Journal of Pediatric Psychology, Vol. 26, No. 2, 2001, pp. 123-129
© 2001 Society of Pediatric Psychology
Brief Report |
Parenting Styles, Regimen Adherence, and Glycemic Control in 4- to 10-Year-Old Children With Diabetes
1 University of Miami, 2 Joe DiMaggio Children's Hospital
All correspondence should be sent to Catherine L. Davis, Georgia Prevention Institute, Medical College of Georgia, 1499 Walton Way, HS1609, Augusta, Georgia 30912. E-mail: cadavis{at}mail.mcg.edu .
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Abstract |
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Objective: To examine relationships among parenting styles, regimen adherence, and glycemic control for preschool and elementary school children who have Type I diabetes.
Methods: Parents of 55 children with diabetes completed parenting style and regimen adherence questionnaires. Glycosylated hemoglobin results were collected by chart review.
Results: Parental warmth was associated with better adherence ratings. Regression analyses showed that parental warmth explained 27% of the variance in adherence ratings. Parental restrictiveness was associated with worse glycemic control in univariate analyses. However, only Black ethnicity, not adherence or parenting variables, predicted glycemic control. Black ethnicity and lower socioeconomic status (SES) were associated with more parental restrictiveness and worse glycemic control.
Conclusions: These results suggest that authoritative parenting, characterized by support and affection, may be advantageous for the regimen adherence and glycemic control of school-age and younger children with diabetes. Demographic characteristics are important and require further study in this context.
Key words: Type I diabetes mellitus; parenting; regimen adherence; glycemic control; children.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Few studies have focused on young children with Type I diabetes mellitus. Yet, now that the Diabetes Control and Complications Trial (DCCT) has shown that attainment of good glycemic control can prevent the incidence or progression of complications of diabetes, there is even more reason to focus attention on the determinants of glycemic control in all individuals with diabetes, especially young children likely to experience longer disease duration (DCCT Research Group, 1994
). During preschool and elementary school, children learn
important skills relevant to diabetes self-care. Habits established during
this period may lower the risk of adherence problems and metabolic crisis
during the adolescent years and may improve long-term adherence and health
outcomes through the life-span.
However, little is known about factors related to adherence or glycemic
control problems in preadolescent or younger children. The few studies that
have included younger children (Hauser et
al., 1990; Jacobson et al.,
1994; Miller-Johnson et al.,
1994) suggest that family functioning is linked to regimen
adherence and glycemic control in preadolescent and younger children with
diabetes. In these studies, family conflict has been associated with poorer
adherence and glycemic control, and family cohesion and organization have been
associated with better adherence and glycemic control. More evidence links
family variables with adherence and glycemic control among adolescents with
diabetes (e.g., Hauser et al.,
1990; Jacobson et al.,
1994; Miller-Johnson et al.,
1994).
The diabetes regimen is too complex and demanding for a young child to
execute adequately without consistent support and assistance from parents or
other adults. Preadolescents who assume greater responsibility for diabetes
care are generally in poorer glycemic control than their peers who have more
parental support for diabetes responsibilities
(La Greca, Follansbee, & Skyler,
1990). Because preschool and elementary school children with
diabetes depend so much more on their families than adolescents, parenting
style may be a more specific predictor of diabetes outcome in this population
than other indices of family functioning, such as cohesion and conflict, which
have been studied predominantly in adolescents. The focus of this study was on
parenting styles as they relate to adherence and glycemic control in preschool
and elementary school children with diabetes, before parents shift
responsibility for diabetes care to the child, typically at around 12 years of
age (La Greca et al.,
1990).
Warmth and control are two well-studied aspects of parental behavior in the
child development literature and may be pertinent for children with diabetes.
Greater parental warmth (support and affection) has been associated with
better outcomes in broad areas of children's social competence, but parental
coercion (i.e., control characterized by punitiveness and power assertion) has
been associated with poorer social competence in children (e.g.,
Rollins & Thomas, 1979).
Authoritative parenting, characterized by warmth and inductive control (i.e.,
control characterized by firmness, maturity demands, explanations, and
flexibility), has been associated with positive outcomes in child development
across different gender, ethnic, and socioeconomic backgrounds
(Lamborn, Mounts, Steinberg, &
Dornbusch, 1991; Rollins &
Thomas, 1979; Slater &
Power, 1987). We expected that characteristics of authoritative
parenting, such as high levels of warmth and low levels of coercive control
(i.e., strictness), would be associated with better adherence and glycemic
control in children with diabetes.
Ethnicity has also been related to parenting; Black parents have been found
to be more strict and parent-centered than White parents, possibly due to
socioeconomic factors such as the quality of the family's neighborhood
(Kelley, Power, & Wimbush,
1992). Race and socioeconomic status (SES) have been related to
adherence and glycemic control in children and adolescents with diabetes:
Blacks have poorer adherence and glycemic control than Whites
(Auslander, Thompson, Dritzer, White, &
Santiago, 1997; Delamater,
Albrecht, Postellon, & Gutai, 1991;
Delamater et al., 1999).
The purpose of this study was to examine the relationships among parenting style, regimen adherence, and glycemic control for preschool and elementary school children who have diabetes, taking demographic factors into consideration. We predicted that greater parental warmth and less strictness would be associated with better adherence and better glycemic control among these children.
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Method |
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Participants
Fifty-five preschool and elementary school children (age: 4-10 years) with Type I diabetes mellitus, and the parent or guardian who accompanied them to a medical appointment (84% mothers), participated in the study. The children were free of other major diagnoses (e.g., mental retardation or another chronic disease). Girls constituted 56% of the sample. Fifty-eight percent of the sample were White non-Hispanic, 16% were Black, and 26% were Hispanic. The sample was predominantly (49%) upper-middle class (Class IV, Hollingshead, 1975
), with a
wide range of SES scores. Approximately a third (36%) of the sample lived in
single-parent families. Four subjects reported hospitalization for diabetic
ketoacidosis (DKA) within the past year, excluding diagnosis. About a fourth
(27%) of the sample had been diagnosed within the past year. Participants were
recruited at two diabetes clinics associated with a university medical center
and two physician's offices. The university-based clinics primarily served
families whose children qualified for publicly funded health insurance. Data
from these sites were combined to achieve a larger, more representative
sample.
Procedure
The parent who accompanied the child with diabetes on a medical visit was
asked to participate in a study of parenting and diabetes. After written
informed consent (approved by the institutional review board) was obtained,
the parent completed the study measures; of 78 families approached, 4 refused
to participate, and 56 completed the study measures. Eighteen families agreed
to participate but were not included in the study because they left the clinic
before completing the measures. One child was excluded from analyses due to
East Indian ethnicity. Demographic data were collected by interview of the
parent, and SES was calculated
(Hollingshead, 1975). The
child's age, date of diabetes diagnosis, number of hospitalizations for DKA in
the past year, and most recent glycosylated hemoglobin (GHb) were collected by
chart review. Six children lacked current GHb results.
Measures
Parenting Style. The Parenting Dimensions Inventory (PDI), a
self-report measure of parenting style
(Power, 1993;
Slater & Power, 1987), is
composed of 47 items that assess eight parenting dimensions. From these eight
scales are derived two scales based on second-order factors: warmth and
strictness. The PDI's reliability and validity is supported by factor analysis
and cross-validation (Kelley et al.,
1992; Power, 1993;
Slater & Power, 1987).
Reliability in this sample was calculated for warmth (
=.85) and
strictness ( =.49) based on their individual items. Due to low internal
consistency of strictness, the three subscales that comprise strictness were
used instead: restrictiveness ( =.72), amount of control (
=.61), and physical punishment ( =.85). Unstandardized scores
(M ± SD) for parenting scales in this study were as
follows: warmth,.02 ± 2.6; strictness, -.06 ± 1.9;
restrictiveness, 27.6 ± 7.5; amount of control, 5.4 ±.88; and
physical punishment,.40 ±.43. Standard (z) scores are
presented from this point forward for ease of interpretation.
Regimen Adherence. The Self-Care Inventory (SCI), a self-report
questionnaire, assesses perceived adherence to diabetes regimens across
several aspects of diabetes care (La Greca
et al., 1990). Parents rated their child's adherence during the
past month on a scale of 1 to 5, where 1 means "never do it," and
5 means "always do this as recommended without fail." For this
study, we calculated an overall adherence score (the mean of six items
measuring blood glucose testing, insulin, and dietary adherence). The seventh
item on the original adherence scale, "exercising regularly," was
eliminated because it had a low item-total correlation (r =.13), and
the scale had better internal consistency without this item ( =.80 vs.
=.76). In a sample of 10- to 17-year-old youths (N = 103; A.
Delamater, personal communication, 1997), parent report on the SCI yielded
good internal consistency ( =.84) and test-retest reliability over 2-4
weeks (r =.77, n = 32). The SCI's validity is supported by
comparison with the 24-hour recall interview
(Greco et al., 1990).
Glycemic Control. The GHb assay, which reflects mean blood glucose
concentration over the previous 2 months
(Blanc, Barnett, Gleason, Dunn, &
Soeldner, 1981), was used as the measure of glycemic control. GHb
values were transformed into z scores based on the normal ranges
reported by each laboratory (M ± 2 SD) to make the
results from different laboratories comparable (GHb z score = [GHb %
— lab M]/lab SD). Due to residual insulin secretion in
the period following diagnosis, 11 newly diagnosed (less than 1 year) children
were excluded from GHb analyses. The mean GHb z score values
including these children (n = 49) were M ±
SD = 6.3 ± 3.1. Raw GHb scores, including newly diagnosed
children, were M ± SD = 8.7 ± 1.5%.
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Results |
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Clinical Characteristics
Correlations, means, and standard deviations are presented in Table I. Mean adherence scores were above 4, indicating good regimen adherence overall. However, a significant percentage of the sample reported difficulty adhering to the regimen, reflected in adherence ratings less than 4 for overall adherence (16%). The mean raw GHb score for the sample was 8.7%, indicating fair to good glycemic control among these children. However, 43% of the sample had GHb values more than 4 SDs above the normal range, indicating fair to poor glycemic control, and 18% were in poor control, over 6 SDs above the normal range. Thus, a substantial percentage reported difficulties with the diabetes regimen or poor glycemic control.
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Demographic Characteristics
Prior to testing specific hypotheses, we examined demographic variables for
interrelationships (child's ethnicity, gender, mother's marital status, age,
disease duration, SES; see Table
I.) No gender differences were found. Ethnicity was found to be
related to SES, F(2, 50) = 10.7, p <.001. Dunn's test
(p <.05) showed that White families (M ±
SD = 44 ± 10; the following ± figures represent
M ± SD) had higher SES than Black (26 ± 12)
and Hispanic (34 ± 13) families. Ethnicity was related to
restrictiveness, F(2, 52) = 29.0, p <.001; Black (1.1
± 0.5) and Hispanic parents (0.7 ± 0.7) reported more
restrictiveness than Whites (-0.6 ± 0.7). Ethnicity was related to
physical punishment, F(2, 50) = 3.4, p <.05; Blacks (0.7
± 1.3) reported more physical punishment than Whites (-0.2 ±
0.7); Hispanics were intermediate (0.1 ± 1.2). Blacks (10.3 ±
3.1) had worse glycemic control (GHb z score) than Whites (5.7
± 2.5) or Hispanics (6.9 ± 2.7), F(2, 42) = 7.75,
p <.01. Lower SES was associated with more parental
restrictiveness (see Table I).
Black families in this sample had the lowest SES, most parental strictness,
and worst glycemic control.
Correlation Analyses
Consistent with hypotheses, warmth was associated with better adherence
ratings, and restrictiveness was associated with poorer glycemic control and
lower SES. However, the hypotheses of restrictiveness linked with poor
adherence and warmth with better glycemic control were not supported (see
Table I). Physical punishment
was inversely related to warmth and positively with restrictiveness. Glycemic
control (GHb z score) was not related to disease duration when
including only those children who had been diagnosed at least a year prior.
The correlation between GHb z score and duration was r =.26
(p <.10, n = 49) in the full sample.
Predicting Adherence
We used hierarchical regression to test the hypothesis that parenting
variables predict adherence ratings, while controlling demographic variables.
Variables entered in each step were retained only if the test of the predictor
was significant at =.10. Demographic variables (age, gender, duration
less than 1 year, ethnicity) were entered in the first step. This model did
not predict adherence (R2 =.08, p >.50,
n = 52), and no predictors were retained. SES was entered in the
second step, because it might mediate ethnic differences. The test of
incremental variance, equivalent to the test of the model, was not significant
(R2 = R2
=.0001, p
>.90, n = 50), and SES was not retained. In the third step,
parenting variables (warmth, amount of control, restrictiveness, physical
punishment) were entered, improving the model significantly
(R2 = R2 =.33, p <.001,
adjusted R2 =.28, n = 52). Warmth was the only
significant predictor, which uniquely explained 27% of the variability in
adherence ratings (bwarmth =.32, p <.001).
Predicting Glycemic Control
We used hierarchical regression to test the hypothesis that parenting
variables predict glycemic control, while controlling demographic variables.
Variables were retained if the test of the predictor was significant at
=.10. Age, gender, and ethnicity were entered in the first step. Black
ethnicity was retained (R2 =.25, p =.05;
n = 36 at each step; bBlack = 4.2, p <.01).
The reduced model significantly predicted GHb z score
(R2 =.23, p <.01, adjusted
R2 =.21). SES was entered in the second step; it did not
improve the model or mediate the ethnicity effect
(R2 =.001, p >.10; bBlack =
3.9, p <.01) and was not retained. Adherence ratings were entered
in the third step but failed to improve the model
(R2 =.01, p >.30) and were not
retained. Finally, parenting variables were entered but did not improve the
model (R2 =.03, p >.10).
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Few behavioral diabetes studies have been published for the preschool through elementary school age group, perhaps due to the higher prevalence of diabetes and worse glycemic control among adolescents (Delamater et al., 1991
;
La Greca et al., 1990).
Nevertheless, it is critical to examine young children with diabetes because
of their profound dependence on their parents, the self-control skills
mastered in middle childhood, and the self-care habits established during this
time. In this study, parenting style was related to diabetes regimen
adherence. Specifically, more parental warmth is associated with better
adherence among preschool through school age children, explaining about a
quarter (27%) of the variance in adherence ratings. This is concordant with
the child development literature, linking parental warmth with good behavior
and positive developmental outcomes
(Rollins & Thomas, 1979).
It also fits in with the diabetes-specific family support literature on
adolescents and extends it specifically to younger children; cohesion is
associated with better adherence and conflict with poorer adherence (e.g.,
Hauser et al., 1990;
Miller-Johnson et al., 1994).
However, conclusions must be tempered by caution, since social desirability
bias may influence parent report of both warmth and adherence. Thus, further
study is needed of these constructs.
Greater parental warmth may improve adherence through a reduction in family
conflict, an increase in cohesion, or both. Another possible mechanism for the
effect of parental warmth on adherence is through the child's development of
self-control. The child's ability to delay gratification and his or her sense
of self-efficacy (and its converse, learned helplessness) are developing
during this period (Diener & Dweck,
1980; Mischel, Shoda, &
Rodriguez, 1989). Rollins and Thomas
(1979) linked parental warmth
with greater self-esteem and internal locus of control. Learned helplessness
has been linked with worse glycemic control
(Kuttner, Delamater, & Santiago,
1990) and self-efficacy with better glycemic control in
adolescents with diabetes (Grossman, Brink,
& Hauser, 1987).
Parental restrictiveness was associated with worse glycemic control, lower
SES, and Black ethnicity in this sample. However, neither SES nor parenting
variables predicted glycemic control when Black ethnicity was a predictor.
Confounding made it impossible to sort out the effects of demographics and
restrictiveness. Restrictiveness could add to previous findings linking more
generalized family conflict to poorer glycemic control in children and
adolescents with diabetes (e.g.,
Miller-Johnson et al., 1994).
A restrictive parenting style may be a response to behavioral problems, a
threatening environment, or other stressors on the family system. Strictness
may also be a source of stress for the child. Thus, an association between
restrictiveness and glycemic control could reflect an array of relationships
between psychosocial stress and glycemic control. Extreme restrictiveness may
contribute to poorer glycemic control, even in Black families where strictness
is the norm, despite other potential advantages of strictness, such as safety
(Kelley et al., 1992). Studies
with larger, multiethnic samples are needed to explore the potentially
important relationships of restrictiveness to demographic characteristics and
glycemic control.
The findings of this study indicate that, although many young children with diabetes adhere well to the diabetes regimen and have adequate glycemic control, there are a significant number of children with regimen adherence problems and poor glycemic control. This contradicts the belief that children have no problems with diabetes until the onset of puberty. These children may benefit from interventions to improve their health care behaviors and glycemic control, thus affecting their long-term health.
The unique contribution of this study is the finding that parenting styles are associated with adherence in an understudied group, young children with diabetes. These findings suggest that parent training interventions might have beneficial effects on children's health behaviors and outcomes. Prospective, randomized intervention studies are needed to test interventions that encourage authoritative parenting, characterized by support and affection, using inductive rather than coercive control techniques. Interventions provided during this period may have lasting effects that could ameliorate the expected worsening of adherence and glycemic control during adolescence and potentially avert or delay the development of complications.
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Acknowledgments |
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This work is based on a master's thesis by Catherine Davis at the University of Miami. This research was supported by NIH grant DK48031. We thank Elyshe Hammerman for assistance with data collection.
Received May 28, 1999; revision received November 15, 1999; accepted March 27, 2000
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L. S. Schilling, M. Grey, and K. A. Knafl A Review of Measures of Self-Management of Type 1 Diabetes by Youth and Their Parents The Diabetes Educator, September 1, 2002; 28(5): 796 - 808. [Abstract] [PDF]
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M. A. Harris, D. Mertlich, and J. Rothweiler Parenting Children With Diabetes Diabetes Spectr, October 1, 2001; 14(4): 182 - 184. [Full Text] [PDF]
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