**4. Parents and diabetes management**

Findings from previous studies have indicated that support from family and friends may fa‐ cilitate self-management for adolescents with Type I diabetes [20]. For example, Drew et al. proposed that parental warmth and acceptance of the child, within a relationship that is open and where communication is high fostered independence for adolescents with diabe‐ tes [21]. Berg et al. also supported the importance of parental involvement and monitoring as a key ingredient for successful diabetes management by adolescents [17]. In a sense both the parent and child are collaborators working to reach high positive levels of communica‐ tion and adherence to the diabetes care regimen for the child. As a coach the parent can also work to encourage adolescent self-efficacy for diabetes management.

High levels of family conflict and a lack of cohesion in family relationships have been relat‐ ed to poor metabolic control (higher glycosated hemoglobin levels) [22]. Similarly, good family relationships may have a positive effect on adherence [23]. Arguably, the most im‐ portant relationship that may drive the aforementioned results about the "family" is the pa‐ rent-child or caregiver-child relationship. Parents' and adolescents' perceptions of family functioning are related to adolescents' adherence, management, and metabolic control, which are critical components of adolescent diabetes care [22,24]. A warm, caring, and sup‐ portive relationship with parents or caregivers appears to be a protective factor, supporting adherence, irrespective of the child's age [15]. A good quality relationship will be marked by regular communication about diabetes management as well as warmth and encouragement [21]. The role of the parent or caregiver changes with the age of the child. The parent plays a more direct role in diabetes management for younger children, while for adolescents the role could be described as a mentoring or coaching relationship, with the adult being a member of a "team" with the child to support his or her diabetes management. We recom‐ mend a "rubber-band" approach for adolescents, based on need. The parent helps more and pulls tight when the adolescent requests or really needs help (e.g., eating irresponsibly) and then relaxes when the adolescent is exhibiting good self-management skills. A rubber band approach also may be appropriate for younger children. However, the parent or caretaker does play a relatively larger role, in terms of caregiver contribution or share of diabetes management tasks, when the child is younger.

indicated some support for these notions. They also reported that fears of hypoglycemic or hyperglycemic episodes might "drive" adolescent behavior and fears could lead to poor dia‐ betes management. We also have found that fear of either type of episode can be related to poor diabetes management in adolescents and older children (i.e., children in late elementa‐ ry school). Hence, it is important to discuss management of diabetes in cases of both hypoand hyperglycemia with youth. Additionally, it is important to discuss how fears of either type of episode can influence poor management choices in order to provide advance guid‐

Di Battista et al. found that social anxiety may be an important indicator of poor diabetes management in adolescent boys as opposed to girls [18]. They concluded that socially anx‐ ious boys may have difficulty managing their diabetes in mid- to older-adolescence. Health care providers should ask questions about anxiety and diabetes management in social situa‐ tions in order to determine if anxiety about peer reactions is influencing choices adolescents, especially males, make in terms of diabetes management. Practicing explaining the need for good management to peers is one way to prepare adolescents to go through stressful peer situations. Another idea is to teach the adolescent who has diabetes to educate his or her peers about what could happen if he or she is in "poor" metabolic control. Finally, teaching relaxation and other anxiety management techniques may assist the adolescent in managing diabetes related anxiety in social situations. When a young male has diabetes, clinicians should inquire about diabetes management in social situations in order to determine if the young man is struggling to manage his diabetes when he is interacting with peers. We be‐ lieve that asking about management of diabetes in front of peers may be important for girls too, because there is a tendency for girls to administer limited insulin or lower insulin doses

Findings from previous studies have indicated that support from family and friends may fa‐ cilitate self-management for adolescents with Type I diabetes [20]. For example, Drew et al. proposed that parental warmth and acceptance of the child, within a relationship that is open and where communication is high fostered independence for adolescents with diabe‐ tes [21]. Berg et al. also supported the importance of parental involvement and monitoring as a key ingredient for successful diabetes management by adolescents [17]. In a sense both the parent and child are collaborators working to reach high positive levels of communica‐ tion and adherence to the diabetes care regimen for the child. As a coach the parent can also

High levels of family conflict and a lack of cohesion in family relationships have been relat‐ ed to poor metabolic control (higher glycosated hemoglobin levels) [22]. Similarly, good family relationships may have a positive effect on adherence [23]. Arguably, the most im‐ portant relationship that may drive the aforementioned results about the "family" is the pa‐ rent-child or caregiver-child relationship. Parents' and adolescents' perceptions of family

work to encourage adolescent self-efficacy for diabetes management.

ance and opportunities to discuss fears related to either type of problem.

as a weight management strategy [19].

436 Type 1 Diabetes

**4. Parents and diabetes management**

One idea to help in building a strong child-caregiver management unit is to describe a team approach to diabetes management. In this approach, parents can be coaches and help moni‐ tor and guide their child's increasing responsibility for diabetes management as he or she passes through adolescence [17]. Both the parent and child could take turns coaching the team or finding ideas to help the child improve his or her "game plan" for self-management of diabetes. This promotes a shared leadership and responsibility framework in the coopera‐ tive relationship between parents or caregivers and children who have Type I Diabetes. Ves‐ co et al. proposed that a "shared responsibility" framework provides the adolescent with the support he or she needs to optimize diabetes management [25]. A spirit of cooperation be‐ tween parents and child, who are both part of a team working to achieve the highest level of diabetes care for the child, can be an optimal framework for a shared responsibility ap‐ proach [21]. Involvement of mothers and fathers is important to positive coping with diabe‐ tes; however, more information is needed on the relative contributions of each parent or caregiver, and on the role that each should take in helping a child manage diabetes.

Parents or caregivers serve as "monitors" of their child's diabetes management and in this role report on the child's management to the medical team. Health professionals need to ask questions and remain cognizant of the fact that premature transfer of diabetes management to the child can have deleterious effects. Both health care professionals and caregivers need to remain aware of the balancing act – between monitoring and direct assistance – that is needed to help children and adolescents manage their diet and other aspects of their medi‐ cal regimen. Premature transfer of diabetes self-management, in the absence of child skills or readiness to manage his or her diabetes, has been associated with poor outcomes [25]. Caregivers may need to remain involved, on some level, throughout the adolescent period [17]. Vesco et al. found that youth-caregiver conflict over "direct" management tasks, such as testing and insulin administration, is indicative of or a marker of potential difficulties in diabetes management [25]. Stress and conflict over indirect management, such as planning meals, can also be a negative influence on management, but is less likely to be related to poor management than conflict over direct management tasks.

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.

Assessing the adolescents' perceptions of parental involvement, in terms of level of involve‐ ment (e.g., "too much" or "too little") can provide key information about the adolescent's perspective; assessing family members' perspectives provides key information too. Finally, asking about diabetes management in social situations with peers can provide other key in‐ formation [18]. When armed with data from the types of questions listed in Table 1, the health professional can take the adolescent's and caregivers' perspectives into account when discussing diabetes management. Health professionals should help the child and caregivers work toward a model of shared decision making that is a best fit for each individual child

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Haugstvedt et al. reported that both mothers and fathers worry about the long-term health outcomes that their child may face [27]. Care is a burden for both parents, especially fear of nocturnal hypoglycemia for the child. There can be differences in mothers' and fathers' per‐ ceptions of their child's diabetes. Mothers may play a greater role in their child's care and subsequently feel more distressed about their child's illness compared to fathers [27, 28]. Be‐ ing more involved with their child's care may be related to mothers feeling more confident about their ability to manage their child's diabetes, although both mothers and fathers may feel confident about their ability to manage their child's diabetes [29]. Leonard et al. found that mothers reported higher confidence for managing their child's diabetes when their child was away from home or experienced changes in activity levels compared to fathers [29]. Mothers and fathers may also have different styles of coping, with mothers being more emotional and fathers being more likely to seek and discuss medical information with their child [28]. Fathers may express hesitancy toward being in support groups, which mothers can find to be of value [29]. Although more research about father involvement is needed, we believe that involvement of fathers in care can provide support for mothers and children.

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

(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)

Their involvement has the potential to improve diabetes management.

**5. Peer factors and diabetes management**

on 7-point Likert scales. The questions are:

and caregiver unit.

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 as those questions listed in Table 1.


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

Assessing the adolescents' perceptions of parental involvement, in terms of level of involve‐ ment (e.g., "too much" or "too little") can provide key information about the adolescent's perspective; assessing family members' perspectives provides key information too. Finally, asking about diabetes management in social situations with peers can provide other key in‐ formation [18]. When armed with data from the types of questions listed in Table 1, the health professional can take the adolescent's and caregivers' perspectives into account when discussing diabetes management. Health professionals should help the child and caregivers work toward a model of shared decision making that is a best fit for each individual child and caregiver unit.

Haugstvedt et al. reported that both mothers and fathers worry about the long-term health outcomes that their child may face [27]. Care is a burden for both parents, especially fear of nocturnal hypoglycemia for the child. There can be differences in mothers' and fathers' per‐ ceptions of their child's diabetes. Mothers may play a greater role in their child's care and subsequently feel more distressed about their child's illness compared to fathers [27, 28]. Be‐ ing more involved with their child's care may be related to mothers feeling more confident about their ability to manage their child's diabetes, although both mothers and fathers may feel confident about their ability to manage their child's diabetes [29]. Leonard et al. found that mothers reported higher confidence for managing their child's diabetes when their child was away from home or experienced changes in activity levels compared to fathers [29]. Mothers and fathers may also have different styles of coping, with mothers being more emotional and fathers being more likely to seek and discuss medical information with their child [28]. Fathers may express hesitancy toward being in support groups, which mothers can find to be of value [29]. Although more research about father involvement is needed, we believe that involvement of fathers in care can provide support for mothers and children. Their involvement has the potential to improve diabetes management.
