**5. Peer factors and diabetes management**

Parents may encourage a child to find benefits related to having diabetes or find benefits as‐ sociated with going through the trials associated with maintaining good diet, exercise, glu‐ cose monitoring, and insulin administration habits. Tran and colleagues found that young adolescents, between the ages of ten to fourteen years, provided higher ratings of positive reactions to diabetes stress if they were also reporting high levels of benefit finding [26]. Benefit-finding was likened to making a positive meaning as one copes with adverse life events. They speculated that those adopting a benefit-finding approach could positively re‐ frame trials and tribulations related to diabetes management; therefore, lowering children's stress levels. Interestingly, they also reported that benefit-finding was associated with high‐ er levels of negative reactions to diabetes-related stress. One idea they had about this was that children who are "benefit-finders" are more attuned to their emotional experiences in general, which allows them to process and move through troubling emotions so that they adapt or move on with their lives. Because they process and deal with negative affect, it be‐ comes *less* disruptive in their lives. Unfortunately, benefit-finding was not related to

changes in blood glucose levels; future research may uncover reasons for this.

• Who adjusts the bolus or insulin dose based on documented blood glucose monitoring?

• Does your child or do you have any fears about *hyperglycemic* or *hypoglycemic* episodes?

as those questions listed in Table 1.

• Who gives the injection or administers the bolus?

• Who remembers to monitor blood glucose?

• Who records or "counts" carbs at mealtimes?

• Who notices and monitors for "highs" and "lows?"

• What is your knowledge of the signs to signal an insulin reaction? • Who decides about and rotates the site for an insulin injection or bolus? • What are your and your child's fears related to managing diabetes?

• Is there any conflict about diabetes management between your child and you?

**Table 1.** Questions to Uncover Information about Diabetes Management

• Who does blood glucose checks?

signs, what happens)

438 Type 1 Diabetes

It is important to assess both parent/caregiver and child views of "who should be responsi‐ ble for what" in terms of diabetes management tasks [21]. This can be especially important to uncover for direct management tasks or factors related to direct management tasks, such

• Who reminds about or remembers the injection or bolus (insulin administration for those on a pump) schedule?

• Is there any conflict or trouble among parents/child related to blood glucose monitoring or insulin checks?

• What do you and your child know about *hyperglycemic* or *hypoglycemic* episodes? (your child's triggers or warning

• Who is responsible for making sure the child has snacks easily available in case of an insulin reaction?

• What are your and your child's ideas about who should be "in charge" of diabetes management?

• What does your child think that you should be doing to help with diabetes management? • Does your child have anxiety about diabetes management tasks in social situations with peers? Peers are integral to adolescents' diabetes management. Adherence behaviors and self-care may suffer in social situations with peers, because adolescents are hesitant to appear differ‐ ent from the norm and perform diabetes management tasks. Adolescents also may report feeling pressure from their peers to eat "junk food" that is not healthy for them [30]. Adoles‐ cents may benefit from "problem-solving" with diabetes educators or counselors in order to learn how to cope and follow their regimen during stressful social situations with peers, such as parties. Children also may benefit from learning refusal skills to help them say "no thank you" to junk food, and to request opportunities to eat foods which are low in carbohy‐ drates and are consistent with their meal and snack plans for optimal management of their diabetes. Salamon et al. developed a four-item "Self-Care Around Friends" (SCF) measure that examines adolescent perceptions of worry in social situations [30]. Questions are rated on 7-point Likert scales. The questions are:

(1) Over the past month, how many times did you have to do your diabetes care around oth‐ er kids?, (2) How stressful was it to do your care around your friends during this time?, (3) How worried were you about your friends' reactions to you doing your self-care in front of them?, and (4) How open were you in doing your care in front of your friends? (p. 53).

and their friends. They found that education received during sessions was effective in im‐ proving friends' knowledge about diabetes. Their findings indicated that friends who at‐ tended the groups were able to offer guidance and emotional support to peers who had diabetes. Much of the research on peer support focuses on adolescents. Extending research to assess the importance and function of peer support for children is an area where further

Type I Diabetes in Children: Facilitating Adherence to Medical Regimens

http://dx.doi.org/10.5772/52283

441

Children and adolescents with Type I Diabetes struggle with adhering to a complex medical regimen. Flexible regimens, which include the use of insulin pumps and adjustments using the pumps, termed basal-boluses, require frequent decisions about diabetes management and heighten the importance of adherence. Family and peer support can be critical to posi‐ tive diabetes management and low glycosated hemoglobin levels. Improving control over

Guidance and support from caregivers or parents also is important. The role of the parent may shift over the course of a child's development, with the caregiver directing manage‐ ment in early childhood, and then shifting his or her role to one of support and coaching as the child enters the teenage years. All things being equal, it is beneficial for parents to re‐ main aware of their child's management and be ready to assist when needed. In this way, the parent can form a band of support around the child that facilitates his or her adherence and self-efficacy for managing his or her diabetes. Encouraging children with diabetes to discuss their self-management needs also may improve the involvement of family and peers. Educating peers, so that they know how to be supportive, can increase their positive influence on the child's diabetes management [32]. In the future, interventions targeting in‐ creasing peer support and defining critical issues for parents in terms of when to act as a coach and when to increase monitoring will have practical implications that will facilitate children's diabetes management. Moreover, conducting longitudinal studies to assess fac‐ tors related to adherence in various populations (e.g., children with diabetes and celiac dis‐ ease versus children with only diabetes; children in single parent versus nuclear families) will shed light on variations in factors related to adherence both within and between popu‐ lations. This will be important in improving our understanding of ways to facilitate diabetes

the child's diabetes management also leads to positive health outcomes.

management for children in special populations.

and Jenny Bartz

**Author details**

University of Cincinnati, USA

Laura Nabors\*

study is needed.

**6. Summary**

These questions, or similar ones, may assist health care professionals in learning about stress experienced by adolescents when interacting with their friends and needing to manage their diabetes.

Salamon et al. also used items from the "Diabetes Stress Questionnaire" (*DSQ*), which is an‐ other measure that can assess adolescent stress [31]. This measure has subscales, "Peer Stress" and "Adverse Interpersonal Effects," that have questions addressing stress in social situations. Examples of questions on these subscales that might be relevant are, I am able to…

(1) have friends tell me foods I shouldn't eat. (2) talk with my friends about my diabetes, (3) eat or snack when my friends are not eating. (4) test and administer insulin while with friends. (p. 54) [31].

Health care professionals and clinicians can use adolescents' responses to these types of questions as a starting point for asking more questions to better understand problem situa‐ tions with peers. Then problem-solving can occur, and the adolescent and health care pro‐ fessional can discuss ideas for managing stressful social situations. Consequently, the *DSQ* is another measure that is useful for assessment of stress related to adherence [31]. We be‐ lieve that the types of questions in this paragraph and the preceding one also can be used to assess how older elementary school-age children interact with peers to assist them with dia‐ betes management.

Skinner et al. assessed children's perceptions of their diabetes. They recruited adolescents with Type I Diabetes from outpatient clinics in four regional hospitals in south England [23]. Participants completed questionnaires measuring well-being, self-management, social sup‐ port, diabetes-specific support, and peer support. Girls had more severe diabetes and re‐ ported greater levels of depression and anxiety, lower positive well-being, and more support from friends than boys. Social support was positively related to perceived control and total well-being. However, none of the social support measures were related to per‐ ceived seriousness or perceived impact of diabetes. They concluded that perceptions of dia‐ betes "well-being" were more positive if adolescents believed they were receiving peer support. Skinner et al. stated that "adolescents need a supportive peer group, whose life‐ style does not radically conflict with the demands of diabetes, for dietary self-care and wellbeing to be optimal (265)."

Schroff-Pendley and her fellow researchers found that peer support was very important to adolescents with Type I diabetes [11]. They suggested that education for peers would allow them to support diabetes management for their friends with Type I Diabetes. Without edu‐ cation and training, they cautioned that peers might not be able to provide support that would be related to higher levels of adherence. Greco et al. conducted a study that showed the value of education in enhancing positive peer support [32]. Greco et al. developed a pro‐ gram for best friends and children with Type I Diabetes to increase support for diabetes management. Participants were children with diabetes between the ages of 10 to18 years and their friends. They found that education received during sessions was effective in im‐ proving friends' knowledge about diabetes. Their findings indicated that friends who at‐ tended the groups were able to offer guidance and emotional support to peers who had diabetes. Much of the research on peer support focuses on adolescents. Extending research to assess the importance and function of peer support for children is an area where further study is needed.
