**4. Adherence to self-care and parental coping**

closely related to a better coping with a chronic disease [85, 90, 91]. Therefore, it is necessary for family dynamics to show a set of fundamental aspects which favor the development of family support among its members, such as: 1) congruent, directional, functional and emo‐ tional communication; 2) consistent and flexible rules; 3) democratic leadership shared with the offspring; 4) self-esteem, 5) integrated couple's relationship, allowing the family to act as a whole but ensuring each individual's personality [92]. The accomplishment of these func‐ tions, in association with the perception of the family as loving, cohesive and with clear boundaries, provides members with important tools for individual growth as well as pro‐

In situations of chronic disease, family support proves to be an important resource in selfcare behaviors for adolescent, with a direct correlation between the perception of family support and an increased motivation for self-care behaviors and health in general [82, 90, 93]. This support appears to be of greatest importance in children and adolescents who ex‐ perience high levels of stress due to a chronic condition and may also affect their develop‐ ment and the quality of their social relationships within their family system [94-96]. However, on one hand, some families become so close that its members are attached, in a way that may affect the autonomy of the patient and, on the other hand, there are families who may become more distant due to the strain that the disease imposes on the family [82]. Within this perspective, a family providing support, affection, guidance and adjusted strat‐ egies to solve problems, establishes and promotes best conditions for adherence to self-care, evidencing its responsibility in sharing diabetes' self-care activities with the adolescent [14, 97]. In fact, the family is the main source of support in chronic disease, whether through tan‐ gible support, such as preparing meals, administering the medication and in the daily care or through emotional and social support ([82, 90]. Both family and friends influence the con‐ trol of diabetes, regarding compliance with the medical treatment, diet and the practice of

Family support represents an important factor in understanding treatment adherence in adolescents with type 1 diabetes, helping the adolescent to adapt to the demands of the dis‐ ease and consequently to diabetes self-care. A low family support is a good predictor of

Family organization significantly affects family health behaviors in the same way that indi‐ vidual's health also affects the family. Therefore, the family is a resource of strategic impor‐ tance, since it may or may not help the adolescent with diabetes to properly manage the disease and to achieve treatment's goals [90]. Family support entails emotional and behavio‐ ral benefits for its members and is therefore, a reciprocal and proactive process with both parties benefiting from its positive effects, which are particularly important in adolescents who experience high levels of stress, such as in the process of a chronic disease [94, 99]. In the case of diabetes, a direct relationship between family support, characteristics of adoles‐ cents with diabetes and therapeutic adherence has been found [70, 82]. The family can act as a support unit for the adolescent's daily self-care tasks, such as motivating physical activity and compliance with the nutrition plan and encouraging insulin administration, after receiv‐

viding its members with a support system [92].

poor adherence to self-care in diabetes [73, 100, 101].

physical exercise [98, 99].

450 Type 1 Diabetes

ing proper guidance, [71, 90].

Coping is related to efforts, whether cognitive or behavioral, used by the individual to face internal or external demands caused by a specific stress-inducing situation [113, 114]. Cop‐ ing also implies a dynamic process depending on individual differences and circumstances occurring throughout life [115-117].

Given that coping is a changing process, the individual is not limited to a single coping strategy, since changes will occur resulting from the assessment of stressful situations [116-118]. For this reason, the individual can begin the process by using a strategy and later keep the same strategy, change it or use a combination of different strategies, as the relation‐ ship with the environment changes [119, 120].

Coping strategies represent actions, thoughts or behaviors to cope with a stress-inducing event that may, according to their function, be subdivided into two types: emotion-focused coping and problem-focused coping [119, 121, 122]. Emotion-focused coping concerns the ef‐ forts to regulate the emotional state that is associated with stress or results from stressful events ([17, 119]. These efforts are directed to somatic sensations or feelings, in order to transform the emotional state manifested by the individual; this type of strategies seeks to minimize the unpleasant physical sensation caused by a state of stress. Problem-focused coping consists of making an effort to act upon a stressful situation, by trying to change it [119, 122, 123]. This type of strategy aims to modify the existing problems in the relationship between the individual and the context that caused the tension [17, 124]. Therefore, coping actions can be directed either inwardly or outwardly [125, 126]. The first type includes strat‐ egies such as cognitive restructuring and the latter includes negotiation strategies to resolve an interpersonal conflict or request help from other individuals [125, 126]. In this sense, the process of coping is considered a mediator between the stressful situation and its conse‐ quences, whether by focusing on the problem or on the emotion, and its main purpose is to improve the emotional state that results from the confrontation with the stressor [123].

adolescent's emotional development. Parents should be enlightened and aware of the specif‐ ic diabetes' treatment demands, so that the adolescent does not become depressive and/or distressed [129]. Some studies show, after the diagnosis, that some mothers of children or adolescents with a chronic disease, have trouble sleeping and present a significant emotion‐

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

Adolescents

453

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

There is a greater responsibility for mothers in the daily care of a child with diabetes. Often, is up to the mother to accompany the child/adolescent to the medical consultation, keep monitoring records of the blood glucose, guide the child regarding diet and care about the daily insulin administration [134, 135]. Sometimes, when a child is diagnosed with diabetes, parents' responses can lead to a family breakdown that may consequently influence the whole process of adapting and adjusting, by family members, to a chronic disease [133]. This situation can occur after the diagnosis, when the family ceases to participate in social events trying to avoid the ingestion of sweets and cakes hiding from the discomfort of hav‐ ing to relate to others in social situations [135]. Thus, parents who intensify the relationship of dependence and protection regarding the adolescent, as a coping strategy, start to lead their lives according to the child's needs and this process may become very tiresome for pa‐

Sharing specific tasks for diabetes management between the family and the adolescent, in‐ creases the later's knowledge about diabetes. The use of assertive behavior, in social con‐ texts, is considered to be an adjusted strategy to cope with the disease and encourages adaptation. Disease management in diabetes can be stress-inducing, both for the adolescent

In most cases, either the adolescent or the family may not act appropriately regarding diabe‐ tes, and ultimately fail to accomplish self-care tasks and may even lie regarding blood glu‐ cose monitoring if afraid of the disapproval or criticism from health professionals [135].

School plays an important role in controlling diabetes, in adolescents, given the association between keeping proper self-care during normal school activities and good disease manage‐ ment and quality of life [29, 137, 138]. The school context can contribute to improve the ac‐ ceptance of diabetes and adolescent' self-esteem and, consequently, have a positive influence on diabetes self-care, due to the continuity of diabetes care during school activi‐ ties, allowing the adolescent to actively participate in school, reducing school interruptions and absences and ensuring the safety and the prevention of diabetes associated complica‐ tions [138-140]. However, many adolescents tend to feel uncomfortable in pursuing diabetes self-care in the school environment, because they do not feel safe and properly supported, which could be one of the possible barriers, to adhere to diabetes self-care tasks [138, 141-144]. Also, the lack of knowledge of school teachers and other professionals about diabe‐ tes, unhealthy and limited food choices, the unfavorable school organization and class rules unfriendly for diabetes management may have a negative impact on adherence and cause

al impact with associated feelings of concern, fear and responsibility [133].

and for the family, and disturb the harmony of the family dynamics [131].

**5. School support in adhering to self-care**

rents after a while [136].

In the case of a chronic disease, coping presents itself as a dynamic process that changes over time, according to the objective demands and the subjective assessments of the situa‐ tion involving changes in thoughts and actions [115-117, 127]. In addition to personal re‐ quirements, defined goals, external resources, such as social support from family, friends and health professionals, economic resources and internal resources, such as intelligence, re‐ silience and locus of control and the characteristics of the disease and treatment are also fac‐ tors that impact the disease evaluation process that is stress-inducing [118, 120]. As a result, each person has a subjective understanding of the disease, personal attitudes and behavior towards the illness that corresponds to coping mechanisms behind the biomedical factors in‐ fluencing the course of the disease. Disease severity does not seem to have a consistent rela‐ tion with the coping used by an individual in adjusting to a chronic disease but coping systems are significantly influenced by psychological and social factors [128].

As a chronic disease, diabetes implies adaptations in terms of physical exercise, food and so‐ cializing with peers, that are considered stressful triggering a process of psychological adap‐ tation, with consequent changes in family dynamics [129]. The entire adapting process depends on both the complexity and the severity of the disease, impacting on the stability of the family structure and the development of coping strategies. However, in most cases, pa‐ rents of children and adolescents with diabetes develop effective coping strategies to man‐ age the diabetes' demands, even if some may show more difficulties and problems adapting to this disease [130, 131].

Chronic disease can be understood as a stress-inducing event affecting the normal develop‐ ment of the child and disturbing the social relations within the family system, changing fam‐ ily routines with constant medical consultations, medication and hospital admissions [96, 132]. Thus, parents and adolescents' psychological resources and the family structure inter‐ act and contribute to the adolescent's adaptation to diabetes [96]. The inadequacy of the ado‐ lescent can be related more with how the family deals with the sick adolescent, than with the behaviors of the adolescent [96, 132]. As a result, family routines change and the family must adapt to living with a sick child, since strict relationship patterns may influence the adolescent's emotional development. Parents should be enlightened and aware of the specif‐ ic diabetes' treatment demands, so that the adolescent does not become depressive and/or distressed [129]. Some studies show, after the diagnosis, that some mothers of children or adolescents with a chronic disease, have trouble sleeping and present a significant emotion‐ al impact with associated feelings of concern, fear and responsibility [133].

There is a greater responsibility for mothers in the daily care of a child with diabetes. Often, is up to the mother to accompany the child/adolescent to the medical consultation, keep monitoring records of the blood glucose, guide the child regarding diet and care about the daily insulin administration [134, 135]. Sometimes, when a child is diagnosed with diabetes, parents' responses can lead to a family breakdown that may consequently influence the whole process of adapting and adjusting, by family members, to a chronic disease [133]. This situation can occur after the diagnosis, when the family ceases to participate in social events trying to avoid the ingestion of sweets and cakes hiding from the discomfort of hav‐ ing to relate to others in social situations [135]. Thus, parents who intensify the relationship of dependence and protection regarding the adolescent, as a coping strategy, start to lead their lives according to the child's needs and this process may become very tiresome for pa‐ rents after a while [136].

Sharing specific tasks for diabetes management between the family and the adolescent, in‐ creases the later's knowledge about diabetes. The use of assertive behavior, in social con‐ texts, is considered to be an adjusted strategy to cope with the disease and encourages adaptation. Disease management in diabetes can be stress-inducing, both for the adolescent and for the family, and disturb the harmony of the family dynamics [131].

In most cases, either the adolescent or the family may not act appropriately regarding diabe‐ tes, and ultimately fail to accomplish self-care tasks and may even lie regarding blood glu‐ cose monitoring if afraid of the disapproval or criticism from health professionals [135].
