Type 1 diabetes (T1D) is one of the most common chronic childhood illnesses. Overall rates have increased significantly over the last half century, with particularly steep rises in rates for children younger than 5 years of age (Gale, 2002
; Karvonen et al., 2000
). The treatment regimen for type 1 diabetes (T1D) is complex and demanding, requiring frequent monitoring of blood glucose levels (at least 4/day), monitoring and control of carbohydrate intake, frequent insulin administration (3–4 injections/day or infusion from a pump), altering insulin dose to match diet and activity patterns, and checking urine for ketones when necessary (American Diabetes Association, 2007
). This intensive regimen places great demands on caregivers of children with T1D, particularly mothers, who are responsible for the majority of treatment management (Kovacs et al., 1990
Mothers of young children with T1D may face additional challenges related to the child’s age. First, the diagnostic presentation is often more severe in younger children than in older children, in that a high proportion of young children present as critically ill at the time of diagnosis (Quinn, Fleischman, Rosner, Nigrin, & Wolfsdorf, 2006
). Disease management is also complicated by developmental and physiological factors unique to this age group; caregivers’ efforts to achieve optimal T1D management are complicated by young children’s rapid growth, erratic eating and changing insulin demands, limited communication of hypoglycemic/hyperglycemic symptoms, and efforts to gain mastery and control in the environment (Halverson, Yasuda, Carpernter, & Kaiserman, 2005
; Kushion, Salisbury, Seitz, & Wilson, 1991
). Thus, there is a need to identify possible effects of the demands of treatment management on mothers of young children with T1D in order to support them and promote the best adjustment to the illness.
Mothers of young children with T1D experience high levels of stress related to treatment management. Researchers describe a common theme of “constant vigilance” among parents of young children with T1D, a sense of continuous responsibility to maintain metabolic control and prevent episodes of hypoglycemia (Sullivan-Bolyai, Deatrick, Gruppuso, Tamborlane, & Grey, 2003
). Mothers of young children may have particularly high levels of worry because their children have a form of “hypoglycemic unawareness;” they do not have the cognitive ability to recognize and respond to symptoms of hypoglycemia (American Diabetes Association, 2007
). Studies of parents of older children and adolescents with T1D reveal significant fears of hypoglycemia (e.g., Clarke, Gonder-Frederick, Snyder, & Cox, 1998
; Green, Wysocki, & Reineck, 1990
; Marrero, Guare, Vandagriff, & Fineberg, 1997
), which have been linked with parenting stress (Streisand, Swift, Wickmark, Chen, & Holmes, 2005
). While some evidence suggests that parents manage these fears by maintaining higher blood glucose levels than recommended (e.g., Marrero et al., 1997
), other studies have failed to find an association between parental fear of hypoglycemia and poorer metabolic control (Clarke et al., 1998
; Green et al., 1990
; Marrero et al., 1997
). In fact, one study found that greater perceived diabetes-related stress in caregivers of young children was related to better
metabolic control (Stallwood, 2005
). These mixed findings point to the need for further research on parenting stress and fear of hypoglycemia in mothers of young children with T1D to determine their relation to maternal psychological symptoms and children’s metabolic control.
The ways in which mothers cope with the stress of treatment management are likely to have important implications for maternal and child adjustment to the illness; however, few studies have examined the coping strategies used by mothers of children with T1D. The extent to which mothers find coping with diabetes upsetting has been related to current maternal distress and level of distress after diagnosis (Kovacs et al., 1990
) and to child’s reported quality of life in school-age and older children (Whittemore, Urban, Tamborlane, & Grey, 2003
). Maternal perceptions of coping were also found to mediate the relationship between maternal and child depressive symptoms in school-age children with T1D (Jaser, Whittemore, Ambrosino, Lindemann, & Grey, in press
). While greater use of approach coping (e.g., problem solving) was related to fewer depressive symptoms in mothers (Blankfelf & Holahan, 1996
), other researchers found that maternal coping was unrelated to child’s metabolic control (Stallwood, 2005
). More research is needed to examine the relationship between coping with diabetes-related stress in mothers of young children with T1D and psychosocial and health outcomes.
Moreover, relatively little is known about rates of anxiety and depression in mothers of young children with T1D. In research with mothers of older children (ages 8–16), 17% of mothers reported moderate to severe depression shortly after diagnosis (Kovacs et al., 1985
), and mothers who initially presented as depressed were more likely to remain depressed years later (Kovacs et al., 1990
). Similarly, a more recent study found that 22% of mothers of school-age children (8–12 years old) reported clinically significant levels of depressive symptoms (Jaser et al., in press
). Other researchers found that 20.4% of mothers of children ages 6–15 exhibited clinically significant symptoms of posttraumatic stress disorder one year after their child’s diagnosis (Landolt, Vollrath, Laimbacher, Gnehn, & Sennhauser, 2005
). These findings suggest that mothers of children with T1D are at risk for significant psychological distress; however, it is unknown whether mothers of younger children experience similar levels of distress.
Maternal symptoms of depression and anxiety have important implications for children’s health outcomes, including both metabolic control and psychological adjustment. Recently, a study of mothers of adolescents with T1D found that maternal anxiety was related to poorer metabolic control (L. D. Cameron, Young, & Wiebe, 2007
), but it is unknown whether this holds true for mothers of younger children. Similarly, depressive symptoms in mothers of older children with T1D have been related to depressive symptoms and poorer quality of life in children (Jaser et al., in press
; Kovacs, Goldston, Obrosky, & Bonar, 1997
) but the effects of maternal depressive symptoms on younger children with T1D are unknown. Taken together, these findings suggest that maternal depression and anxiety and their relationship with children’s metabolic control and psychosocial functioning warrant further attention in this population of younger children with T1D.
In sum, parents of young children with T1D are likely to experience high levels of stress related to managing their children’s treatment, related to the sense of “constant vigilance” and fears of hypoglycemia. While other factors are likely to contribute to maternal stress, fear of hypoglycemia may be one of the most salient sources of stress for mothers of young children with T1D (Streisand et al., 2005
). Maternal perceptions of coping with this stress may determine whether symptoms of anxiety and depression develop. Given the demands of treatment management, greater attention needs to be paid to this population of parents to document their psychosocial distress and better characterize its likely impact on metabolic control.
The purpose of this study was to examine the relationship between mothers’ stress related to fears of hypoglycemia, perceptions of coping with diabetes-related stress, and maternal symptoms of anxiety and depression. We expected to find that mothers of young children with T1D were experiencing increased symptoms of anxiety and depression. Second, we expected that mothers’ who perceived coping with the stress of diabetes management to be more difficult and more upsetting, and mothers who reported greater fear of hypoglycemia would have higher levels of anxiety and depression. Finally, we wanted to examine the relationship between children’s metabolic control and maternal symptoms of anxiety/depression.