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

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].

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

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

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

systems are significantly influenced by psychological and social factors [128].

to this disease [130, 131].

452 Type 1 Diabetes

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 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 negatively influence adherence [142, 147, 148].

Young people report having more difficulty in adhering to self-care activities in the school context and with their peer group [31, 138, 153, 154, 160, 163, 164]. The anticipation of peer pressure and the fear of being discriminated influence adolescents not to follow adherence to diabetes regimen, which means higher risks regarding their health [165]. In fact, interac‐ tion with the peer group and the social context influence adherence to self-care either through positive attitudes, such as the companionship of friends, or through negative atti‐ tudes, such as prejudices related to the adolescent's food choices [153, 160, 166]. However, a study on the relationship between adherence and peer support did not reveal a strong rela‐ tionship probably due to the role that cognitive attributions and evaluations play: if positive, they may be considered a protective factor, if negative, adolescent adjustment to chronic dis‐ ease may be negatively influenced [152]. Yet another study found that support from peers and teachers, as well as satisfaction with the support received, were associated with good

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

Adolescents

455

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

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

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‐

metabolic control, in diabetes [137].

**6. Conclusion**

the family.

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 about their disease [105, 161, 162].

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‐ ed to good adherence [108].

Young people report having more difficulty in adhering to self-care activities in the school context and with their peer group [31, 138, 153, 154, 160, 163, 164]. The anticipation of peer pressure and the fear of being discriminated influence adolescents not to follow adherence to diabetes regimen, which means higher risks regarding their health [165]. In fact, interac‐ tion with the peer group and the social context influence adherence to self-care either through positive attitudes, such as the companionship of friends, or through negative atti‐ tudes, such as prejudices related to the adolescent's food choices [153, 160, 166]. However, a study on the relationship between adherence and peer support did not reveal a strong rela‐ tionship probably due to the role that cognitive attributions and evaluations play: if positive, they may be considered a protective factor, if negative, adolescent adjustment to chronic dis‐ ease may be negatively influenced [152]. Yet another study found that support from peers and teachers, as well as satisfaction with the support received, were associated with good metabolic control, in diabetes [137].
