Many challenges face adolescents and young adults as they transition from home to independent living, whether that be college, technical school, or employment. For adolescents with a chronic disease such as diabetes, these challenges are magnified.
I worked in a pediatric endocrine clinic as a clinical nurse specialist for several years before completing my certification to become a family nurse practitioner. My first nurse practitioner position was in an adult endocrine practice in the same city. This was my first opportunity to see the challenges young adults faced as they moved from a pediatric to an adult medical setting.
Many of these young adults were patients I knew as children. Some had been lost to follow-up for a few years. Some were in successful jobs or doing well in college. All of them faced challenges in managing their diabetes in the face of their other daily life demands. Adolescents and young adults must navigate through many levels of transition, including change in medical care providers, increased expectations for self-care, often a move away from home, changed relationships, increased responsibility with school or jobs, increased financial responsibility, and, in some cases, increased responsibility such as teen pregnancy and early parenting. Although the American Diabetes Association's clinical practice recommendations offer guidance about the medical care of children and adolescents, there is little direction for how to help adolescents transition from the structure of home and high school to the less structured young adult world.1
J.J. Arnett, in an article published in 2000, proposed a developmental stage between adolescence and young adult called “emerging adulthood.”2 The developmental stage of emerging adulthood defines the period from 18 to 25 years of age, with young adulthood defined as the mid to late 20s and early 30s.2,3 The developmental stage of emerging adulthood is a time of exploration of possibilities, but it is also a time of increased anxiety and uncertainty.3 The length of this stage can vary depending on societal, cultural, and socioeconomic factors.3
These developmental stages of adolescence, emerging adulthood and young adulthood, can provide a framework for our interactions with young adults as we seek to better structure medical care and education processes for this population. Understanding these developmental stages can provide insight into the struggles that affect patients' ability to manage diabetes effectively. As I think back to past patients and look at the teens and young adults in my current practice, this has helped give me a better understanding of how to direct my communication with this population. It has also given me a better perspective for watching for potential pitfalls on their road to improved diabetes management.
I now work in a rural setting, continuing to provide diabetes care to children, teens, and young adults. In this setting, most of the care is provided in family practice clinics instead of a pediatric diabetes center. However, transition issues still occur.
A major issue for emerging adults in my setting is the financial struggle for ongoing access to health care, including access to diabetes supplies and medications. The unemployment rate in my area is high, with many labor industries suffering cutbacks. Employment opportunities that do exist are often part-time and do not offer benefits such as health insurance. Most states have good funding sources for pediatric patients who would be otherwise uninsured, in the form of state Medicaid programs or Children's Health Insurance programs. However, coverage through these programs ends when patients reach the age of 19 years.
At a crucial stage of development, emerging adults are faced with the burden of finding adequate resources for diabetes management, which is a struggle that overwhelms most adults, let alone young adults in transition. I have seen young adults attempt to save money by choosing between basal and prandial insulins, trying to reduce doses, or changing to older, less expensive insulin preparations. Most of the time, they do not understand the full impact this will have on their glucose control until they are in the Emergency Department or hospitalized with diabetic ketoacidosis. As the struggling economy and limited access to health care continue to burden young adults, it is important that pediatric care providers anticipate these problems and assist the families or young adults in their practice in their search for financial aid.
It is my hope that this issue's From Research to Practice section (p. 7–25) will stimulate thoughts and ideas about how to better meet the needs of emerging adults and young adults as they navigate through their life with diabetes and will help all of us in our assessment of clinical and education needs for this population. The long-term goal is to provide the access and support necessary to decrease the poor clinical outcomes that are seen all too often in this population.
