All of these aspects of development play a role in how young children understand and respond to diabetes care. For example, magical thinking may lead a young child to believe his injections will cure his diabetes or possibly that his injections are punishment for misbehavior or inappropriate thoughts. Family power struggles may emerge around diabetes care as a child becomes able to perform some of his own diabetes care tasks, such as doing fingersticks, and also begins to want more control over what happens to his body. However, while some children can monitor their own blood glucose at an early age, parents are still responsible for, and encouraged to remain closely involved in, all aspects of diabetes management.
Children in this age range tend to be concerned about how health-care experiences and procedures will affect their bodies. They may be disturbed by “holes” being made in their skin by needles or concerned about running out of blood.
A lack of understanding about conservation may help explain why children often prefer fingersticks to insulin injections. From an adult’s perspective, insulin needles and lancets are both sharp metal objects that cause a pricking or painful sensation. From a child’s perspective, however, there are some important differences. An insulin syringe has a naked needle on the end, which, no matter how short, is still clearly a needle. Lancets, however, are neatly hidden within the lancing device. Even though children may watch the lancet being inserted into the lancing device, they will often not be as focused on the lancet once it is hidden.
The issue of outward appearances, combined with limitations in logical reasoning, may also help to explain why young children often protest larger doses of insulin. The more insulin that’s in the syringe, the larger its physical appearance. A syringe that is filled with insulin can be as long as 5 inches from the top of the plunger to the tip of the needle. If getting insulin is thought of as scary or painful, more insulin may seem worse.
Injections also encroach on a child’s personal space. The closer to the midline or center of the body, the more threatening the procedure may seem to the integrity and safety of the body. This probably explains why young children tend to be much more resistant to rotating injections on their bellies than on their legs or arms. Fingersticks, on the other hand, feel less invasive because they can be done with the child holding his hand out several inches away from his body.
Young children will often share their thoughts and perceptions of injections through play. Recently, a four-year-old child sat on the clinic playroom floor pretending to give insulin with a needle-less syringe to a baby doll. She pulled the plunger back as far as it would go.
“This baby is gonna get a big shot. He’s crying,” she said. I followed her script and made soft crying sounds on behalf of the doll.
“She needs more,” the girl said as she pretended to refill the syringe, this time only pulling the syringe back a few units. I continued the soft crying for the doll, thinking I was still following her lead.
“No! The baby’s not crying. It’s just a little shot,” she said, as if it were obvious that a small amount of insulin would not cause the baby to cry the way a large amount did.
Another typical playroom scenario involves the dolls receiving injections in the face, neck, or chest. The children will often look toward an adult immediately after an injection as if to ask, “What are the chances of that happening to me?” My response to this type of play is always supportive and reassuring: “We can pretend to give the baby his insulin there, but real children would never get an insulin shot in those places.”
The problem of pain
Understanding cognitive ability is only the first step in grasping the children’s message about their experiences with injections and fingersticks. The second is accepting the existence of pain in diabetes management. It seems less harsh and more comforting to tell parents and children that it really doesn’t hurt at all. When children do report pain, adults may say it’s “just anxiety” or that the child is “seeking attention” or “trying to gain control.” While these emotional and behavioral issues are likely to play an important role in pain perception, they are not separate from actual pain.