It’s a natural pairing. Glandular and metabolic disorders — growth problems, puberty issues, juvenile diabetes — pose obvious emotional challenges. Diabetes adds an additional hardship because it requires a level of patient compliance — monitoring blood sugar, regulating diet, injecting insulin — that anyone would find tough, let alone a kid.
When diabetic children become teens, it can really get hairy, because adolescence is all about identity, differentiating yourself, breaking away from authority figures. Which isn’t to say that all diabetic teens act out medically. Many ease into mature self-management.
Others are like Efren Casagrande.
He came to me as one of those last-resort panic referrals, a fourteen-year-old “exceptionally brittle” diabetic who needed to draw blood multiple times a day and control his food with a level of precision that would faze a competitive bodybuilder. Diagnosed at age eight, he’d been reasonably compliant until the onset of puberty, when his attitude shifted to “Fuck this shit,” and he simply stopped cooperating.
During the past half year, he’d ended up in the E.R. thirteen times, had nearly died twice.
His doctor tried to talk sense into him.
Efren listened attentively, claimed he understood.
Blithe lie.
The same applied to pleading by his mother, two older sisters, an aunt who worked as a health care aide and was deemed the family medical guru, a hospital social worker named Sheila Baxter who was damn good and had accomplished wonders with other patients.
Three days after assuring Sheila he’d changed his ways, Efren ended up in a near coma.
She called me the day he was discharged. “Got time for an interesting one, Alex?”
“Anything you can’t handle has to be interesting.”
She recited the history wearily.
I said, “Want me to be brutally honest?”
She sighed. “Hopeless?”
“I’m always hopeful, Sheila, but I can’t perform magic.”
“No? Isn’t that what mental health’s all about? Spells and incantations and head-shrinking voodoo hexes? Heck, Alex, maybe I should break out my Tarot deck, couldn’t be any less effective than I already am.”
I said, “The lightbulb.”
“I know, I know, it has to want to change. Which is fine when we’re talking naughtiness in school. But this kid — and he’s personable and bright when he’s not screwing up — is going to die soon.”
“I’ll give it a shot, Sheila.”
“That’s all I can ask for. And guess what? This family can pay, I’m not asking you for charity.” A beat. “Which leads me to something else about the family. They’re intact in an official sense but the father hasn’t been around for a long time. He got sent to Pelican Bay when Efren was three and will be there for twenty more years.”
I said, “Pelican’s all about serial killers and major-league gangsters.”
“In this case, it’s the latter. Efren’s daddy was a player in the heroin trade.”
“Business trumps prison walls, huh? Ergo the family’s ability to pay.”
“Alex, please don’t tell me you just got qualms. Because no matter where the money originates, Efren really needs help and, believe it or not, his mother’s a good person. Long suffering, you know? And effective; two older sisters are in college.”
“Do I get reimbursed with Baggies of black tar?”
Another sigh. “I would think not, dear.”
“Don’t worry, then. Qualms are for sissies.”
She laughed. “I’m sure Efren would agree. Who knows, you two might actually get a rapport going.”
Rosalinda Casagrande phoned two hours later and set up an appointment with my service for the following morning. Precisely on time, a low-riding Chevy painted gold with green pin-striping and a black Aztec eagle emblazoned on the trunk huffed up in front of the house. As its engine continued to pulsate, a skinny kid in droopy duds got out of the passenger side, scratched his saggy-khaki butt, and squinted up at the sun.
The Chevy’s engine kept running. Anyone else in the car was concealed by heavy-tint windows.
I stood in full view of the boy. He looked everywhere but at me.
When he began to turn his back, I called down: “Efren?”
Reluctant swivel.
“C’mon up.”
He stood there.
I said, “Or don’t.”
His mouth dropped. “Wuh?”
“We can talk inside or out here.” I laughed. “You can even stay down there and we’ll yell at each other. Good workout for the vocal cords.”
His face aimed up at me.
I said, “Nice wheels. Maybe one day you can drive it.”
His lips pretzeled. “I already drive.”
“Great.”
The Chevy revved loud. The boy flinched. A second clap of gasoline thunder got him rolling his head, as if trying to dispel the noise. Rev number three sent him trudging up the stairs.
By the time he reached the top, the trudge had been replaced by a comical swagger. Up close, he was far from impressive: small for his age, a whole lot more bone than muscle, a chin that could use help, sallow cheeks assaulted by acne. His head was shaved to the skin. A toss of pimples had chosen his scalp for a nesting spot. He had long, soft-looking arms, not much upper body. Smallish feet that he tried to augment with too-large work boots verging on cartoonish. His fingernails were clean and he didn’t emit body odor but his clothes gave off that three-day-old must that flavors adolescent bedrooms.
I held out my hand. He looked at it.
Withdrawing, I entered the house and continued to my office without checking to see if he’d followed. I was behind my desk for ninety-four seconds before he appeared in the doorway and gave the room a quick scan.
“You got a lot of things, man.” His voice cracked a couple of times. Alto aiming for tenor but a long way from success. On the phone, he could be mistaken for a girl. Hopefully testosterone would eventually come to the rescue. Insulin sure hadn’t been there for him.
“A lot of things,” he repeated.
The office was free of personal mementos, the way a therapy space needs to be. “Think so?”
“Yeah, those art pictures out there.”
“You into art?”
“Nah …” He bobbed his head a couple of times, as if adjusting to an internal beat. “You trust me with all that, man?”
“All what?”
He smiled. His teeth were uneven but white. “Your things, man. You got nice things, I was out there with ’em and you were in here, man.”
“You want my things?”
“I can have ’em?”
“Not a chance.”
He stared at me.
I said, “You can sit.”
He didn’t budge.
“Or don’t,” I said, moving papers around and consulting my appointment book.
He continued to stand there.
I said, “Here’s how I see the situation. Everyone’s getting on your case to be a good boy with your diabetes. It’s like a mountain of noise, coming at you all the time. So you tell ’em sure, no problem, but you mean, ‘Fuck you, leave me alone.’ ”
The obscenity caused his head to retract. Black eyes sharpened. A boot tapped.
“Noise, nonstop.” I ticked my fingers. “From Dr. Lowenstein, from your mom, Aunt Inez, Aunt Carmen, Aunt Dolores, Ms. Baxter. Maybe a curandero I don’t know about.”
He didn’t react.
I said, “Basically, you’ve got an army of people getting on your case, so you need to defend yourself.”
He shook his head.
I said, “I’m wrong?”
“You don’t know me, man.”
“You’ve got that right.”
“Whatever.” The tapping picked up speed. An index finger bumped atop a thumb. A dozen times.