**2. Adherence to self-care in the adolescent with type 1 diabetes**

the immune system's T cells to destroy these potentially invading agents also act on the pan‐

Self-management and self-care is of critical importance for the control of this type of diabe‐ tes in children and adolescents. In fact, the responsibility of regularly monitoring the disease and its symptoms and the compliance with the treatment lies with the family and later, in accordance with the growth and the development phase, are gradually transferred to the child/adolescent [14-17]. Therefore, the main goals for type 1 Diabetes Mellitus's treatment, in children and adolescents, emphasize the prevention of symptoms and their severity, the prevention of short and long term complications, and the appropriate growth and develop‐ ment of the adolescent allowing the suitable maintenance of daily activities such as those re‐

However, the multiple physiological and psychosocial modifications occurring during ado‐ lescence compromise diabetes treatments during this developmental period [15, 21, 22] and often, the adolescent show serious difficulties in adhering to self-care management of diabe‐ tes and the prevention of its complications. The conflicts arising from the demands and com‐ plexities involved in the self-management of diabetes, and the adolescent's expectations regarding their own experiences, in this developmental phase, may account for this scenario

According to the World Health Organization (WHO), adolescence is placed between 10-19 years, during which the individual is subjected to changes of biological nature, determined by puberty that will produce a rapid growth with consequently distinct body transforma‐ tions; changes of cognitive nature, with a higher complexity in reasoning skills, through the attainment of autonomy and identity construction and also changes of social nature with the experience of new and different roles [25-27]. However, the constant need to declare autono‐ my and independence leads the adolescent to idealize feelings of invulnerability, inconsis‐ tent with the acceptance of a chronic disease such as type 1 diabetes that may encourage

Parental involvement, communication, cohesion and family conflicts that arise when man‐ aging diabetes self-care, are good examples of the type of family support available to the adolescent. A higher level of family conflict and less involvement account for worse out‐ comes of adherence to diabetes self-care in adolescents [28]. In turn, schools with staff and peers also account from other sources of social support that the adolescent with type 1 dia‐ betes may count on, in daily life, that may influence metabolic control and quality of life [29]. Peer pressure and the demands of the social environment (school, recreational activities

This chapter's main goal is to describe the relationship among family support, school sup‐ port and parental coping in adolescents with type 1 diabetes on adherence to self-care in or‐ der to inform the development of interventions programs to meet adolescents' needs

and family) may hinder adherence to self-care in adolescents with diabetes [30, 31].

creas β cells, destroying them [11-13].

[23, 24].

446 Type 1 Diabetes

non-adherence to self-care [22].

regarding diabetes management.

lated to family dynamics, school and social life [15, 18-20].

The diagnosis of a chronic condition such as diabetes involves a change in lifestyle as well as the use of therapeutic methods that, at times, adolescents may not have the will or capacity to integrate into their daily lives resulting in risks to their health [32-35]. Considering that the prescribed treatment regimen can be complex, the role of health professionals involved with patient's care is of crucial relevance and intervention should emphasize symptoms' control and the promotion of quality of life [36-38].

There are strong evidences that individuals with chronic diseases, such as diabetes, present difficulties in adhering to the prescribed therapeutic regimes, with the consequent complexi‐ ties of managing and controlling the disease [39, 40]. However, the literature shows that some adolescents have problems in adhering to a self-administrate treatment regardless of the type of disease or its severity [41].

Non-adherence to treatment of a chronic disease, particularly in type 1 diabetes, embodies a problem of multifactorial etiology and indeed different attempts to explain adherence be‐ havior to prescribed treatments have been proposed [32]. According to the World Health Organization [41], different factors affecting adherence can be classified into five groups: 1) social, economic and cultural factors; 2) factors related to the health services and professio‐ nals; 3) factors underlying the disease and the comorbidity; 4) factors related to the treat‐ ment and 5) factors related to the patient.

Adolescents with diabetes, in particular, go through a phase of strong psychosocial changes and have to deal simultaneously with the changes of adolescence itself and as well as coping with the demands of controlling the disease treatment specificities [16, 42-45]. The hormonal changes occurring during puberty that cause insulin resistance, the rebelliousness character‐ istic of this phase, and almost total absence of residual insulin secretion by the pancreas, may complicate diabetes treatment, particularly, adherence [15, 46, 47].

The stigma associated with chronic disease, the need for self-care in social contexts and the risk of hypoglycemia, reinforces the idea that adolescents with diabetes are different from their colleagues and friends, which can lead to a feeling of inferiority and negatively influ‐ ence adherence to self-care behaviors outside their family and personal context [46, 48, 49]. Since adolescence corresponds to the transition between childhood and adulthood, both families and health professionals encourage and stimulate the independence of these young‐ sters regarding the management of their diabetes [46, 48, 49]. However, this rapid transition can lead to personal and family conflicts, probably because the adolescent has not devel‐ oped the necessary maturity to assume this type of responsibility [16]. In fact, management of diabetes can be considered a major challenge for adolescents, worsened by physical and hormonal changes, characteristic of this developmental phase which may lead to frequent changes in the therapeutic regimen [50]. Living with a chronic disease, during adolescence is hard and the adolescent may experience more difficulties in adapting to diabetes [2, 17]. Very often, adolescents with diabetes mention their frustration, stress and anxiety, with a lack of motivation regarding the management of the disease, which may negatively influ‐ ence their adherence to self-care. This set of emotions may also hinder the behaviors neces‐ sary for adherence to treatment [51, 52].

velopment, may also negatively influence adherence to self-care [59, 72-75]. Generally, ado‐ lescents tend to have worse outcomes regarding the administration of insulin, the practice of physical exercise, nutrition care and self-monitoring of blood glucose, when compared to children [39, 76]. However, a greater knowledge of diabetes and long experience with the disease decreases attitudes of denial, allowing the adolescent to gradually begin to accept the therapeutic regimen with better results [77, 78]. Also, adolescents who are more respon‐ sible for their treatment will have their task of identity formation and psychosocial develop‐

The Influence of Family Support, Parental Coping and School Support on Adherence to Type 1 Diabetes' Self-Care in

Adolescents

449

http://dx.doi.org/10.5772/53062

Male adolescents have worse adherence to self-care than female adolescents [69], but the lat‐ ter show higher incidence of depression, eating disorders and psychosocial implications, which may interfere with the process of body image's acceptance [43, 51, 79]. However, liter‐ ature is controversial regarding gender. A study [80] found male adolescent to present high‐ er levels of adherence to self-care. In other gender related studies, the differences in adherence to self-care were minimal, which may suggest that there are many similarities in the reactions and behaviors of adolescents of both genders regarding their performance in diabetes self-care, meaning that gender may not be considered a risk factor [41, 79, 81].

Family impacts on its members' health and the opposite is also true [82]. Family support consists of the individual perception regarding the availability and the caregiving received from their family that allows the development of greater resilience and psychological wellbeing in the face of stress-inducing events [83-85]. Family support is a complex multidimen‐ sional concept associated with the individual's mental health and in direct relation to support received from family members [84, 86, 87]. Hence, family support relates to the be‐ haviors of affection, sensitivity, cooperation and trust, encouraging the autonomy and inde‐

There are numerous types and qualities of support available to families: tangible family sup‐ port, such as actions that cause well-being among family members; family emotional sup‐ port, which has to do with empathy, listening, and attention to family members giving advice, which is vital in moments of great difficulties and important decision-making [86, 88]. However, the perception of family support is influenced by personal factors, stable

The perception of high levels of family support is associated with a positive disposition [89] and, as a result, when family support is positively perceived, feelings of well being within

The concept of family support can also be defined as a part of one's informal and close rela‐ tionship network, benefiting the individual with the exchanges among family members [85]. In this sense, the individual develops greater resilience and psychological well-being, that enables the development of more adjusted responses to stress-inducing events that are

ment facilitated due to the management of their diabetes [65].

**3. The family support in adherence to self-care**

traits and intrinsic changes, in each person, over time [86, 88].

pendence amongst family members [86].

the family members are promoted [86].

A chronic condition, such as diabetes, implies a permanent process of compliance with selfcare in order to minimize the effects of its progression and, as a result, is often associated with lower therapeutic adherence [14, 49, 53, 54]. The methods aimed at increasing the suc‐ cess of therapeutic adherence can be classified into four main groups: 1) patient education; 2) existing communication between healthcare professionals and patient; 3) dosage and type of drugs and 4) the accessibility of health services to attend the patient [55]. However, evi‐ dence showed that through a multidisciplinary approach comprising educational and be‐ havioral interventions, treatment adherence rates can significantly improve, when compared to the strategies that use each intervention separately [56, 57]. So, taking in con‐ sideration the different variables that contribute to noncompliance, it is fundamental to con‐ sider a multifactorial approach, to the extent that a single approach will not successfully improve patients' adherence to treatment [55].

Adherence to diabetes self-care involves a complex set of daily behaviors that require the frequent monitoring of blood glucose, insulin administration, recommendations about nutri‐ tion and physical exercise [58] as well as making changes and adjustments whenever one of these factors changes [47, 59]. Therefore, the complexity of self-care behaviors may explain low adherence rates and may lead to significant suffering, although compliance significantly reduces the incidence and progression of associated complications [60-62]. Positive out‐ comes regarding adherence may be related to how each adolescent interprets, learns and draws conclusions regarding the meaning of the disease and its treatment [17]. However, some adolescents with diabetes may lie about their self-care behaviors to avoid being repri‐ manded by their parents or physician [63, 64].

Good adherence to self-care, in adolescents, may be explained by feelings of social accept‐ ance, distorted or optimistic perception of their behavior or by minimizing the importance of strict compliance with the treatment [51, 65]. On the other hand, non-adherence may be related to specific psychosocial characteristics of adolescent's developmental phase [15, 43, 47, 50, 58]. Peer pressure and fear of a negative reaction from the group can lead to loss of support from colleagues, thus increasing the risk of diabetes complications [58]. The de‐ mands associated with self-care does not facilitate the adolescent's growing desire for au‐ tonomy and both diabetes and its treatment may result and be perceived as limitations in physical activities, and one's lifestyle [44, 66, 67].

Whereas the responsibility for diabetes self-care increases with adolescent's age, compliance follows in the opposite direction, indicating that adolescents show better adherence when they are more in tune with the guidelines and values of their parental figures [50, 66, 68, 69]. In fact, in the late adolescence stage, older adolescents show a greater concern with the body, sexuality and with independence from parents and authority figures what may ex‐ plain poor results regarding adherence compared to younger adolescents [50, 65, 70-72].

The increase of emotional distress and autonomy and less acceptance of diabetes, due to a higher awareness of the impact of diabetes on the adolescent's identity and psychosocial de‐ velopment, may also negatively influence adherence to self-care [59, 72-75]. Generally, ado‐ lescents tend to have worse outcomes regarding the administration of insulin, the practice of physical exercise, nutrition care and self-monitoring of blood glucose, when compared to children [39, 76]. However, a greater knowledge of diabetes and long experience with the disease decreases attitudes of denial, allowing the adolescent to gradually begin to accept the therapeutic regimen with better results [77, 78]. Also, adolescents who are more respon‐ sible for their treatment will have their task of identity formation and psychosocial develop‐ ment facilitated due to the management of their diabetes [65].

Male adolescents have worse adherence to self-care than female adolescents [69], but the lat‐ ter show higher incidence of depression, eating disorders and psychosocial implications, which may interfere with the process of body image's acceptance [43, 51, 79]. However, liter‐ ature is controversial regarding gender. A study [80] found male adolescent to present high‐ er levels of adherence to self-care. In other gender related studies, the differences in adherence to self-care were minimal, which may suggest that there are many similarities in the reactions and behaviors of adolescents of both genders regarding their performance in diabetes self-care, meaning that gender may not be considered a risk factor [41, 79, 81].
