**2. Children and diabetes management**

Caregivers of preschool-age children may feel that they need to be vigilant and constantly monitor their child's diabetes. Sullivan-Bolyai, Knafl, Deatrick, and Gray found that mothers of preschoolers valued education from health care professionals that would provide them with solutions to diabetes management dilemmas [12]. Mothers said that they valued being able to contact health care professionals by telephone when they had a question about their child's diabetes. As they become more comfortable with diabetes management for their child, mothers appreciate being able to converse about methods for maintaining their child's medical regimen and "good" care while at the same time working to find ways to fit diabe‐ tes care into the framework of family routines and the daily life of the family. Health care professionals can support caregivers by helping them identify their strengths and by provid‐ ing affirmations and encouragement if their confidence for managing their child's diabetes decreases [12].

Chisholm and colleagues studied predictors of adherence in children ages two- to eightyears-old who had Type I diabetes. Mothers were primary informants and participants re‐ sided in Britain. Mothers provided data by telephone interview about the foods consumed by their child in the last 24 hours. Other information was collected through a review of the child's medical chart. Results of this study indicated that mothers were following medical recommendations. Also, increased education of mothers was related to higher or better lev‐ els of adherence, such as more frequent blood glucose monitoring and lower glycosated he‐ moglobin levels for children. Monitoring of injections was more consistent than monitoring blood glucose testing and diet, which were more difficult to consistently record and review. The authors concluded that parents may benefit from repeated education sessions to review information related to adherence, especially ideas related to nutrition and diet. The afore‐ mentioned studies provide some evidence of the importance of assessing adherence in younger children. Prospective, longitudinal studies are needed with younger children, to determine strategies for improving adherence.

Davis and her colleagues found that younger children, in the preschool- and elementary school-age range have adherence problems [13]. Davis et al. found that parental warmth was related to better adherence for children between the ages of four and ten years. In con‐ trast, parents who were characterized as being overly strict with their child tended to have children with poorer glycemic control. Davis et al. concluded that parental warmth is relat‐ ed to better family cohesion and reduced family conflict, which are variables that are associ‐ ated with better adherence in children. Results of the study by Davis et al. also revealed that children residing in low-income families were likely to have poorer adherence. Overall, there is a paucity of research on adherence for young children as compared to adolescents, and we believe that this is an area for further research. Habits from childhood continue to the later years and good management in childhood can also transfer to the adolescent years, making good adherence practices a pattern of behavior that is a resilience factor for a child throughout his or her life.

The clinician or health care provider should assess parent reactions and strategies for coping with misbehavior during mealtime, when he or she is working with parents of younger chil‐ dren. Wilson, DeCourcey, and Freeman found that over-reaction and over-correction of mealtime problems was associated with relatively poor parental coping and management of the child's diabetes. These researchers speculated that, "parents who perceive themselves as over-reactive may be removing themselves from oversight of the illness (p. 220)." Children, in turn, appear to benefit from parental guidance and education. Patton et al. assessed young children's mealtime behaviors with parents [15]. Children were between the ages of two and eight years, with a mean age of approximately five and a half years. Children who were in poorer control, with relatively poorer diabetes management, had mealtime relation‐ ships with their parents that were characterized by rigidity and coercive feeding behaviors on the part of parents. Increasing positive and open communication between children with Type I diabetes and their parents or caregivers also may lead to improved parent-child in‐ teractions and positive diabetes management. Wilson et al. proposed that longitudinal stud‐ ies should be conducted to gain a greater understanding of the ways that parent-child interactions support diabetes management. Health professionals and clinicians should strive to advise parents about and assist them in developing a pattern of positive mealtime interac‐ tions with their child.
