**3. Adolescents and diabetes management**

are important and critical as adherence and good self-management lead to positive health

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

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

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

outcomes for youth who have diabetes.

decreases [12].

434 Type 1 Diabetes

**2. Children and diabetes management**

determine strategies for improving adherence.

Self-efficacy for diabetes management is grounded in a social cognitive approach, which em‐ phasizes a "can do" attitude toward managing problem situations [16]. The adolescent should be encouraged to think of him- or herself as being able to complete diabetes manage‐ ment tasks that he or she is capable of managing, and be encouraged to gain expertise and master new skills, such as administering his or her own insulin. The tasks assigned to the adolescent should be commensurate with his or her abilities so that he or she can master the self-management task and move to a higher level of self-efficacy for working with his or her diabetes. Berg et al. also stated that high feelings of self-efficacy for managing diabetes may be especially helpful for adolescents with "acting out" behavior problems or *externalizing* problems [17].

Another important thing to address is fear of hypoglycemia or hyperglycemia, especially with adolescents and their parents. Battista, Hart, Greco, and Gloizer assessed adolescent re‐ port of diabetes management for youth with Type I Diabetes for adolescents between the ages of thirteen to eighteen [18]. The youth in their sample were experiencing social anxiety. These authors thought it was important to assess social anxiety as it might be a factor contri‐ buting to poor diabetes management and because social anxiety might contribute to poor diabetes management when an adolescent was in social situations with peers. Their findings 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‐ ance and opportunities to discuss fears related to either type of problem.

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

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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.

poor management than conflict over direct management tasks.

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

management tasks, when the child is younger.

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 as a weight management strategy [19].
