The present study is the first to demonstrate that adolescents who are oriented toward their peers (i.e., seek advice and support from their peers over their parents) may put themselves at risk for poorer diabetes management, and peer orientation may partially mediate associations between adolescent-parent relationships and diabetes management. Good quality adolescent-mother and adolescent-father relationships were associated with better health outcomes and less peer orientation. Additionally, peer orientation mediated the associations of both adolescent-mother and adolescent-father relationship quality with diabetes outcomes. Although prior research has demonstrated the importance of adolescent-parent relationships for good diabetes management (Berg et al., 2008
; Miller-Johnson, et al., 1994
; Wiebe, et al., 2005
), we know little about the processes whereby the quality of the adolescent-parent relationship and peer orientation are associated with diabetes outcomes. The developmental literature suggests that a warm, high quality, cohesive relationship with parents allows adolescents to value their parents' opinions, respect their rules, and thus be less likely to rely on their peers for advice (Kim et al. 2001
; Fugilini & Eccles, 1993; Goldstein, Davis-Kean, & Eccles, 2005
; Steinberg, 1990
). Adolescents normatively seek parental advice throughout adolescence, but often experience closer relationships with mothers than with fathers (Buhrmester & Furman, 1987
; Larson & Richards, 1994
). We found that adolescents who perceived both their mother and their father to be accepting, communicative, and encouraging of independence were less likely to sacrifice their health for peer acceptance and seek their peers' advice over their parents, and had better health outcomes.
When adolescents with type 1 diabetes are extremely peer oriented, it is likely that they place importance on peer relationships rather than their own health. Adolescents who are peer oriented may modify their behavior to fit in with their peers to avoid being viewed as different (Bronfenbrenner, 1967
; Devereux, 1970
; Fuligni & Eccles, 1993
; Fuligni et al. 2001
; Steinberg, 1987
). For adolescents who are coping with a chronic illness such as diabetes, not being seen as different may be more difficult given the continuous demands of their treatment regimen (e.g., regularly checking their blood glucose, eating healthy foods, administering insulin injections). These adolescents may limit or modify diabetes management behaviors to fit in with the group norms, and poorer adherence can have serious consequences for their blood glucose control.
A high quality adolescent-parent (mother, father) relationship can positively influence peer choices, the manner in which adolescents manage their diabetes, and ultimately metabolic control and adherence to diabetes regimens. During adolescence, the adolescent-parent relationship is subject to changes, where adolescents spend less time with their parents and more time with their peers, although complete rejection of the parent is rare (Buchanan, et al. 1990
; Larson, Richards, Moneta, Holmbeck, Duckett, 1996
; Steinberg, 1990
). It is developmentally appropriate for adolescents and parents to have a high quality cohesive relationship through acceptance, regular communication, and encouragement of independence, which may encourage adolescents to have a healthy balance of parent influence and peer affiliation (Kim et al. 2001
; Fugilini & Eccles, 1993; Goldstein, Davis-Kean, & Eccles, 2005
). Although it is normal for adolescents to seek advice and support from peers, this may become more common when adolescents do not have a high quality cohesive relationship with their parents. Findings from the current study support the hypothesis that adolescents' orientation towards their peers occurred in the context of lower quality adolescent-parent relationships. The low quality adolescent-parent relationship can be detrimental for diabetes care, as it may place adolescents at risk of positive healthy development by ignoring their parents' advice to be accepted by their peers.
The present findings add to the literature documenting the importance of parental involvement for managing diabetes during adolescence, and identify adolescents' peer orientation as a potential mediating mechanism. Parental involvement in pediatric diabetes care is crucial for good management (Anderson, Ho, Brackett, Finkelstein, & Laffel, 1999
; Wysocki et al., 1996
). During adolescence, however, the nature of that involvement ideally shifts to support the adolescents' developing autonomy and independence in diabetes management. Relationships that are characterized by warmth and acceptance (Berg et al., 2008
), and that support autonomy through collaboration and teamwork (Helgeson et al., 2008
; Laffel et al., 2003
; Wysocki et al., 2009) and low parental control (Wiebe et al., 2005
) appear particularly beneficial for adolescents' diabetes management. The present data suggest that such benefits may occur because adolescents who maintain good quality relationships with parents are less likely to take risks (i.e., miss injections) with their health for peer acceptance. Interventions that promote parents' interactive communication, acceptance, and encourage independence, may increase opportunities for parental support while minimizing peers distracting adolescents from their diabetes management.
Several limitations of this investigation deserve mention. As the purpose of this study was to determine how the adolescent perceived their social world, we focused our examination solely from the perspective of the adolescent and their perceptions of their relationships with peers and parents. Previous studies have indicated adolescents' perceptions of parenting are more strongly associated with diabetes outcomes than are parental perceptions (Berg et al. 2008
). The cross-sectional nature of our study prevents us from making causal statements regarding the direction of effects between child-parent relationships, peer orientation, and diabetes management. The moderate reliability of the EPO, communication, and independence-encouragement scales should be taken into consideration when reviewing the results.
Age was not significantly associated with peer orientation and was not a moderator of the associations between peer orientation and diabetes outcomes. This is likely due to the small age range. The majority of participants were placed at mid-adolescence when there is a peak in peer pressure (Sumter, Bokhorst, Steinberg & Westenberg, 2009
), possibly making them more likely to be oriented toward their peers. The adolescent-parent relationship quality measures probed non-diabetes specific interactions between the adolescent and the parent. Parenting measures that asked diabetes specific questions regarding acceptance, communication, and encouraging independence in diabetes care may have resulted in stronger associations in diabetes outcomes. Future research would benefit from a comparison between diabetes-specific and general parenting measures to examine differential associations with diabetes outcomes.
The EPO scale has not been previously used in the context of diabetes, and more work needs to be done to fully understand the meaning of the results. It is conceivable, for example, that adolescents who are not experiencing any events of peer orientation are adolescents who have better adherence because they are more reliant on their parents. This could be beneficial for diabetes management in the short-run, but may not facilitate necessary independent diabetes management skills. Adolescents, who experience events of peer orientation, may become distracted by peer influence and take unnecessary risks (i.e., not administering insulin injections or eating sugary foods), thus are likely to have difficulty managing their diabetes. Due to the normative nature of peer relationships, it is likely that a balanced relationship between peer interactions and self-care is important for adolescents coping with diabetes. By identifying risk factors in the social world of the adolescent, researchers and clinicians can more effectively target interventions to prevent serious risk and unhealthy illness management patterns in this vulnerable population.
These findings suggest that high quality involvement between adolescents and their parents consisting of parental acceptance, open communication, and encouraging independence provides an environment likely to foster adolescents who value both their parents and their peers. The mediational analyses suggested a more balanced orientation to peers may be one path toward better adherence and metabolic control. We did not test the differences between mother and father relationship quality with the adolescent, but similar patterns were found for both parents. High quality relationships with mother and with father appear important for helping adolescents balance parent and peer influences for more positive adolescent health and development.