**2. The challenges of type 1 diabetes**

Type 1 Diabetes (T1D) is a complex and challenging disease for children and adolescents due to the necessary integration of daily medical tasks (e.g., blood glucose monitoring) and lifestyle modifications. Evidence suggests that a substantial percentage of children are nonadherent to these demands.[1,2] Although some of those who are non-adherent experience few negative consequences, a large number of non-adherent children are at risk for significant medical complications including diabetic ketoacidosis (DKA), neuropathy, nephropathy, retinopathy, and cardiovascular disease.[3] Despite improvements in fluid and insulin therapy, fatality rates are still estimated at 1 to 2% of youth who experience a DKA episode. Non-adherence can also negatively impact clinical decisions made by health care providers such as prescribing incorrect insulin doses. Further, poor adherence results in increased morbidity and mortality, as well as problematic medication use and excessive use of health care services.[4,5] Numerous factors have a significant impact on adherence and glycemic control.

Contributing Factors to Poor Adherence and Glycemic

reliability and validity for this population.

as well as an improvement in general parent-adolescent conflict.

children with T1D.

Control in Pediatric Type 1 Diabetes: Facilitating a Move Toward Telehealth 143

with adherence and glycemic control in a sample of T1D adolescents. It is common for mothers to be more involved in the care giving process than their male counterparts, which can often lead to high levels of stress among mothers with children with T1D. In a study by Lewin, Storch, Silverstein, Baumeister, Strawser, and Geffken[17] illness-related stressors linked with a mother's caretaking role were highly correlated to a mother's stress and state anxiety. Parenting stress was positively correlated to child behavior problems. Similarly, Hilliard, Monaghan, Cogen, and Streisand[18] found that general anxiety and parenting stress were associated with parents' perceptions of their children's problematic behavior in

In addition to the management of T1D and behavioral problems, parenting stress has been related to initial diagnosis of the disorder. Streisand and colleagues[19] found that parents exhibited the highest levels of anxiety and depressive symptoms at the time of their child's diagnosis. These results implicate the importance of providing additional support and education to parents of newly diagnosed children as well as assessing for anxious and depressive symptoms. Parents are also at risk for developing chronic sorrow pertaining to the diagnosis of pediatric T1D. Results of a study examining chronic sorrow showed that parents exhibited a grief reaction upon initial diagnosis and continued to experience intermittent emotional distress.[20] The mothers in the study sample were more comfortable talking about their grief than fathers, however, both mothers and fathers displayed evidence of chronic sorrow. With growing evidence supporting the positive association between parenting stress and other issues related to T1D, recent interventions have been created to focus specifically on these issues among parents of children with the disorder. In a study by Monaghan, Hilliard, Cogen, and Streisand,[21] the authors assessed the efficacy and practicality of a telephone-based intervention designed for parents of children with T1D. The intervention aimed to improve parental quality of life by decreasing parenting stress, increasing social support and improving the management of pediatric T1D. The subjects scored lower on parenting stress and higher on social supportpost-intervention. This evidence suggests the utility of interventions with families coping with T1D. The Pediatric Inventory for Parents has been proven to be an effective instrument for measuring parenting stress in mothers of children with T1D.[14] The instrument displayed internal consistency

Current research suggests that family conflict may also have a negative impact on the management of pediatric T1D. In a study examining youth and adolescents with T1D, perception of family conflict was the highest predictor of medical adherence.[22] Perception of family cohesion predicted improved adherence. Parent-child conflict has also been linked to poor adherence as well as poor metabolic control in children with T1D.[23] Similarly, Williams, Laffel, and Hood[24] found a positive relationship between psychological distress and diabetes-specific conflict in pediatric T1D. The results of these studies indicate the importance of family cohesion for better management of pediatric T1D. According to the findings of Harris, Freeman, and Beers[25] Behavioral Family Systems Therapy (BFST) produced an improvement in mother-adolescent conflict related to diabetes specific issues

Given the impact of family cohesion on diabetes management, it is no surprise that spousal support is also an important factor in the examination of adherence and glycemic control in children with T1D. Marital conflict has been shown to influence the link between motheradolescent relationships and adherence. Lewandowski and Drotar[26] found that higher levels of perceived spousal support were associated with lower mother-adolescent conflict
