**6. Summary**

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).

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

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

(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

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‐

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 well-

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

diabetes.

440 Type 1 Diabetes

to…

friends. (p. 54) [31].

betes management.

being to be optimal (265)."

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

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 management for children in special populations.
