect more from children than they are able to do. If they are
unable to do the tasks, they may develop a sense of failure and
later poor self-esteem resulting in poor self-care. Family
members need to watch for signs that the child needs more
assistance, especially during times of high blood sugars.
The ability to do certain tasks may vary from day to day and
parents must be available to help as needed. The children
should be encouraged to gradually assume care for themselves
as they are able. The ability to successfully live independently,
both in everyday life and with diabetes care, is the eventual goal
for all of our children.

193

The purpose of this chapter is to review

normal child development and how it relates
to diabetes care. Although parts of this chapter
may not be important for each reader, sections
may be helpful to some families. It must be
remembered that all children develop at
different rates (and our own children are always
the most advanced).
Age alone, as a guideline, does not tell us
when an individual child is ready to assume
tasks. There is no such thing as a magic age
when the diabetes suddenly becomes the
responsibility of the child or teenager. Be
patient! Independence takes a long time. The
suggestions below may vary for any given child
or family. Diabetes is a family disease and
the family must work together. Family
members need to help each other. Sharing tasks
will help prevent the diabetes care from
becoming the responsibility of just one person.

194

CHILD UNDER THREE

YEARS
Traits and Responsibilities Not Related
to Diabetes
This is a time of rapid development of a
small, wondrous creature who eats, sleeps, cries,
soils diapers and starts to learn about the world.
Motor and brain development are the most rapid
of any time in life:
sitting (6-8 months)
crawling (6-12 months)
walking (12-18 months)
language development
These developments open up a whole new
world.

Chapter 18 Responsibilities of Children at Different Ages

Accidents are the infants major danger.

They must be protected from:
stairs where they might fall
poisons and medicines they might swallow
(from cupboards, garages and purses)

separate a low blood sugar from normal

fussiness. The temptation to let an infant nap
longer than usual is offset by the possibility of
hypoglycemia.
Blood sugar levels:

auto accidents
other dangers (including coffee tables with
sharp edges)
All infants with or without diabetes need
love. Parents and care providers need to cuddle
and hold infants frequently throughout the day.
This is particularly true after shots and blood
sugar tests, as infants do not understand parents
causing pain. Parents must remember that the
testing and shots are essential to their infants life
and they must move beyond feelings of guilt (as
discussed in Chapter 10). Much of the fussing
around blood sugar tests and shots is due to the
interruption in the childs activity rather than
pain. Infants develop trust during this period
and combining the diabetes care with love will
help to make the diabetes care a part of normal
life. Young adults often look back with
appreciation to their parents for the shots and
care they gave them when they were young.

Although babies and toddlers are not able to

do any of their own self-care, the following are
some special suggestions that may help parents.
Blood sugar testing:

Toes are used more frequently as a site

for doing the testing.

The BD Ultrafine lancets are smaller and

may hurt less.

More frequent blood sugar testing is usually

done (see Chapters 6 and 7) because the babies
and toddlers cannot tell if their blood sugars
are low.
The parents may learn to recognize a cry,
crankiness or body movements that are different
than usual and that indicate a need to do a
blood sugar level. Teething can be a difficult
time when more blood sugars are needed to

Low blood sugars can be treated with

less carbohydrate than for an older child
(usually 5-10g due to smaller body size).
This amount is found in 1/4 cup of
milk, orange or apple juice or 2-3 oz of
sugar pop (soda), although the amount
needed may vary from infant to infant.
Infants who suck on a bottle of milk or
juice frequently during the day or night
will tend to have higher blood sugar
levels. Overnight sucking on a bottle can
also lead to dental decay.

Shots:

Responsibilities Related to Diabetes

The blood sugar level to aim for is also

higher (80-200 mg/dl [4.5-11.1
mmol/L]; see Chapter 7) as severe lows
may be more dangerous to the infants
rapidly developing brain.

Shots are sometimes given while the

infant is sleeping (if he/she tends to get
very upset). If the child squirms or
awakens at the time of the shot, the dad
(or mom) should reassure the child. A
statement such as, It is just daddy (or
mommy) giving you your insulin may
be all that is needed.
The bottom (buttock) is used more
frequently as a place to give the shot.
Eating is often variable and parents can
wait to give the shot until they see what is
eaten. This is easiest to do when the
rapid-acting Humalog/NovoLog/Apidra
insulin is being used. The dose of insulin
can then be reduced if intake is low.
The amount of time taken to eat a meal
should be the same for all the children,
with or without diabetes. Special
treatment can result in eating problems.
It is important for the parents to stay in
control.

Chapter 18 Responsibilities of Children at Different Ages

195

Table 1

Age-Related Responsibilities and Traits

Non-diabetes-related

Age below
3 years

Age 3-7 years

developing gross motor

skills
developing speech skills
learning to trust
responding to love
imaginative/concrete
thinkers
cannot think abstractly
self-centered

Diabetes-related

Age 8-12 years

concrete thinkers
more logical and
understanding
more curious
more social
more responsible

Age 13-18 years

196

more independent
behavior varies
body image important
away from home more
more responsible
abstract thinking
able to understand the
importance of doing
something now to
prevent problems in
the future

parents must do all care

acceptance of diabetes care as part
of normal life
often give shots after seeing what
is eaten
parent does all tasks
gradually learns to cooperate
for blood sugar tests and insulin shots
inconsistent with food choices may
still need to give shots after meals
gradually learns to recognize
hypoglycemia
undeveloped concept of time
adult needs to do all insulin pump
management
can learn to test blood sugars
at age 10 or 11, can draw up and
give shots on occasion, although
they still need supervision
can make own food choices; can learn
initial carb-counting
do not appreciate that doing something
now (e.g., good diabetes control) helps
to prevent later problems (e.g., diabetes
complications)
can recognize and treat hypoglycemia
by 11 or 12 years, can be responsible
for remembering snacks, but may still
need assistance of alarm watches or
parent reminders
can do own insulin pump boluses, but
needs adult help to remember
capable of doing the majority of
shots or insulin pump management
and blood sugar tests, but still
needs parental involvement and
review to make decisions about dosage
knows which foods to eat; can do
carbohydrate counting
gradually recognizes the importance
of good sugar control to prevent later
complications
may be more willing to inject multiple
shots per day

Chapter 18 Responsibilities of Children at Different Ages

The amount of rapid-acting insulin is kept

low due to body size and due to an
apparent increased sensitivity to rapidacting insulin. With the insulin syringes
currently available, it is not usually
necessary to dilute insulins. Most parents
learn how to judge 1/2 unit dosages
using the 0.3cc (30 unit) insulin syringes.
The Precision Sure Dose 0.3cc syringes
have markings for half-unit measurements
(Chapter 9). Similarly, the BD Pen Mini
can deliver half-unit increments.

It is important for parents of infants with

diabetes to incorporate the diabetes into their
everyday lives. Children learn through
imitation. If parents have adjusted to the
diabetes and can view their child with the same
positive feelings they had prior to the diagnosis
of diabetes, it will help the child to grow up
feeling positive and psychologically healthy. A
summary of non-diabetes and diabetes traits for
each age group is shown in Table 1.

AGES 3-7 YEARS

Traits and Responsibilities Not Related
to Diabetes

They may progress from playing with a toy

alone to gradually learning to share a toy or
to share the love of their parents. Primary
attachments are to parents and family.
Interest in other relationships, such as school
peers, begins at six to seven years of age.
Age responsibilities in children 5-7 years old
begin to increase dramatically.
They can help pick up their toys, make their
bed or put their dirty clothes in the hamper
when guided by the parent. They are capable
of fixing simple foods, such as cereal or a
sandwich, but still do not understand simple
dangers such as putting a knife in a toaster or
being careful around boiling water. They
must have much parental supervision.
Children 5-7 years old are learning to read,
opening a whole new world.
They are discovering many new things,
asking lots of questions and practicing new
skills. They feel more independent and, in
some ways, they are. Usually they are
cooperative and love to be helpful.
However, they still require a good deal of
adult supervision.

Responsibilities Related to Diabetes

They think concretely.
The parents must do all diabetes related tasks.
Concrete thinking means things are either
black or white, right or wrong, good or bad.
They do not think abstractly. For example,
they are unable to realize that Having a shot
of insulin will help me to stay healthy.
Instead, a shot may be considered a
punishment for doing something wrong.
Parents need to repeat over and over that the
child hasnt done anything wrong and to try
to describe in the childs language why pokes
and shots are important.
They start to see themselves as separate
individuals from their parents.
Children gradually become very curious in
this period. They often want to know how
things work. They can annoy parents with
the simple words how and why.
Children of this age are very self-centered.

Fine motor coordination (the coordination

of the fingers when handling small items) is
not yet fully developed. They cannot do
tasks such as accurately drawing insulin into
a syringe. This is also true when a child of
this age is using an insulin pump. The adult
must always be available to do all of the
pump management.
They can gradually learn to cooperate with
their parents (e.g., sitting still for blood
sugar tests and insulin shots)
They can help by choosing or cleaning a finger
for a blood test or by choosing the site for the
insulin shot.
Children as young as three or four can
sometimes recognize low blood sugars.
They can tell parents when they are hungry.

Chapter 18 Responsibilities of Children at Different Ages

197

Their complaints may be vague or seem

strange to us (Mommy, my tummy tickles
or Daddy, I dont feel good.) However,
these clues can be very helpful to parents.
Helping children verbalize the body
sensations of low blood sugars is an
important task for family members.
If a shot (e.g., Lantus) is going to be given
after the child is asleep, this should be
discussed between the child and parents.
Some children will say fine. Others want
control and will ask to have the shot given
before they go to sleep.
By age 5-7 years, recognizing low blood sugars
is more completely developed, particularly if
the parents have encouraged it.
Children of ages 4-7 years may have some
concept of which foods they can eat.
They can be taught to ask, Does it have
sugar in it? or Do you have a diet pop?
They cannot be expected to always or even
very often make the right choices over the
ones that look or taste good. They will
probably choose foods that are similar to
what friends or family are eating. They can
be expected to have some temper tantrums
at being limited in high-sugar food.
There is not much concept of time at this
age. An adult will need to make sure that a
snack is taken at a specific time. Sometimes
a watch that beeps at a set time can be used
as a reminder for a snack.
They usually have no objection to wearing a
diabetes ID bracelet or necklace.
It is good to get children into the habit of
wearing the ID when they are young. This
may help them to do this as they get older.
It is important for parents of children in this
age group (as in all age groups) to keep a
positive attitude. Remember the blood
sugar tests and insulin shots help to keep the
child healthy. Playing games around
diabetes chores and gradually getting the
child to help (even in little ways) may be
beneficial. One fun game is to use quarters
or stickers to reward the child for guessing

198

the blood sugar number while the meter

counts down. Whoever is closest wins. It
will help the child to learn to tell when they
are high or low. Hugs and kisses will
reassure the child that the parents love
continues. To be able to keep a positive
attitude, parents need their own support for
their worries and hard work. Friends,
family, diabetes support groups or other
sources of support can be extremely helpful.

AGES 8-12 YEARS

Traits and Responsibilities Not Related
to Diabetes
Children of this age continue to think in
concrete ways.
They can gradually think more objectively and
understand another persons point of view.
Fairness and meeting their needs are very
important.
Children at these ages are more social and
peers begin to play a more important role in
their lives.
They usually begin to spend nights at
friends houses. They have more peer
activities than do younger children.
Becoming involved in some team sports can
help them to stay involved as they get older.
This is a great age to do classroom
education about diabetes. The more peers
understand, the less likely they will tease.
They can soon become a real support to
your child. Peer support is important,
especially later during adolescence.
Children can be helpful by learning to take on
increased responsibilities.
They may help with doing dishes, feeding
pets, cleaning their own room and other
rooms or taking out the garbage. Special
rewards, such as stars on a calendar, may be
helpful in encouraging certain activities.
They are capable of more complex food
preparation and can better understand safety
and danger issues.

Chapter 18 Responsibilities of Children at Different Ages

Responsibilities Related to Diabetes

Some children begin to do their own blood
sugar testing at ages 8-10.
At about this age some children wish to begin
to give some of their own insulin shots.
The ability to accurately draw up the insulin
is a bit slower in developing, but it is usually
present at 10 or 11 years of age. The
coordination needed between seeing
something and using the fingers to
successfully do the job (eye-hand
coordination, fine motor skills) develops
during this age. This is an exciting time to
watch a child develop. Adult supervision is
essential for all of these important tasks.
The child can get burned out if:

they begin any of these tasks at too

young an age
they have too much responsibility
without the parent being available to
take over when needed

They will be more likely to rebel during the

teen years by missing shots or not testing
blood sugar levels. In addition, they may
have difficulty requesting their parents help
when needed if they are expected to
perform self-care tasks alone. Parents must
stay involved in diabetes management with
this age group!
Children of this age sometimes feel that life
isnt fair, particularly as it pertains to
diabetes.
It is helpful to just listen to them if they
express such feelings.
Children may be able to give their own shots
when staying at a friends house.
As the children are usually very active when
staying at a friends, we often suggest
reducing or omitting the dose of rapidacting insulin and reducing the dose of the
evening long-acting insulin by 10-20
percent. The parent can draw up the shot
ahead of time and put it in a small box,

toothbrush holder or other container and

leave it at the friends home. They may
even place it in the Inject-Ease. They may
ask the friends parent to supervise the shot.
It is important to remember to roll a syringe
containing NPH insulin between the hands
to re-mix it prior to giving the shot.
It is also essential that the friends parents be
informed about hypoglycemia. The handouts
in the school or baby-sitters sections
(Chapters 23 and 24) may be helpful.
Children of this age can eat lunch at school
and make choices to avoid high sugar foods.
Some will begin to learn to count
carbohydrates.
They can gradually learn to recognize and
treat their own hypoglycemic reactions.
They are also more aware of time and can
learn to be responsible for eating a snack at a
set time.
Insulin pumps are sometimes considered by the
family in this age group.
It is important for the family to meet with
all team members (Chapter 26). This helps
to determine who is truly ready to start
using the pump.
Sports can be very important at this age.
A child who learns to enjoy athletics is
starting a healthy pattern for their life as
well as for controlling diabetes.
Parents of the child in this age range must be
patient in teaching the child about diabetes
and how to do diabetes-related tasks. The
parents must still be very involved in
supervision of the diabetes care. They must
also be secure enough to let the child begin to
assume some responsibilities on his/her road
to becoming an independent person.
Diabetes camp, group ski trips, hikes or
other events allow the children to receive
invaluable support from each other and to
realize that they are not the only person in
the world with diabetes.

Chapter 18 Responsibilities of Children at Different Ages

199

AGES 13-18 YEARS

Traits and Responsibilities Not Related
to Diabetes
Teens gradually develop independence and a
sense of their own identity.
As noted in Chapter 19, Special Challenges
of the Teen Years, this age group varies
greatly between wanting independence
versus needing dependence. Some
rebellious behavior may be demonstrated
toward parents as teens grow into separate
individuals.
Skills increase greatly in this age group.
Automobiles can be driven legally and
power lawn mowers can (hopefully) be
used. Teenagers may take jobs to earn their
own money. Activities, in general, are
greatly increased.
Body image becomes a major concern.
Teenagers worry about how others view
them. The slightest pimple may become a
catastrophe. Early in this period, friends of
the same sex are very important, whereas
later, interest in the opposite sex usually
begins.

PERSON WITH DIABETES,

REGARDLESS OF AGE. Even parents of
older teens still need to help with making
sure adequate diabetes supplies are available
(and paying for them) and making sure that
clinic appointments are made and kept every
three months.
Parents should come to the clinic, although
the staff may request to see a teen
individually to discuss issues that may be
difficult to talk about with parents present.
Many teens dislike the chore of writing blood
sugar results in a log book.
If the parents agree to do this at the end of
each day (with the teenagers OK), it is a
way for the parents to keep tabs on the
diabetes. Having values written down (and
often faxed to the diabetes care provider) is
important in looking at trends and knowing
when changes in insulin dosages need to be
made.
Experimentation with alcohol will likely upset
the diabetes control (see Chapter 11) and can
cause severe hypoglycemia.
Experimentation with street drugs upsets
schedules and diabetes as well. The use of
drugs can result in:

More time is spent with friends.

The older teen is away from the home more

and stays out later with friends.

Experimentation with alcohol at some point is

common.

Responsibilities Related to Diabetes

Teens gradually take over more of their
diabetes care.
Parents still need to be available to assist
with giving a shot from time to time. They
need to take over the diabetes care for a
period of time if the youth seems burned
out. Teens generally do better if they get
extra help, particularly with insulin dosage.
As noted in Chapter 19, A SUPPORTIVE
ADULT CAN BE AN ASSET FOR A

200

increased appetite and higher blood

sugars
loss of incentive for good diabetes
management
eating meals irregularly

Good peer support can help the continuation

of:

an exercise regimen

a healthy diet

a consistent lifestyle

not using tobacco products (an added

risk for diabetic kidney disease and for
later heart attacks). Most people who
are going to use tobacco will begin prior
to age 20 years. Usually, if the peer

Chapter 18 Responsibilities of Children at Different Ages

Table 2

Average Ages for Diabetes-Related Skills

Age of Mastery (in years)
__________________________________________________
Recommended by the
Survey of
American Diabetes Association
Care Providers

Skill
A. Hypoglycemia
1. Recognizes and reports
2. Able to treat
3. Anticipates/prevents

8-10
10-12
14-16

4-9
6-10
9-13

B. Blood glucose testing

8-10

7-11

C. Insulin injection
1. Gives to self (at least sometimes)
2. Draws two insulins
3. Able to adjust doses

12-14
14-16

8-11
8-12
12-16

10-12

10-13

14-16
14-16

9-15
10-15

D. Diet
1. Identifies appropriate
pre-exercise snack
2. States role of diet in care
3. Able to alter food in relation
to blood glucose level

Abstracted from a survey done by Drs. T. Wysocki, P. Meinhold, D.J. Cox and W.L. Clarke at Ohio State University and the
University of Virginia (Diabetes Care 11:65-68, 1990).

group does not smoke or chew, the

youth will make a similar choice.
Identification with peers is so important in
this age group that their support (or lack of
it) may greatly affect the teens diabetes
management.
A belief in God and church, synagogue or
mosque activities may help guide the teen.
Continued involvement with parents can
provide stability, limits, love and support.
Grandparents can be a tremendous help at
any age (see Chapter 24).
Again, support from peers (with or without
diabetes) is very important in this age group
(see Chapter 19, Special Challenges of the
Teen Years).
There is often a feeling of invincibility or it
cant happen to me.

Regular clinic visits at this age may help the

teen realize that diabetes care and
responsibility are important. Teens with
diabetes are faced with more difficult tasks
and more serious life issues than their peers.
Teens with diabetes often seem to mature
earlier than teens without diabetes. They
learn at an earlier age when they have to be
serious in life and when they can have fun.
Insulin pump use is often considered in this
age group (Chapter 26).
Transition to a pump is more successful
if this is the teens choice. If the parents
push for an insulin pump, but the teen is
not ready, there is a lower chance for
success. It is important to have the help of
the entire diabetes team when making this
decision. Readiness for the pump can be
assessed together. This age group is often
quicker than parents in learning the use of

Chapter 18 Responsibilities of Children at Different Ages

201

the pump (a mini-computer). Glucose

control can improve ONLY if meal boluses
are remembered. This activity can often
require adult help.
The parents role for the teenager is to be
available to help when either forward or
backward steps toward adult maturity are taken.
Providing support, stability, limits and love are
essential at this difficult age (as at all ages).
Age alone should not be the primary
factor in deciding that a person should
assume responsibility for diabetes selfmanagement. Parents who offer continued
assistance and who share the responsibilities
with the teen will generally have a teen in better
diabetes control.
The average ages for mastering tasks as
recommended by the American Diabetes
Association and by a survey of care providers
are shown in Table 2.

DEFINITIONS
Eye-hand coordination: The ability to use the
hands to finely adjust what is seen with the eyes.
This ability usually develops around the age of 10.
Fine motor control: The ability to carefully
move the fingers with precision (e.g., drawing
insulin to an exact line on a syringe). This
ability usually develops around age 10 or 11.
Self-esteem: How a person feels about
himself/herself.

202

QUESTIONS AND ANSWERS

FROM NEWSNOTES
It seems like every time our eightyear-old son stays at his friends
house or has his friend stay
overnight at our house he has low blood
sugar the next morning. Should we be
making changes?

Overnights are an important social

and developmental step in our society.
It is important that children with
diabetes be able to participate just like any other
child. Overnights are also a step in developing
independence and are sometimes the first night
spent away from the parents. It is important for
the child to be safe in relationship to the
diabetes. The children usually run and play a
bit harder with their friend on overnights.
They also stay up a bit later than normal and
use more energy. It is generally wise to reduce
the insulin dose, both the rapid-acting (20-50
percent) and the long-acting (10-20 percent)
insulins, on these nights.

A good bedtime snack is also advisable.

Remember the pizza factor, that pizza tends
to keep a blood sugar up better than most other
foods. If there is a frozen pizza in the freezer, it
may be a good night to use it. It is also wise to
awaken the child at a reasonable time in the
morning and to get a glass of juice or milk
down sooner rather than later.
Do remember that if the child is able to do
a shot but is not yet old enough to draw it up,
the morning NPH and rapid-acting insulin can
be pre-drawn. The syringe can be put into a
little box or toothbrush holder and just rolled
to mix the next morning. Think about
reducing the dose again for the morning shot if
it is likely that the two friends will be playing
together much of the next day.

Chapter 18 Responsibilities of Children at Different Ages