Chronic Poor Metabolic Control in the Pediatric Population: A Stepwise Intervention Program

Improving metabolic outcomes in children and adolescents with IDDM who are in chronically poor metabolic control is one of the most difficult tasks confronting health care providers. These patients have clinical histories characterized by recurrent episodes of diabetic ketoacidosis and the persistance of acute disease symptoms. Complex psychosocial factors play a critical role in the genesis of chronic poor control, and patients are often resistant to standard interventions. To guide treatment of these difficult patients, we have developed a stepwise intervention program that addresses psycho social issues and provides strategies for improving metabolic control. The steps include documentation of patient response to insulin and the correction of educational deficiencies, defining and renegotiating the family care role, confronting families' inappropriate perceptions of care, and legal interventions. Previous evaluation has shown that appli cation of this approach can nearly eliminate recurrent episodes of diabetic ketoacidosis.