Social Environment

The vast majority of research on young people's social environment has been focused on the family. This can be considered to consist of two broad aspects, its objective composition (such as number, age and gender of siblings, including birth order) and its subjective experience of social interactions. With the changing nature of our society, parent-child relations can take on increasingly varied forms, and although the traditional family, a child living with their two biological parents, is probably still the norm, there are increasing numbers of children in one-parent and reconstituted families.

Some studies have reported that young people in non-traditional families have poorer diabetes control than children in traditional families123'124. In a more detailed analysis of family composition, Marteau and colleagues125 found that it was only children not living with a biological parent (always the mother in this study) that were in significantly worse metabolic control. However, neither of these studies made attempts to match their comparison group. With changes in family composition arising from separation, divorce, bereavement and remarriage, all of which are accompanied by changes in finances, personal resources and the family environment, it is important to at least to control for some of these factors.

This was highlighted by Hanson and colleagues126 who compared 30 traditional families with 30 matched father-absent families. Their analysis indicated that, although there were no differences between groups on metabolic control of diabetes, the father-absent adolescents with diabetes were more adherent to their treatment than adolescents from the traditional families. Although not conclusive, this more methodologically rigorous study would suggest that it is probably not the actual family composition per se that is important, but the subjective elements of the family environment that is important when considering health in adolescents.

The role of the family environment in supporting the young person with diabetes is probably the most extensively researched area on adolescent and childhood diabetes. To provide a means of integrating the very disparate operationalizations used in the research, two dimensions that family researchers, reviewers and theorists have consistently identified will be used. The labels more usually used for these dimensions are family support and family control. Family support comprises behaviours which foster in an individual feelings of comfort and belonging, and that he/she is basically accepted and approved of as a person by the parents and family. Family control reflects an environment which directs the behaviour of an individual in a manner desirable to the parents, to the power base in the family127.

A number of studies report significant associations between family support and psychological adjustment124'128-131, with two smaller studies reporting no significant association between family support and adjustment132'133. In a review of the general paediatric literature, Drotar134 concluded, that, although most studies found an association between support and adjustment, with better adjustment associated with more supportive families, this finding is by no means universal.

Although several studies report significant associations between family support and glycated haemoglobin, with greater support associated with better control49'82'101'123'125'131'135'140, there are an equally impressive number of studies failing to support this association73'81'84'91'121'124'128'141'143'144, with longitudinal studies also producing mixed results121'123'136'142'143. However, family support would appear to be relatively consistently related to self-care behaviour42'63'82'91'101'128'139'146-148, with no identified studies failing to find an association between some aspect of family support and self-care behaviour. Furthermore, Liss and colleagues137 found that adolescents who had been admitted for DKA subsequent to diagnosis came from less supportive family environments. The importance of family support for diabetes self-care is highlighted in the structural equation modelling of Hanson and colleagues101. Although family stress was directly associated with metabolic control, family relations affected diabetes control indirectly through its association with adherence. Furthermore, no one subscale of support shows consistent relations with self-care across studies. This suggests that family support is important in promoting self-care, but exactly which aspects are important remains to be resolved.

Conflict in the family is frequently cited as the key aspect in determining the level of family support, but the literature fails to provide consistent support for this84'123. For instance, even when using the same measures and protocol, Miller-Johnson and colleagues139 found substantial differences in the role of conflict between adolescents receiving their diabetes care in private compared to public practices. Furthermore, although Hauser and colleagues146 found that initial levels of adherence were associated with conflict, changes in conflict were not associated with changes in adherence over the 4 years of their prospective longitudinal study. This may be a result of conflict over minor issues being common and even normative in adolescence, with some commentators arguing that conflict in the family is essential for the development of young people's interpersonal skills149-151. However, it is important to remember that extreme levels of conflict, and/or conflicts that remains continuously unresolved, are likely to disrupt the family and impact on poor control. Therefore, communication and conflict resolution may be a more critical issue, as highlighted by Bobrow and colleagues93, who examined the interaction between mothers and adolescent daughters with diabetes. They concluded that adolescent girls who had adherence problems had interactions with their mothers that were 'not conducive to opening up about deeper concerns' and that 'good adherers and their mothers were judged to be lower on seemingly unresolved conflict'. Alternatively, conflict within the family may act as a normative stress (i.e. one that is experienced by most adolescents as part of their negotiating independence from parents), or non-normative stress (in the context of family break-up), which acts to increase stress. As highlighted by Hanson and colleagues101, family stress would seem to have both a direct effect on diabetes control and an indirect influence on adherence by affecting family relations. This also highlights the need for greater refinement in the operationalization of constructs, with minor conflict, conflict resolution, and family stress clearly overlapping and influencing one another. However, if conflict resolution is the key problem, then interventions designed to provide families with the skills and strategies to resolve conflicts, with resulting benefits for the family as a whole and for the management of diabetes, would be helpful, and this is an approach being developed in some centres115'154.

Moving on to consider the dimension of family control, the results fail to support a strong association between measures of family control and adjustment, metabolic control or self-care, some studies reporting a significant association73'81'84'91'122'128'130'131'133'138'140'142'144, whilst others do not support an association49'81'82'91'95'105'121'123'124'128'136'137'139'141'143'146'152'153

Although linear associations are not consistently evident in these studies, this may be a result of the failure to consider the possibility of non linear associations. Gustafsson and colleagues142 split their samples into those whose family were in the balanced range and those in the disturbed range of family functioning (either above or below the balanced area). They found that participants from balanced families were in significantly better control of their diabetes than those in the disturbed range. This conception of balanced vs. disturbed family functioning clearly needs further consideration. It is more likely that the extreme ends of family functioning cause the problem, rather than looking for a continuum of family functioning that the parents and child need to move up in order to improve diabetes self-care and control.

Alternatively, the lack of consistency in results may be a consequence of the lack of specificity in the measures of family control measures. Research that has looked at the degree of parental involvement in diabetes care has produced noticeably consistent results. The greater responsibility taken by the adolescent with diabetes, and the less parental involvement, the worse their control5'106'109'140'141'144'156. More detailed examination of parent and child perceptions of responsibility indicated that where no-one was taking responsibility, the young person with diabetes was in worse diabetes control155. This handing over of responsibility needs to be not only negotiated and managed but also to match the maturity of the individual and his/her ability to take responsibility7'156.

Adding weight to the critical role of continued parental involvement in diabetes management is research on the problem of recurrent diabetic ketoacidosis. White and colleagues157 identified lack of parental involvement in diabetes care as a common problem in their sample of poorly controlled and recurrently re-admitted young patients. Furthermore, intervention studies158-162 that have had a significant impact on metabolic control included a focus on strategies for negotiating appropriate levels of parental involvement and adolescent responsibility for diabetes care. Addressing this issue is also something that could be readily integrated into normal diabetes care and consultations without increasing diabetes-related conflict158'159.

The results of these studies replicates the data on general adolescent development, which also implicates parental involvement as the single most important predictor of positive adolescent outcomes186. The key to understanding this approach is to acknowledge that the major developmental task of adolescence is movement away from dependence on the family, not toward complete independence but rather toward interdependence. Interdependence does not require the adolescents to distance themselves emotionally from parents, but requires a reorganization in which the family members renegotiate and redistribute responsibilities and obligations158.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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