In the important developmental period of preadolescence, critical parenting behaviors appear to be related to youth’s self-efficacy for diabetes management, with depressive symptoms also playing a significant role. These findings are consistent with previous literature concerning older youth or adolescents, which has demonstrated that parenting characterized by regulating a child’s behavior though criticism is associated with lower levels of self-efficacy and greater levels of depression (Butler et al., 2007
). The current study corroborates these findings in a younger preadolescent population and elucidates the mechanisms by which critical parenting behaviors are associated with self-efficacy and self-care behaviors.
The relationship identified between critical parenting behaviors and child psychological well-being is of concern because youth with T1D have already been shown to be at greater risk than their non-T1D peers for psychiatric disorders (Blanz, Rensch-Riemann, Fritz-Sigmund, & Schmidt, 1993
), including depression (Kovacs, Mukerji, Iyengar, & Drash, 1996
). Therefore, the findings from the current study illustrate the importance of helping parents to be involved with their children’s diabetes care in a noncritical way, so as to lower risk for depressive symptoms and poor self-efficacy. Clinically, parental involvement in diabetes care is a primary focus of treatment of adolescents with T1D. However, the quality
of that involvement, and the importance of promoting positive
parental involvement in care with preadolescents, is highlighted by these findings. Indeed, previous research has found that youth who view their parents as being collaboratively involved in diabetes management report better self-care, fewer depressive symptoms, and more positive mood (Berg et al., 2007
; Wiebe et al., 2005
In the second mediation model, controlling for age, self-efficacy fully explained the relationship between depressive symptoms and self-care behaviors, such that more depressive symptoms were associated with lower self-efficacy, which was associated with fewer self-care behaviors. These findings are consistent with the current literature in adults, which has identified self-efficacy as a mediator of depression and glycemic control in males with T2D (Cherrington, Wallston, & Rothman, 2010
). Notably, the current study helps to fill a gap in the literature identified by DiMatteo et al. (2000)
by illuminating a mechanism of how depression may affect self-care behaviors, specifically by contributing to the relationship between self-efficacy and self-care behaviors. These findings also highlight the importance of continued assessment of, and potential intervention to improve, self-efficacy for diabetes self-care.
It is interesting to note that, contrary to prior works indicating higher depressive symptoms in older teens (Whittemore et al., 2002
), in the current sample, the younger preadolescents, even within our small age range, showed more depressive symptoms than the older preadolescents, although most scores remained in the subclinical range. It is possible that the younger preadolescents in this sample are on the cusp of beginning to take responsibility for their own diabetes management (Anderson et al., 1990
) and therefore are subject to an increase of stress, while at the same time, due to their young age, are less able to effectively cope with these new stressors (Landolt, Vollrath, & Ribi, 2002
). This increase in responsibility for diabetes care stress coupled with ineffective coping strategies may lead to an increase in depressive symptoms (Berg et al., 2009
) that declines with age as children develop more flexible and sophisticated coping styles (Hema et al., 2009
). Future research should examine other variables associated with depressive symptoms (e.g., coping styles) and the developmental trajectory of these symptoms into early adolescence.
The fact that there was no significant correlation between critical parenting behaviors and self-care behaviors is consistent with other literature which has failed to find a relationship in younger youth (Schafer, McCaul, Glasgow, 1986
; Lewin et al., 2006
), although critical parenting has been shown to affect adherence and metabolic control in older adolescents (Duke et al., 2008
; Lewin et al., 2006
). The explanation for the absence of a correlation may be that, for younger preadolescent children, parents are still responsible for a majority of diabetes-related tasks; therefore, critical parenting behaviors may not have a direct influence on self-care behaviors. However, the negative interactions between youth and their parents may have a deleterious effect on the child’s psychological well-being, including depressive symptoms and poor self-efficacy, which are risk factors for poorer adherence in these preadolescents, as well as in the future as these youth take on more self-care responsibilities.
The lack of a significant relationship between current study variables and A1c is consistent with previous findings that have failed to find a direct relationship between psychosocial variables and glycemic control (Berg et al., 2007
; Dantzer et al., 2003
). Further, Helgeson (2009)
found that depressive symptoms were not predictive of metabolic control concurrently, but rather were related to difficulties in metabolic control over time. Therefore, the relationship of depressive symptoms with glycemic control may not be seen in cross-sectional research (Helgeson, Siminerio, Escobar, & Becker, 2009
). Future research should examine the effects of depressive symptoms on A1c over time.
Although our findings that self-care was not related to glycemic control are not consistent with the overall literature (Hood, Peterson, Rohan, & Drotar, 2009
), it appears that the relationship between adherence and A1c in preadolescents may not be as clear as this relationship in adolescents. It has been speculated that hormonal changes associated with puberty account for the majority of differences in metabolic control during early adolescence, and self-care accounts for more variability in metabolic control as teens move to later adolescence (Helgeson et al., 2009
). Indeed, research has found that poor self-care was more highly associated with poor glycemic control among older adolescents than younger adolescents (Helgeson et al., 2009
; Iannotti et al., 2006
; La Greca, Follansbee, & Skyler, 1990
). Therefore it could be that the effects of poor self-care behaviors in preadolescence on glycemic control may not be detectable until later adolescence.
Of note is that parent report of self-care behavior, in contrast to child report, was not correlated with youth self-efficacy for diabetes, although it was related to youth depressive symptoms and youth report of self-care behaviors. Because preadolescence is a time period when some responsibilities are transferred to the child, and neither parent nor child report is a perfect measure of actual behaviors, future research should continue to examine both parent and child report.
The results from the current study suggest paying careful attention to, and potentially working toward minimizing, critical parenting behaviors in diabetes-specific interactions with preadolescents. There has been significant recent attention on encouraging parental involvement with diabetes management and continuing that involvement through adolescence (Wysocki et al., 2009
). The quality
of the involvement is clearly essential. If healthcare providers simply encourage parents to be involved with their preadolescent’s diabetes management without guidelines for promoting the type of supportive involvement necessary, parents may end up not only decreasing child self-care behaviors, but increasing risk for their child’s depressive symptoms and lowering their self-efficacy for diabetes management. Instead, providers could be specific that parental involvement should include encouragement and praise for self-care and avoid criticism or “nagging.” Indeed, research has shown that supportive parenting in conjunction with parental monitoring of diabetes tasks contributes to adherence (Ellis et al., 2007
). Examples of clinical applications include the design of brief prevention programs aimed at providing parents with ideas of how to stay involved using authoritative, supportive parenting, and reducing critical parenting behaviors.
The current study also suggests that depressive symptoms are relevant to self-care in preadolescent children with diabetes. It is important not to ignore the importance of mood until youth reach adolescence, but rather to recognize the cascading impact that depressive symptoms, even those that are subclinical, may play on diabetes management. Therefore, it is important to assess for depressive symptoms in order to refer and treat these symptoms as a way to improve self-efficacy and self-care in youth (Monaghan, Singh, Streisand, & Cogen, 2010
; Silverstein et al., 2005
Because of the importance and interconnectedness of both parenting behaviors and youth internalizing concerns, it is crucial to involve both parents and youth in prevention and intervention efforts aimed at improving diabetes management in preadolescent children. Further, the importance of quality of parental involvement and child depressive symptoms cannot be ignored until adolescence, but needs to be addressed earlier in childhood.
Limitations and Future Research
Although findings are clinically relevant and add to the existing literature based largely on adolescents, the current study has several limitations that should be addressed. First, the study is cross-sectional which limits the ability to determine causality and the elucidation of the transactional relationship between child and parent factors. Future research should be longitudinal, particularly focused on expanding the understanding of how these relationships change across childhood and through adolescence. Second, only preadolescent report of parenting behaviors, internalizing concerns, and diabetes self-care were utilized. This adds to the possibility that the results may be inflated because of single-rater bias. Although the youth’s perception of these issues is important and relevant, future research should also examine parent reports of these concerns as well as other indicators of adherence and metabolic control, such as blood glucose variability. In addition, the internal consistency for the DFBC in the current study was marginal (α
.66) so results should be interpreted with caution. Additionally, data collection for this study began in 2003, and newer measures currently exist. Future research should utilize a more reliable measure of critical parenting to confirm the results of the current study, as well as utilizing the most up-to-date and well-validated measures.