**2. Methods**

124 Type 1 Diabetes – Complications, Pathogenesis, and Alternative Treatments

When faced with the choice of appropriate self-care behavior, older adolescents have better problem solving skills but are more vulnerable to non-adherence in the face of peer pressure (Thomas et al., 1997). Another study showed that adolescents, who perceive their friends reacting negatively to their diabetes' self-care behavior, report more stress which, in turn, is

Research examining the positive and negative aspects of friends and peers, on diabetes outcomes and psychological well-being, is not clear. There seems to be more evidence that conflictual relationships are more harmful than supportive relations are beneficial, which is consistent with the literature on healthy adults (Helgson, 2006). Besides peers' support, teachers' support is also important. A study found that 9 % of parents had to change glucose monitoring and 16% changed treatment administration because of lack of support from teachers (Amillategui et al., 2007). In fact, teachers in general need to be knowledgeable of hyperglycemia and hypoglycemia's episodes in order to assist the adolescent if needed. Support from friends and peers are key factors that help the integration of the adolescent

Although diabetes does not cause pain on adolescents, impacts nonetheless, the adolescent and family's daily living and, therefore, the quality of life of all involved (Hanas, 2007) at

Girls perceived lower levels of QOL compared to boys. Worries about metabolic control increase with age but, regardless of gender, as age increases QOL decreases (Hoey et al., 2001). Adolescents who monitor their glucose levels, several times a day, reported better quality of life (Novato, 2009). The monitoring of blood glucose levels allows the teenager to know the variation of blood sugar, over time, perceiving what behaviors impact metabolic control, resulting in better quality of life (Novato, 2009). Regarding the association between quality of life and adherence to self-care in diabetes, literature is contradictory. Diabetes treatment has adverse effects on quality of life (Watkins et al., 2000). In fact, adolescents with diabetes need to follow a set of requirements that can negatively impact the perception of their quality of life and interaction with others. However, other studies conclude that adherence to diabetes care is not related to quality of life (e.g. Snoek, 2000). Diabetics with good metabolic control (measured through glycated hemoglobin) show better quality of life (e.g Glasgow et al., 1997; Silva, 2003) however, in some studies, this relationships has not been found and, in other studies, this relationship is very weak or does not exist (e.g. Grey et al., 1998; Laffel et al., 2003). Family also plays an important role in the perception of adolescents' QOL because QOL is affected by how the family deals with the disease (Hanson, 2001). Family conflict predicts lower QOL in adolescents (Dickenson et al., 2003). Family environment was shown to influence QOL as well as adherence and metabolic control in adolescents with diabetes

While there is a growing interest in psychological issues in diabetes, it is important to identify which variables predict better outcomes. The present study aims to answer this question namely understanding the relationship between psychological variables and diabetes outcomes. The purpose is to find the best predictors of adherence, metabolic control and quality of life in adolescents with type 1 diabetes taking in consideration adolescent variables and family variables. Due to the fact that research on adolescents and chronic

associated to poor metabolic control (Hains et al., 2007).

teenager in the school setting, facilitating adaptation to diabetes.

physical, emotional, social and family 's levels (Pereira et al., 2008).

**1.7 Quality of Life (QOL)** 

(Pereira et al., 2008).

#### **2.1 Sample characteristics**

A convenient sample of 170 subjects participated in the study: 85 adolescents and 85 family members that accompanied the teenager to their routine medical appointments, in a diabetes pediatric unit in two central Hospitals, and in a Diabetics Association. All teens received treatment in the hospital and therefore no differences were present between the sample from the Diabetics Association versus Hospitals.

All participants (teenagers and family members) were volunteers. Adolescents' criteria for inclusion were: age between 12 and 19 years, fulfilling ISPAD (1995) criteria for the diagnosis of type 1 diabetes, having a diagnosis longer than a year, being in ambulatory treatment, absence of another chronic and/or mental disease, not being pregnant and having normal cognitive development.

#### **2.2 Procedure**

Questionnaires were answered separately by adolescents and family members after they had been informed of the study's goals and filled the informed consent. The value of glycated hemoglobin (HbA1c) was determined by a nurse who collected a drop of blood from the adolescent before the medical appointment. Criteria of good metabolic control was based on ISPAD (2009) i.e. smaller than 7,5% is considered optimal, 7,5% - 9,0% suboptimal and higher than 9%, high risk.

### **2.3 Instruments**
