**6. Conclusion**

feelings of discrimination among adolescents with diabetes [138, 141, 142, 145, 146]. Along with these barriers, the lack of private places for administering the insulin, which has to be done often in inappropriate places such as the bathroom, the absence of locations for adoles‐ cents with diabetes to keep the materials needed for diabetes self-care and the indifference of school staff regarding symptoms and difficulties expressed by these adolescents, may also

For parents of teenagers with diabetes, the existence of well-informed teachers regarding diabetes and a proper school structure to receive students with this health condition, are considered the main support that school needs to provide for diabetes management in ado‐ lescents [29]. In a school environment, the strongest support comes from teachers and peers [107, 141]. Consequently, it is essential to improve communication between the family and the school, to improve the education of school professionals, to develop healthy menus in the canteen and cafeteria and also to have nurses available to take care of adolescents with diabetes or other chronic diseases, when needed, as well as promoting the education of school staff, students and teachers regarding diabetes, the same way as the school has

learned how to care and accommodate students with special education needs [149].

Social support from the peer group has been rated as one of the most important resources for adolescents with diabetes, given that friends tend to provide more companionship and emotional support for self-care behaviors than family members [29, 106, 47, 150, 51]. Social support from peers significantly influences adolescent's adherence to self-care, with strong evidence suggesting that this support improves metabolic outcomes [31]. Despite the differ‐ ences between the type of support provided by the family and peers, both types of support are also complementary, since the family provides more support in daily tasks, such as insu‐ lin administration and meal preparation, while friends provide more emotional support in relation to the practice of physical exercise and glucose monitoring contributing to a better psychological adjustment to diabetes [150, 152-155]. In fact, friends and peers allow the ado‐ lescent to enjoy moments of fun and relaxation, contributing to the successful management of diabetes. However, conflict situations between the adolescent with diabetes and peers, al‐ though normal and appropriate for psychosocial development, are associated with worse metabolic results, especially in female adolescents [156-158]. In turn, older adolescents, de‐ spite having better skills in problem solving, are more vulnerable and prone to peer group pressure regarding diabetes self-care which is associated with worse metabolic outcomes [159, 160]. The way adolescents cope with the need to be part of the group and treated the same way as other members may explain the secrecy regarding diabetes and its symptoms, in an attempt to avoid a negative impact on their social image if significant others find out

A study on the influence of school and family support on self-care, in adolescents, found that these two types of support act as moderators in the relationship between the quality of life and adherence to the treatment, so when school support and family support were per‐ ceived as high, in adolescents with type 1 diabetes, good quality of life was positively relat‐

negatively influence adherence [142, 147, 148].

454 Type 1 Diabetes

about their disease [105, 161, 162].

ed to good adherence [108].

Psychosocial and physiological demands, typical of the adolescent's developmental phase and the intensive and demanding characteristics of diabetes treatment influence adherence to diabetes self-care. However, the support from family, peers and school play, an important role in managing and controlling diabetes by adolescents, who tend to present better adher‐ ence to self-care behaviors when support is perceived as appropriate. Therefore, interven‐ tion programs designed to promote adherence to diabetes self care in adolescents should also include family members and take in consideration the social context of adolescents.

In terms of family support, it is important for adolescent to have access to tangible support from the family in preparing food, monitoring the levels of glycemia and in administering insulin. However, if a high family support is associated with good adherence to the selfcare, sometimes too much family involvement can entail a negative influence if the adoles‐ cent perceives this support to be a barrier to the development of his/her identity and autonomy. Consequently, it is also important for intervention, in diabetes, to include conflict resolution skills, self-efficacy and stress management strategies for both the adolescent and the family.

Coping strategies adopted by parents in order to deal with daily tasks and challenges, that diabetes management implies, interfere with the organization of family dynamics and im‐ pact on adherence to diabetes self-care. Given that the effectiveness of coping strategies in‐ fluence adherence, it becomes important for parents and adolescents to integrate self-help groups or even family therapy, when they have trouble adapting to diabetes management.

Diabetes is a disease that requires constant monitoring and surveillance even within social contexts outside the family environment, as in the case of peer group activities. The support from both the school and the peer group impacts on adherence outcomes in adolescents. As a result, education regarding diabetes in schools is important, in order to improve knowl‐ edge about the management of diabetes and also to make support and resources more effi‐ cient and appropriate regarding diabetes self care's behaviors in the school context.

[9] Raine JE, Donaldson MD, Gregory J, Van-Vliet G. Practical Endocrinology and Dia‐

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

Adolescents

457

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

[10] Escobar O, Drash AL, Becker DJ. Management of the Child with Type 1 Diabetes. In: Lifshitz F. (ed.) Pediatric Endocrinology. 5th ed. New York: Informa Healthcare; 2007.

[11] Thorsdottir I, Ramel A. Dietary Intake of 10- to 16-Year-Old Children and Adoles‐ cents in Central and Northern Europe and Association with the Incidence of Type 1

[12] Dorman JS, Laporte RE, Songer TJ. Epidemiology of Type 1 Diabetes. In: Sperling MA. (ed.) Type 1 Diabetes. Etiology and Treatment. New Jersey: Humana Press;

[13] Lernmark Å, Chung CH. Molecular Biology of β-Cell Destruction by Autoimmune Processes. In: Sperling MA. (ed.) Type 1 Diabetes Etiology and Treatment. New Jer‐

[14] Silva I, Pais Ribeiro J, Cardoso H. Adesão ao Tratamento da Diabetes Mellitus: A Im‐ portância das Características Demográficas e Clínicas. Revista Referência 2006;2(2)

[15] Fagulha A, Santos I, Grupo de Estudo da Diabetes Mellitus. Controlo glicémico e tra‐ tamento da diabetes tipo 1 da criança e adolescente em Portugal. Acta Médica Portu‐

[16] Skinner TC, Channon S, Howells L, McEvilley A. Diabetes During Adolescence. In: Snoek FJ, Skinner TC. (eds.) Psychology in Diabetes Care. West Sussex: John Wiley &

[17] Barros L. Psicologia Pediátrica. Perspectiva desenvolvimentista. 2nd ed. Lisboa: Cli‐

[18] Hanas R. Diabetes tipo 1 em crianças, adolescentes e jovens adultos. Lisboa: Lidel Ed‐

[19] Pina R. Diabetes na Criança. In: Duarte R. (ed.) Diabetologia Clínica. 3th ed. Lisboa:

[20] American Diabetes Association (ADA). Standards of Medical Care in Diabetes. Dia‐

[21] Anderson BJ. Family Conflict and Diabetes Management in Youth: Clinical Lessons from Child Development and Diabetes Research. Diabetes Spectrum. Diabetes Spec‐

[22] Pereira M, Almeida P. Barreiras à Adesão ao Regime Terapêutico da Diabetes In: Ma‐ chado C, Almeida L, Gonçalves M, Ramalho V, (eds.) X Actas da Conferência Inter‐ nacional de Avaliação Psicológica: Formas e Contextos. Braga: Psiquilibrios; 2004.

betes in Children. 2nd ed. Massachusetts: Blackwell Publishing; 2006.

Diabetes. Annals of Nutricion & Metabolism 2003;47 267-275.

p101-124.

2003. p3-22.

33-41.

sey: Humana Press; 2003. p71-92.

guesa 2004;17(2) 173-179.

Sons; 2000. p25-59.

mepsi Editores; 2003.

trum 2004;17(1) 22-26.

p170-179.

Lidel Editores; 2002. p229-242.

betes Care 2007;30(Suppl. 1) S4-S41.

itores; 2007.

Finally, psychological interventions must also acknowledge the implications of diabetes on the adolescent's lifestyle in order not to jeopardize the development of autonomy, inde‐ pendence and social skills and instead, promote normal psychosocial development of the adolescent in the family, school, and other significant social environments.
