Laura NaborsSchool of Human Services

College of Education, Criminal Justice, and Human Services

University of Cincinnati

Assisting Children with Type 1 Diabetes in Schools

Type 1 DiabetesType I diabetes is characterized by pancreatic failure.

Daily exogenous insulin replacement is necessary for the child's survival.

The care of children with Type I diabetes involves complex procedures including daily blood glucose testing, dietary monitoring, intensive insulin therapy, and increased physical activity to maintain metabolic control.

In this presentation… I will discuss ideas for supporting children at

school1) general ideas for improving children’s

coping at school2) nurses perspectives on helping children

with diabetes in school3) parent and children’s general ideas about

barriers to child management and help children need to support their diabetes management

4) children’s reports of what they need in terms diabetes management at school

Goal: Through this review present ideas about barriers and supports for children and review research on school-based management of diabetes

Improving Children’s Coping at SchoolDiabetes Care PlanAvailable at American Diabetes Association website

Elements of a Care Plan how to handle high’s and low’s as well as signs to look for when the child is high or low, what teachers should have on hand as far as snacks, nursing plan, emergency plan…

Improving Children’s Coping at SchoolMore elements of a care plan….after

school sports plan, emphasis on the importance of allowing the child to examine his or her blood glucose level as needed

Care card for the teacher’s desk in the classroom

Communication for the child, our research shows that the children get sick of talking about it. Make certain information is shared to each new teacher!

Improving Children’s Coping at SchoolHelp the child identify a friend to walk to

the nurse with if he or she feels high or low {I get by with a little help from my friends…}

Assist the child in establishing a relationship with school staff (and school counselor if needed)

Encourage the child to keep working at self-management, increasing efficacy for chronic illness management can improve management

Have a certified diabetes educator on staff at each school district

Switch gears & Let’s talk about…Opinions of and information from School Nurses

In a study of school nursesNinety-seven percent reported that after school leaders and coaches should become more knowledgeable about diabetes. Most (57%) were not available to help after school and 73% did not believe that after school activities should be included in written health care plans.

“Teachers and coaches are nervous about potential problems on field trips, athletic events … it causes a lot of stress.”

Data provided by school nurses indicated that…Improving support for adolescents

involved providing instrumental support so that adolescents could test when needed and have snacks and medical care necessary to cope with episodes of low blood sugar. Written care plans, based on a communication process involving youth, the medical team, parents, teachers, and nurses and then dissemination to all involved was recommended, in order to facilitate comprehensive management.

School nurses also said…Nurses also stated that care plans needed to be updated regularly with input from the child’s medical team or physician.

Children and adolescents needed to learn how to communicate with others about their diabetes management and their NEEDS

Food management education and support needed.

School nurses reported teachers need:Education!!!!“Teachers and staff need more education

about Type 1 Diabetes. They do not understand the complications of the disease and they are afraid to help the students properly manage it.”

“Educate teachers to recognize highs and lows.”

“Adequate time and resources to train staff.”

“Educational support for the nurses…continuing ed. And updating of procedures with introduction to new ideas.”  

Other information from school nurses…Children don’t want to be singled

out because of their diabetes. “I am the only nurse for five

buildings so I am not always in the building when questions arise.”

“Some teachers do not understand why it is necessary to send students to the nurse and provide a buddy.”

“Lack of qualified substitutes and no RN in building at times.”

Switch gears

Child and parent perceptions {barriers and supports}

Children's Perceptions StudyWhat do kids and parents say?Sixty children (22 boys and 36 girls) and completed telephone interviews. Children ranged in age from 8 years, 6 months to 15 years, 8 months (M = 12 years, 2 months; SD = 2 years, 1 month). Forty-nine mothers, six fathers, and 4 guardians also completed interviews.

Children saw having “junk” food around the home as a barrier, because they could sneak food

Children's Perceptions StudySome children had the attitude that no matter what I do my levels won’t be good [this notion is related to the idea that there is not a “1-1” correspondence between adherence and HgbA1C levels.

Another barrier to good self-management was not feeling motivated to count carbs

Children’s Perceptions StudyBeing on the Pump was seen as an

advantage in most cases…I didn’t use to like taking shots, but now

it’s better because I have the pump.I’m on a pump and my blood sugars

have been better since I have been on the pump. I can take care of all the stuff that goes with having a pump.

 Children may need supervision of their pump use and other management activities, suggesting that shared management with a parent-child or adult-child teamwork approach can be helpful

Some parents reported barriers…She’s not doing real good with it.

What she does I think is eat and not give herself insulin and I don’t think it’s working for her. She won’t let me know what carbs she’s had during the day and I can’t help with calculations.

He has a lot of knowledge he doesn’t apply. He’s too casual and doesn’t take it seriously enough.

She doesn’t always check [test] before she eats.

Several parents reported that their child needed coaching, because…Just forgetful …gets…you know…busy doing whatever and forgets to do what needs to be done.

She sometimes forgets to take her insulin.

The adult role was to provide support, assistance when requested and provide reminders!

Parents also liked the pumpShe’s doing a better job with it (the pump) because she has more flexibility and freedom

Let’s talk about children’s ideas of help they need at school… (Study of over 50 children surveyed)

Children’s ideas How is School Going Scalequestions address children’s perceptions

of the amount of support that they needed from teachers, nurses, friends, and parents while they were at school for: (1) monitoring their blood sugar levels, (2) administering insulin, and (3) following their meal plan. Children recorded their answers to questions on 4-point rating scales (1 = “never/none” to 4 = “all the time/every day”). They also discussed types of support they needed from each group.

How is School Going ScaleA chi-square analysis showed no

differences in boys’ and girls’ ratings for the amounts of support they needed from nurses, teachers, and friends. They needed a moderate amount of support from all three. Younger children reported needing more support from teachers (X2 (1) = 5.22, p < .05) and nurses (X2 (1) = 20.29, p < .001) than older children. Results indicated no difference in younger and older children’s ratings for the amount of support that children needed from their friends, both groups required a moderate level of support from their friends.

TYPE OF SUPPORT NURSES

% (45)

TEACHERS

% (53)

FRIENDS

% (49)

REMINDERS TO TAKE SHOTS 13.3% (6) 100% (53)

HELP ME TEST (TEST GLUCOSE

LEVEL)

42.2% (19) 3.89% (2) 8.2% (4)

HAVE A SNACK AVAILABLE 68.9% (31) 62.3% (33)

HAVE JUICE AVAILABLE 73.3% (33) 66% (35)

HELP WITH LOWS 82.2% (37) 30.2% (16)

HAVE SUPPLIES FOR TESTING

AVAILABLE

80% (36) 28.3% (15)

HELP WITH FOLLOWING MEAL PLAN

AT LUNCH28.9% (13) 17% (9) 14.3% (7)

HELP ME RECOGNIZE WHEN I AM

BEGINNING TO EXPERIENCE A LOW58.5% (31) 49% (24)

SEND ME TO THE NURSE RIGHT

AWAY IF I AM LOW66% (35)

LET ME TEST WHENEVER I NEED TO 79.2% (42)

DON’T GIVE ME SNACKS 38.8% (19)

FIND AN ADULT IF I LOOK UNWELL 44.9% (22)

WALK ME TO THE NURSE IF I NEED

TO GO

63.3% (31)

Critical Issues Who Can Help

Improve knowledge of diabetes.Everyone: nurses, teachers, friends, substitute teachers, cafeteria staff

Nurse should be there every day. Nurses

Let me keep my test kit with me and allow me to retake tests if I need to.

Teachers

Supplies, especially snacks should be available. Teachers, Nurses

Walk with me to the nurse if I feel really low. Friends, Teachers

Encourage me to stick to my meal plan. Don’t eat junk food in front of me or have alternative snacks and treats for me.

Friends, Teachers

Children reported… Qualitative DataWhat needs to happen at school is(1) improving staff knowledge, (2)

availability of supplies and snacks, (3) staff and teachers needing flexibility, (4) help with lows, (5) reminders, and (6) support from other people to help them manage their diabetes at school.

The children mentioned that participating in after-school activities was difficult, because nurses were not on site and their supplies were often locked in the nurse’s office.

Thanks very much!!! Selected References American Diabetes Association (2004). Diabetes care in the school and day care setting.

Diabetes Care, 27(Supplement 1), S122-128. Butler, D. A., & Lawlor, M. T. (2004). It takes a village: Helping families live with diabetes.

Diabetes Spectrum, 17, 26-31. Nabors, L., Lehmkuhl, H., Christos, N., & Andreone, T. L. (2003). Children with diabetes:

Perceptions of supports for self-management at school. Journal of School Health, 73, 216-221.

Nabors, L., Troillett, A., Nash, T., & Masiulis, B. (2005). School nurse perceptions of barriers and supports for children with diabetes. Journal of School Health, 75, 119-124.

Nabors, L., & Lehmkuhl, H. (2004). How is School Scale. Author. Smith, J., Nabors, L., Henderson, E., Kichler, J., and Andreone, T. L. (2010). Parent and

child perceptions of managing childhood diabetes. A. Fortier and S. Turcotte (Eds). Health Education: Challenges, Issues, and Impact. Series: Education in a Competitive and Globalizing World (pp. 229-236). Nova Science Publishers.

Skinner, T. C., & Hampson, S. E. (1998). Social support and personal models of diabetes in relation to self-care and well-being in adolescents with type 1 diabetes mellitus. Journal of Adolescence, 21, 703-715.

Ruggerio, L., Kairys, S., Fritz, G., & Wood, M. (1991). Accuracy of blood glucose estimates in adolescents with diabetes mellitus. Journal of Adolescent Health, 12, 101-106.