Type 1 diabetes (T1DM) is a common childhood illness that involves a rigorous daily self-care regimen which includes insulin administration, blood glucose monitoring, dietary management, and exercise (Silverstein et al., 2005
). Based on current clinical care guidelines for children less than 7 years old, it is recommended that parents assume the burden of daily diabetes self-care (Silverstein et al., 2005
), However, when working with young children, completing these daily self-management tasks can present many challenges (Silverstein et al., 2005
; Sullivan-Bolyai, Deatrick, Gruppuso, Tamborlane, & Grey, 2002
). Developmentally, young children lack a full understanding of their disease and often seek independence in their daily activities, which may make it challenging for parents to complete necessary diabetes-care activities (Golden, Russell, Ingersoll, Gray, & Hummer, 1985
; Patton, Dolan, & Powers, 2006a
; Sullivan-Bolyai et al., 2002
). Physiologically, young children are also more susceptible to wide fluctuations in blood glucose levels because of their unpredictability in food intake and exercise patterns, greater sensitivity to insulin, and because of limitations in the minimum insulin dose that can be measured via the traditional syringe mode of administration (Golden et al., 1985
; Silverstein et al., 2005
). All of these factors combined may impact parents’ functioning and their perception of stress.
In past research, parenting stress was examined in a sample of young children with T1DM and matched controls (Powers et al., 2002
). In this early study, young children with T1DM all followed a conventional, two shot per day insulin regimen. Parenting stress was measured using the Parent Stress Index (PSI), which is a general measure of parenting stress and does not focus specifically on the experiences of having a child with a chronic illness. The results found that for general parenting stress, parents of young children with T1DM reported higher stress levels than parents of control children (Powers et al., 2002
The current study extends the previous findings by now focusing on pediatric parenting stress and the potential correlates of this stress in a sample of parents of young children with T1DM. Pediatric parenting stress is a construct used to define stress specifically associated with raising a child with a chronic illness (Streisand, Braniecki, Tercyak, & Kazak, 2001
). It is separate from general parenting stress because of its inclusion of items specific to child health, parental responsibility and perceptions of burden, and parental adaptation to the illness (Streisand et al., 2001
). Pediatric parenting stress has been measured previously in parents of school-age children with T1DM and parents of children newly diagnosed with T1DM (Streisand et al., 2008
; Streisand, Swift, Wickmark, Chen, & Holmes, 2005
). However, there has been only limited research in parents of young children with T1DM (Mitchell et al., 2009
; Monaghan, Hilliard, Cogen, & Streisand, 2009
It is important to study pediatric parenting stress in young children with T1DM as stress may impact parents’ ability to care for their child (Streisand et al., 2005
). This notion is consistent with Kazak’s social–ecological framework for chronic illness which predicts that child illness will impact parents’ response to stress and their functioning (Kazak, 1989
). Research examining correlates of pediatric parenting stress is also necessary to help in the development of targeted interventions for parents of young children with T1DM to reduce parents’ stress levels and improve their overall functioning. For this manuscript, a model of psychosocial correlates of pediatric parenting stress was built based on correlates that are amenable to intervention and the available literature. Specifically, three possible correlates were selected: parental fear of hypoglycemia, depressive symptoms, and parental perceptions of mealtime problems ().
Study-specific theoretical model of pediatric parenting stress
Fear of hypoglycemia in parents of young children with T1DM has been documented in several studies (Grey, 2009
; Monaghan et al., 2009
; Patton, Dolan, Henry, & Powers, 2007
) and linked to higher blood glucose levels in young children in at least one study (Patton et al., 2007
). Two studies have also linked fear of hypoglycemia to pediatric parenting stress. In the first study, focused on school-age youth with T1DM, Streisand et al. (2005)
found parental greater fear of hypoglycemia to be positively associated with both parental perceptions of parenting stress difficulty and frequency. Likewise, in a sample of father’s of young children with T1DM, Mitchell et al. (2009)
found greater fear of hypoglycemia correlated positively with fathers’ perceived difficulty with parenting stress. While the available research suggests that parental fear of hypoglycemia is common in parents of young children with T1DM and a correlate of parenting stress, more research is needed to examine fear in a model containing other factors known to correlate with parenting stress as these data could help to prioritize intervention strategies.
A recent study suggests that the rate of depressive symptoms in mothers of young children with T1DM is consistent with rates reported for mothers of other chronically ill children (Grey, 2009
). Thus, given the responsibility parents of young children bear for diabetes management, the experience of parental depressive symptoms is also expected to have an effect on their perceptions of parenting stress. Specifically, two studies have found a positive correlation between parental depressive symptoms and pediatric parenting stress in children with T1DM (Mitchell et al., 2009
; Streisand et al., 2005
). Similarly, examining parental perceived problems coping with stress related to diabetes management, Grey (2009)
found a positive correlation between coping problems and maternal depressive symptoms. Interestingly, this study also examined the association between maternal depressive symptoms and young children’s metabolic control and found no relation. Within the larger diabetes literature, studies correlating maternal depressive symptoms and children’s metabolic control have produced mixed results (Grey, 2009
). Thus, it is possible maternal depressive symptoms may only affect children’s metabolic control indirectly, such as via increased parental monitoring or stress (Grey, 2009
). Understanding how parenting stress and maternal depressive symptoms may be related in parents of young children with T1DM can help with the development of interventions to decrease parenting stress and their experience of depressive symptoms.
In line with understanding how parental perceptions of diabetes control may impact their perceptions of parenting stress and psychological functioning, it is important to determine the role played by child behavior. Looking at families of young children with T1DM, only one study has specifically examined the association between child behavior and pediatric parenting stress (Mitchell et al., 2009
). This study recruited a sample of fathers of young children with T1DM and using maternal reports on the Eyberg Child Behavior Inventory, a general measure of child behavior, found a positive correlation between difficult child behavior and fathers’ perceptions of difficulty related to pediatric parenting stress (Mitchell et al., 2009
). Nonetheless, it is notable to mention that in families of young children with T1DM, several studies have reported mealtime behaviors to be challenging likely due to the importance of matching insulin to carbohydrate intake (Patton, Williams, Dolan, Chen, & Powers, 2009
; Powers et al., 2002
; Wysocki, Huxtable, Linscheid, & Wayne, 1989
). There are no studies which have examined parental perceptions of mealtime behavior problems and pediatric parenting stress, but past research has found problems with mealtime behaviors are correlated to parents’ reporting of general parenting stress (Powers et al., 2002
).Thus, it is possible child mealtime problems may also be associated with pediatric parenting stress, making it an important correlate to consider in a model examining parenting stress in young children with T1DM.
To summarize, parents of young children with T1DM are expected to experience pediatric parenting stress because of their central role in managing their child’s diabetes. Past research has individually correlated pediatric parenting stress with measures of parental fear of hypoglycemia, depressive symptoms, and child behavior problems, but a model of pediatric parenting stress containing these correlates has not yet been examined. There are cognitive-behavioral treatments available to help parents of young children cope with parenting stress, address child behavior problems, and manage their feelings of depression and fear of hypoglycemia. Examining pediatric parenting stress in a model containing all of these correlates may help with intervention development and in prioritizing specific treatments.
Subsequently, the objective of this study was to examine pediatric parenting stress and psychological correlates of parenting stress in a sample of parents of young children with T1DM. Based on the literature, we hypothesized that among parents of young children with T1DM, greater perceived mealtime problems, parental depressive symptoms, and parental fear of hypoglycemia would be related to higher pediatric parenting stress.