Open access

The Influence of Family Support, Parental Coping and School Support on Adherence to Type 1 Diabetes’ Self-Care in Adolescents

Written By

A. Cristina Almeida, M. Graça Pereira and Engrácia Leandro

Submitted: 03 May 2012 Published: 27 February 2013

DOI: 10.5772/53062

From the Edited Volume

Type 1 Diabetes

Edited by Alan P. Escher and Alice Li

Chapter metrics overview

1,878 Chapter Downloads

View Full Metrics

1. Introduction

Diabetes Mellitus is a globe and a growing serious public health problem. Type 1 Diabetes is estimated to be one of the five most prevalent chronic diseases in children and adolescents, corresponding to 5-10% of all cases worldwide [1, 2]. Type 1 diabetes is an autoimmune chronic disease resulting from total absence of insulin secretion. In order to replace the absence of insulin production by the cells in the islets of Langerhans, located in the pancreas, it is necessary to administer exogenous insulin [3-5].

Nutrition and physical exercise also play fundamental roles in managing type 1 diabetes, in association with insulin therapy. The nutrition of an adolescent with diabetes should be guided by the principles of healthy eating and by the regular practice of physical exercise, in order to facilitate the control of blood glucose levels, prevent associated complications, maintain body weight within the normal standards and reduce cardiovascular diseases risk factors, providing psychosocial and familiar well-being [6-9]. However, diet and physical activity are the type of self-care activities that adolescents with diabetes are less concerned with [10].

Type 1 diabetes has a multifactorial etiology, in which genetic factors are important, due to modifications in the HLA complex (Human Leukocite Antigen Complex), behavioral factors, which can include viral infections (enteroviruses, coxsackie virus, congenital rubella) and environmental borne toxins, such as nitrosamines or even food such as the early exposure to cow's milk proteins, cereals or gluten, and in this case, the antibodies produced by the immune system's T cells to destroy these potentially invading agents also act on the pancreas β cells, destroying them [11-13].

Self-management and self-care is of critical importance for the control of this type of diabetes in children and adolescents. In fact, the responsibility of regularly monitoring the disease and its symptoms and the compliance with the treatment lies with the family and later, in accordance with the growth and the development phase, are gradually transferred to the child/adolescent [14-17]. Therefore, the main goals for type 1 Diabetes Mellitus’s treatment, in children and adolescents, emphasize the prevention of symptoms and their severity, the prevention of short and long term complications, and the appropriate growth and development of the adolescent allowing the suitable maintenance of daily activities such as those related to family dynamics, school and social life [15, 18-20].

However, the multiple physiological and psychosocial modifications occurring during adolescence compromise diabetes treatments during this developmental period [15, 21, 22] and often, the adolescent show serious difficulties in adhering to self-care management of diabetes and the prevention of its complications. The conflicts arising from the demands and complexities involved in the self-management of diabetes, and the adolescent’s expectations regarding their own experiences, in this developmental phase, may account for this scenario [23, 24].

According to the World Health Organization (WHO), adolescence is placed between 10-19 years, during which the individual is subjected to changes of biological nature, determined by puberty that will produce a rapid growth with consequently distinct body transformations; changes of cognitive nature, with a higher complexity in reasoning skills, through the attainment of autonomy and identity construction and also changes of social nature with the experience of new and different roles [25-27]. However, the constant need to declare autonomy and independence leads the adolescent to idealize feelings of invulnerability, inconsistent with the acceptance of a chronic disease such as type 1 diabetes that may encourage non-adherence to self-care [22].

Parental involvement, communication, cohesion and family conflicts that arise when managing diabetes self-care, are good examples of the type of family support available to the adolescent. A higher level of family conflict and less involvement account for worse outcomes of adherence to diabetes self-care in adolescents [28]. In turn, schools with staff and peers also account from other sources of social support that the adolescent with type 1 diabetes may count on, in daily life, that may influence metabolic control and quality of life [29]. Peer pressure and the demands of the social environment (school, recreational activities and family) may hinder adherence to self-care in adolescents with diabetes [30, 31].

This chapter’s main goal is to describe the relationship among family support, school support and parental coping in adolescents with type 1 diabetes on adherence to self-care in order to inform the development of interventions programs to meet adolescents’ needs regarding diabetes management.


2. Adherence to self-care in the adolescent with type 1 diabetes

The diagnosis of a chronic condition such as diabetes involves a change in lifestyle as well as the use of therapeutic methods that, at times, adolescents may not have the will or capacity to integrate into their daily lives resulting in risks to their health [32-35]. Considering that the prescribed treatment regimen can be complex, the role of health professionals involved with patient’s care is of crucial relevance and intervention should emphasize symptoms’ control and the promotion of quality of life [36-38].

There are strong evidences that individuals with chronic diseases, such as diabetes, present difficulties in adhering to the prescribed therapeutic regimes, with the consequent complexities of managing and controlling the disease [39, 40]. However, the literature shows that some adolescents have problems in adhering to a self-administrate treatment regardless of the type of disease or its severity [41].

Non-adherence to treatment of a chronic disease, particularly in type 1 diabetes, embodies a problem of multifactorial etiology and indeed different attempts to explain adherence behavior to prescribed treatments have been proposed [32]. According to the World Health Organization [41], different factors affecting adherence can be classified into five groups: 1) social, economic and cultural factors; 2) factors related to the health services and professionals; 3) factors underlying the disease and the comorbidity; 4) factors related to the treatment and 5) factors related to the patient.

Adolescents with diabetes, in particular, go through a phase of strong psychosocial changes and have to deal simultaneously with the changes of adolescence itself and as well as coping with the demands of controlling the disease treatment specificities [16, 42-45]. The hormonal changes occurring during puberty that cause insulin resistance, the rebelliousness characteristic of this phase, and almost total absence of residual insulin secretion by the pancreas, may complicate diabetes treatment, particularly, adherence [15, 46, 47].

The stigma associated with chronic disease, the need for self-care in social contexts and the risk of hypoglycemia, reinforces the idea that adolescents with diabetes are different from their colleagues and friends, which can lead to a feeling of inferiority and negatively influence adherence to self-care behaviors outside their family and personal context [46, 48, 49]. Since adolescence corresponds to the transition between childhood and adulthood, both families and health professionals encourage and stimulate the independence of these youngsters regarding the management of their diabetes [46, 48, 49]. However, this rapid transition can lead to personal and family conflicts, probably because the adolescent has not developed the necessary maturity to assume this type of responsibility [16]. In fact, management of diabetes can be considered a major challenge for adolescents, worsened by physical and hormonal changes, characteristic of this developmental phase which may lead to frequent changes in the therapeutic regimen [50]. Living with a chronic disease, during adolescence is hard and the adolescent may experience more difficulties in adapting to diabetes [2, 17]. Very often, adolescents with diabetes mention their frustration, stress and anxiety, with a lack of motivation regarding the management of the disease, which may negatively influence their adherence to self-care. This set of emotions may also hinder the behaviors necessary for adherence to treatment [51, 52].

A chronic condition, such as diabetes, implies a permanent process of compliance with self-care in order to minimize the effects of its progression and, as a result, is often associated with lower therapeutic adherence [14, 49, 53, 54]. The methods aimed at increasing the success of therapeutic adherence can be classified into four main groups: 1) patient education; 2) existing communication between healthcare professionals and patient; 3) dosage and type of drugs and 4) the accessibility of health services to attend the patient [55]. However, evidence showed that through a multidisciplinary approach comprising educational and behavioral interventions, treatment adherence rates can significantly improve, when compared to the strategies that use each intervention separately [56, 57]. So, taking in consideration the different variables that contribute to noncompliance, it is fundamental to consider a multifactorial approach, to the extent that a single approach will not successfully improve patients’ adherence to treatment [55].

Adherence to diabetes self-care involves a complex set of daily behaviors that require the frequent monitoring of blood glucose, insulin administration, recommendations about nutrition and physical exercise [58] as well as making changes and adjustments whenever one of these factors changes [47, 59]. Therefore, the complexity of self-care behaviors may explain low adherence rates and may lead to significant suffering, although compliance significantly reduces the incidence and progression of associated complications [60-62]. Positive outcomes regarding adherence may be related to how each adolescent interprets, learns and draws conclusions regarding the meaning of the disease and its treatment [17]. However, some adolescents with diabetes may lie about their self-care behaviors to avoid being reprimanded by their parents or physician [63, 64].

Good adherence to self-care, in adolescents, may be explained by feelings of social acceptance, distorted or optimistic perception of their behavior or by minimizing the importance of strict compliance with the treatment [51, 65]. On the other hand, non-adherence may be related to specific psychosocial characteristics of adolescent's developmental phase [15, 43, 47, 50, 58]. Peer pressure and fear of a negative reaction from the group can lead to loss of support from colleagues, thus increasing the risk of diabetes complications [58]. The demands associated with self-care does not facilitate the adolescent’s growing desire for autonomy and both diabetes and its treatment may result and be perceived as limitations in physical activities, and one’s lifestyle [44, 66, 67].

Whereas the responsibility for diabetes self-care increases with adolescent’s age, compliance follows in the opposite direction, indicating that adolescents show better adherence when they are more in tune with the guidelines and values ​​of their parental figures [50, 66, 68, 69]. In fact, in the late adolescence stage, older adolescents show a greater concern with the body, sexuality and with independence from parents and authority figures what may explain poor results regarding adherence compared to younger adolescents [50, 65, 70-72].

The increase of emotional distress and autonomy and less acceptance of diabetes, due to a higher awareness of the impact of diabetes on the adolescent’s identity and psychosocial development, may also negatively influence adherence to self-care [59, 72-75]. Generally, adolescents tend to have worse outcomes regarding the administration of insulin, the practice of physical exercise, nutrition care and self-monitoring of blood glucose, when compared to children [39, 76]. However, a greater knowledge of diabetes and long experience with the disease decreases attitudes of denial, allowing the adolescent to gradually begin to accept the therapeutic regimen with better results [77, 78]. Also, adolescents who are more responsible for their treatment will have their task of identity formation and psychosocial development facilitated due to the management of their diabetes [65].

Male adolescents have worse adherence to self-care than female adolescents [69], but the latter show higher incidence of depression, eating disorders and psychosocial implications, which may interfere with the process of body image’s acceptance [43, 51, 79]. However, literature is controversial regarding gender. A study [80] found male adolescent to present higher levels of adherence to self-care. In other gender related studies, the differences in adherence to self-care were minimal, which may suggest that there are many similarities in the reactions and behaviors of adolescents of both genders regarding their performance in diabetes self-care, meaning that gender may not be considered a risk factor [41, 79, 81].


3. The family support in adherence to self-care

Family impacts on its members’ health and the opposite is also true [82]. Family support consists of the individual perception regarding the availability and the caregiving received from their family that allows the development of greater resilience and psychological well-being in the face of stress-inducing events [83-85]. Family support is a complex multidimensional concept associated with the individual’s mental health and in direct relation to support received from family members [84, 86, 87]. Hence, family support relates to the behaviors of affection, sensitivity, cooperation and trust, encouraging the autonomy and independence amongst family members [86].

There are numerous types and qualities of support available to families: tangible family support, such as actions that cause well-being among family members; family emotional support, which has to do with empathy, listening, and attention to family members giving advice, which is vital in moments of great difficulties and important decision-making [86, 88]. However, the perception of family support is influenced by personal factors, stable traits and intrinsic changes, in each person, over time [86, 88].

The perception of high levels of family support is associated with a positive disposition [89] and, as a result, when family support is positively perceived, feelings of well being within the family members are promoted [86].

The concept of family support can also be defined as a part of one’s informal and close relationship network, benefiting the individual with the exchanges among family members [85]. In this sense, the individual develops greater resilience and psychological well-being, that enables the development of more adjusted responses to stress-inducing events that are closely related to a better coping with a chronic disease [85, 90, 91]. Therefore, it is necessary for family dynamics to show a set of fundamental aspects which favor the development of family support among its members, such as: 1) congruent, directional, functional and emotional communication; 2) consistent and flexible rules; 3) democratic leadership shared with the offspring; 4) self-esteem, 5) integrated couple’s relationship, allowing the family to act as a whole but ensuring each individual’s personality [92]. The accomplishment of these functions, in association with the perception of the family as loving, cohesive and with clear boundaries, provides members with important tools for individual growth as well as providing its members with a support system [92].

In situations of chronic disease, family support proves to be an important resource in self-care behaviors for adolescent, with a direct correlation between the perception of family support and an increased motivation for self-care behaviors and health in general [82, 90, 93]. This support appears to be of greatest importance in children and adolescents who experience high levels of stress due to a chronic condition and may also affect their development and the quality of their social relationships within their family system [94-96]. However, on one hand, some families become so close that its members are attached, in a way that may affect the autonomy of the patient and, on the other hand, there are families who may become more distant due to the strain that the disease imposes on the family [82]. Within this perspective, a family providing support, affection, guidance and adjusted strategies to solve problems, establishes and promotes best conditions for adherence to self-care, evidencing its responsibility in sharing diabetes’ self-care activities with the adolescent [14, 97]. In fact, the family is the main source of support in chronic disease, whether through tangible support, such as preparing meals, administering the medication and in the daily care or through emotional and social support ([82, 90]. Both family and friends influence the control of diabetes, regarding compliance with the medical treatment, diet and the practice of physical exercise [98, 99].

Family support represents an important factor in understanding treatment adherence in adolescents with type 1 diabetes, helping the adolescent to adapt to the demands of the disease and consequently to diabetes self-care. A low family support is a good predictor of poor adherence to self-care in diabetes [73, 100, 101].

Family organization significantly affects family health behaviors in the same way that individual’s health also affects the family. Therefore, the family is a resource of strategic importance, since it may or may not help the adolescent with diabetes to properly manage the disease and to achieve treatment’s goals [90]. Family support entails emotional and behavioral benefits for its members and is therefore, a reciprocal and proactive process with both parties benefiting from its positive effects, which are particularly important in adolescents who experience high levels of stress, such as in the process of a chronic disease [94, 99]. In the case of diabetes, a direct relationship between family support, characteristics of adolescents with diabetes and therapeutic adherence has been found [70, 82]. The family can act as a support unit for the adolescent’s daily self-care tasks, such as motivating physical activity and compliance with the nutrition plan and encouraging insulin administration, after receiving proper guidance, [71, 90].

Regarding diabete’s treatment, parents are considered the major providers of social support, even more than peers. Those adolescents, whose parents are less involved and therefore less supportive, show lower adherence to self-care behaviors [70, 102, 103]. The existence of good communication, good skills for an effective resolution of problems and conflicts and flexibility among family members are essential conditions for the adolescent to effectively adapt to the demands of diabetes [17]. Therefore, parental support is positively associated with adolescents' adherence to the prescribed therapeutic regimen [98, 104-106]. In a study involving adolescents with diabetes, a higher family support was a good indicator of adherence to self-care, suggesting the influence that perceived family support has on the implementation and management of diabetes in the daily life of adolescents [107]. In fact, family support appears to have a direct effect on adolescents' adherence to self-care through direct parental supervision on self-care activities. The authors found family support to be a moderator between adolescents’ adherence to self-care and quality of life i.e. when family support was high, a positive relationship between adherence and quality of life was found [108]. However, the adolescent may sometimes perceive family support as invasive [109, 110]. In fact, diabetes may modify the process of adolescent’s development and family dynamics, and the psychosocial tasks of progressively acquiring autonomy and independence, on the part of the adolescent, may be affected. Therefore, the family’s challenge relies on allowing the adolescent to acquire independence with the consequent constraints associated with diabetes, without being super-protective [111].

Given the specific tasks and behaviors in managing diabetes self-care, family support was significantly higher among younger children and in those where the disease was more recently diagnosed [70, 82].

Diabetes requires from the adolescent, family and health professionals a set of efforts in order to achieve a good metabolic control and reduce future complications [112]. Family’s participation and collaboration play an important role when it comes to ensure the well-being of the adolescent with diabetes [111].


4. Adherence to self-care and parental coping

Coping is related to efforts, whether cognitive or behavioral, used by the individual to face internal or external demands caused by a specific stress-inducing situation [113, 114]. Coping also implies a dynamic process depending on individual differences and circumstances occurring throughout life [115-117].

Given that coping is a changing process, the individual is not limited to a single coping strategy, since changes will occur resulting from the assessment of stressful situations [116-118]. For this reason, the individual can begin the process by using a strategy and later keep the same strategy, change it or use a combination of different strategies, as the relationship with the environment changes [119, 120].

Coping strategies represent actions, thoughts or behaviors to cope with a stress-inducing event that may, according to their function, be subdivided into two types: emotion-focused coping and problem-focused coping [119, 121, 122]. Emotion-focused coping concerns the efforts to regulate the emotional state that is associated with stress or results from stressful events ([17, 119]. These efforts are directed to somatic sensations or feelings, in order to transform the emotional state manifested by the individual; this type of strategies seeks to minimize the unpleasant physical sensation caused by a state of stress. Problem-focused coping consists of making an effort to act upon a stressful situation, by trying to change it [119, 122, 123]. This type of strategy aims to modify the existing problems in the relationship between the individual and the context that caused the tension [17, 124]. Therefore, coping actions can be directed either inwardly or outwardly [125, 126]. The first type includes strategies such as cognitive restructuring and the latter includes negotiation strategies to resolve an interpersonal conflict or request help from other individuals [125, 126]. In this sense, the process of coping is considered a mediator between the stressful situation and its consequences, whether by focusing on the problem or on the emotion, and its main purpose is to improve the emotional state that results from the confrontation with the stressor [123].

In the case of a chronic disease, coping presents itself as a dynamic process that changes over time, according to the objective demands and the subjective assessments of the situation involving changes in thoughts and actions [115-117, 127]. In addition to personal requirements, defined goals, external resources, such as social support from family, friends and health professionals, economic resources and internal resources, such as intelligence, resilience and locus of control and the characteristics of the disease and treatment are also factors that impact the disease evaluation process that is stress-inducing [118, 120]. As a result, each person has a subjective understanding of the disease, personal attitudes and behavior towards the illness that corresponds to coping mechanisms behind the biomedical factors influencing the course of the disease. Disease severity does not seem to have a consistent relation with the coping used by an individual in adjusting to a chronic disease but coping systems are significantly influenced by psychological and social factors [128].

As a chronic disease, diabetes implies adaptations in terms of physical exercise, food and socializing with peers, that are considered stressful triggering a process of psychological adaptation, with consequent changes in family dynamics [129]. The entire adapting process depends on both the complexity and the severity of the disease, impacting on the stability of the family structure and the development of coping strategies. However, in most cases, parents of children and adolescents with diabetes develop effective coping strategies to manage the diabetes’ demands, even if some may show more difficulties and problems adapting to this disease [130, 131].

Chronic disease can be understood as a stress-inducing event affecting the normal development of the child and disturbing the social relations within the family system, changing family routines with constant medical consultations, medication and hospital admissions [96, 132]. Thus, parents and adolescents’ psychological resources and the family structure interact and contribute to the adolescent's adaptation to diabetes [96]. The inadequacy of the adolescent can be related more with how the family deals with the sick adolescent, than with the behaviors of the adolescent [96, 132]. As a result, family routines change and the family must adapt to living with a sick child, since strict relationship patterns may influence the adolescent’s emotional development. Parents should be enlightened and aware of the specific diabetes‘ treatment demands, so that the adolescent does not become depressive and/or distressed [129]. Some studies show, after the diagnosis, that some mothers of children or adolescents with a chronic disease, have trouble sleeping and present a significant emotional impact with associated feelings of concern, fear and responsibility [133].

There is a greater responsibility for mothers in the daily care of a child with diabetes. Often, is up to the mother to accompany the child/adolescent to the medical consultation, keep monitoring records of the blood glucose, guide the child regarding diet and care about the daily insulin administration [134, 135]. Sometimes, when a child is diagnosed with diabetes, parents' responses can lead to a family breakdown that may consequently influence the whole process of adapting and adjusting, by family members, to a chronic disease [133]. This situation can occur after the diagnosis, when the family ceases to participate in social events trying to avoid the ingestion of sweets and cakes hiding from the discomfort of having to relate to others in social situations [135]. Thus, parents who intensify the relationship of dependence and protection regarding the adolescent, as a coping strategy, start to lead their lives according to the child’s needs and this process may become very tiresome for parents after a while [136].

Sharing specific tasks for diabetes management between the family and the adolescent, increases the later’s knowledge about diabetes. The use of assertive behavior, in social contexts, is considered to be an adjusted strategy to cope with the disease and encourages adaptation. Disease management in diabetes can be stress-inducing, both for the adolescent and for the family, and disturb the harmony of the family dynamics [131].

In most cases, either the adolescent or the family may not act appropriately regarding diabetes, and ultimately fail to accomplish self-care tasks and may even lie regarding blood glucose monitoring if afraid of the disapproval or criticism from health professionals [135].


5. School support in adhering to self-care

School plays an important role in controlling diabetes, in adolescents, given the association between keeping proper self-care during normal school activities and good disease management and quality of life [29, 137, 138]. The school context can contribute to improve the acceptance of diabetes and adolescent’ self-esteem and, consequently, have a positive influence on diabetes self-care, due to the continuity of diabetes care during school activities, allowing the adolescent to actively participate in school, reducing school interruptions and absences and ensuring the safety and the prevention of diabetes associated complications [138-140]. However, many adolescents tend to feel uncomfortable in pursuing diabetes self-care in the school environment, because they do not feel safe and properly supported, which could be one of the possible barriers, to adhere to diabetes self-care tasks [138, 141-144]. Also, the lack of knowledge of school teachers and other professionals about diabetes, unhealthy and limited food choices, the unfavorable school organization and class rules unfriendly for diabetes management may have a negative impact on adherence and cause feelings of discrimination among adolescents with diabetes [138, 141, 142, 145, 146]. Along with these barriers, the lack of private places for administering the insulin, which has to be done often in inappropriate places such as the bathroom, the absence of locations for adolescents with diabetes to keep the materials needed for diabetes self-care and the indifference of school staff regarding symptoms and difficulties expressed by these adolescents, may also negatively influence adherence [142, 147, 148].

For parents of teenagers with diabetes, the existence of well-informed teachers regarding diabetes and a proper school structure to receive students with this health condition, are considered the main support that school needs to provide for diabetes management in adolescents [29]. In a school environment, the strongest support comes from teachers and peers [107, 141]. Consequently, it is essential to improve communication between the family and the school, to improve the education of school professionals, to develop healthy menus in the canteen and cafeteria and also to have nurses available to take care of adolescents with diabetes or other chronic diseases, when needed, as well as promoting the education of school staff, students and teachers regarding diabetes, the same way as the school has learned how to care and accommodate students with special education needs [149].

Social support from the peer group has been rated as one of the most important resources for adolescents with diabetes, given that friends tend to provide more companionship and emotional support for self-care behaviors than family members [29, 106, 47, 150, 51]. Social support from peers significantly influences adolescent’s adherence to self-care, with strong evidence suggesting that this support improves metabolic outcomes [31]. Despite the differences between the type of support provided by the family and peers, both types of support are also complementary, since the family provides more support in daily tasks, such as insulin administration and meal preparation, while friends provide more emotional support in relation to the practice of physical exercise and glucose monitoring contributing to a better psychological adjustment to diabetes [150, 152-155]. In fact, friends and peers allow the adolescent to enjoy moments of fun and relaxation, contributing to the successful management of diabetes. However, conflict situations between the adolescent with diabetes and peers, although normal and appropriate for psychosocial development, are associated with worse metabolic results, especially in female adolescents [156-158]. In turn, older adolescents, despite having better skills in problem solving, are more vulnerable and prone to peer group pressure regarding diabetes self-care which is associated with worse metabolic outcomes [159, 160]. The way adolescents cope with the need to be part of the group and treated the same way as other members may explain the secrecy regarding diabetes and its symptoms, in an attempt to avoid a negative impact on their social image if significant others find out about their disease [105, 161, 162].

A study on the influence of school and family support on self-care, in adolescents, found that these two types of support act as moderators in the relationship between the quality of life and adherence to the treatment, so when school support and family support were perceived as high, in adolescents with type 1 diabetes, good quality of life was positively related to good adherence [108].

Young people report having more difficulty in adhering to self-care activities in the school context and with their peer group [31, 138, 153, 154, 160, 163, 164]. The anticipation of peer pressure and the fear of being discriminated influence adolescents not to follow adherence to diabetes regimen, which means higher risks regarding their health [165]. In fact, interaction with the peer group and the social context influence adherence to self-care either through positive attitudes, such as the companionship of friends, or through negative attitudes, such as prejudices related to the adolescent’s food choices [153, 160, 166]. However, a study on the relationship between adherence and peer support did not reveal a strong relationship probably due to the role that cognitive attributions and evaluations play: if positive, they may be considered a protective factor, if negative, adolescent adjustment to chronic disease may be negatively influenced [152]. Yet another study found that support from peers and teachers, as well as satisfaction with the support received, were associated with good metabolic control, in diabetes [137].


6. Conclusion

Psychosocial and physiological demands, typical of the adolescent’s developmental phase and the intensive and demanding characteristics of diabetes treatment influence adherence to diabetes self-care. However, the support from family, peers and school play, an important role in managing and controlling diabetes by adolescents, who tend to present better adherence to self-care behaviors when support is perceived as appropriate. Therefore, intervention programs designed to promote adherence to diabetes self care in adolescents should also include family members and take in consideration the social context of adolescents.

In terms of family support, it is important for adolescent to have access to tangible support from the family in preparing food, monitoring the levels of glycemia and in administering insulin. However, if a high family support is associated with good adherence to the self-care, sometimes too much family involvement can entail a negative influence if the adolescent perceives this support to be a barrier to the development of his/her identity and autonomy. Consequently, it is also important for intervention, in diabetes, to include conflict resolution skills, self-efficacy and stress management strategies for both the adolescent and the family.

Coping strategies adopted by parents in order to deal with daily tasks and challenges, that diabetes management implies, interfere with the organization of family dynamics and impact on adherence to diabetes self-care. Given that the effectiveness of coping strategies influence adherence, it becomes important for parents and adolescents to integrate self-help groups or even family therapy, when they have trouble adapting to diabetes management.

Diabetes is a disease that requires constant monitoring and surveillance even within social contexts outside the family environment, as in the case of peer group activities. The support from both the school and the peer group impacts on adherence outcomes in adolescents. As a result, education regarding diabetes in schools is important, in order to improve knowledge about the management of diabetes and also to make support and resources more efficient and appropriate regarding diabetes self care’s behaviors in the school context.

Finally, psychological interventions must also acknowledge the implications of diabetes on the adolescent’s lifestyle in order not to jeopardize the development of autonomy, independence and social skills and instead, promote normal psychosocial development of the adolescent in the family, school, and other significant social environments.


  1. 1. Faulkner M, Chang L. Family Influence on Self-Care, Quality of Life, and Metabolic Control in School-Age Children and Adolescents with Type 1 Diabetes. Journal of Pediatric Nursing 2007;22(1) 59-68.
  2. 2. Duarte R, Góis C. Diabetes na Adolescência. In: Duarte R. (ed.) Diabetologia Clínica. 3th ed. Lisboa: Lidel - Edições Técnicas; 2002. p243-250.
  3. 3. Shah B, Zinman B. Insulin Regimens for Type 1 Diabetes. In: Sperling M. (ed.) Type 1 Diabetes. Etiology and Treatment. New Jersey: Humana Press; 2003. p199-214.
  4. 4. Haller MJ, Silverstein JH, Rosenbloom AL. Type 1 Diabetes in the Child and Adolescent. In: Lifshitz F. (ed.) Pediatric Endocrinology. 5th ed. New York: Informa Healthcare; 2007. p63-82.
  5. 5. Doliba NM, Matschinsky FM. The Metabolic Basis of Insulin Secretion. In: Sperling MA. (ed.) Type 1 Diabetes. Etiology and Treatment. New Jersey: Humana Press; 2003. p115-144.
  6. 6. Smart C, Vliet EA-v, Waldron S. Nutritional management in children and adolescents with diabetes. Pediatric Diabetes 2009;10(Suppl. 12) 110-117.
  7. 7. Beebe CA. Nutritional Management in Type 1 Diabetes. In: Sperling MA. (ed.) Type 1 Diabetes. Etiology and Treatment. New Jersey: Humana Press; 2003. p261-278.
  8. 8. Robertson K, Adolfsson P, Riddell M, Scheiner G, Hanas R. Exercise in children and adolescents with diabetes. Pediatric Diabetes 2009;10(Suppl. 12) 154-168.
  9. 9. Raine JE, Donaldson MD, Gregory J, Van-Vliet G. Practical Endocrinology and Diabetes in Children. 2nd ed. Massachusetts: Blackwell Publishing; 2006.
  10. 10. Escobar O, Drash AL, Becker DJ. Management of the Child with Type 1 Diabetes. In: Lifshitz F. (ed.) Pediatric Endocrinology. 5th ed. New York: Informa Healthcare; 2007. p101-124.
  11. 11. Thorsdottir I, Ramel A. Dietary Intake of 10- to 16-Year-Old Children and Adolescents in Central and Northern Europe and Association with the Incidence of Type 1 Diabetes. Annals of Nutricion & Metabolism 2003;47 267-275.
  12. 12. Dorman JS, Laporte RE, Songer TJ. Epidemiology of Type 1 Diabetes. In: Sperling MA. (ed.) Type 1 Diabetes. Etiology and Treatment. New Jersey: Humana Press; 2003. p3-22.
  13. 13. Lernmark Å, Chung CH. Molecular Biology of β-Cell Destruction by Autoimmune Processes. In: Sperling MA. (ed.) Type 1 Diabetes Etiology and Treatment. New Jersey: Humana Press; 2003. p71-92.
  14. 14. Silva I, Pais Ribeiro J, Cardoso H. Adesão ao Tratamento da Diabetes Mellitus: A Importância das Características Demográficas e Clínicas. Revista Referência 2006;2(2) 33-41.
  15. 15. Fagulha A, Santos I, Grupo de Estudo da Diabetes Mellitus. Controlo glicémico e tratamento da diabetes tipo 1 da criança e adolescente em Portugal. Acta Médica Portuguesa 2004;17(2) 173-179.
  16. 16. Skinner TC, Channon S, Howells L, McEvilley A. Diabetes During Adolescence. In: Snoek FJ, Skinner TC. (eds.) Psychology in Diabetes Care. West Sussex: John Wiley & Sons; 2000. p25-59.
  17. 17. Barros L. Psicologia Pediátrica. Perspectiva desenvolvimentista. 2nd ed. Lisboa: Climepsi Editores; 2003.
  18. 18. Hanas R. Diabetes tipo 1 em crianças, adolescentes e jovens adultos. Lisboa: Lidel Editores; 2007.
  19. 19. Pina R. Diabetes na Criança. In: Duarte R. (ed.) Diabetologia Clínica. 3th ed. Lisboa: Lidel Editores; 2002. p229-242.
  20. 20. American Diabetes Association (ADA). Standards of Medical Care in Diabetes. Diabetes Care 2007;30(Suppl. 1) S4-S41.
  21. 21. Anderson BJ. Family Conflict and Diabetes Management in Youth: Clinical Lessons from Child Development and Diabetes Research. Diabetes Spectrum. Diabetes Spectrum 2004;17(1) 22-26.
  22. 22. Pereira M, Almeida P. Barreiras à Adesão ao Regime Terapêutico da Diabetes In: Machado C, Almeida L, Gonçalves M, Ramalho V, (eds.) X Actas da Conferência Internacional de Avaliação Psicológica: Formas e Contextos. Braga: Psiquilibrios; 2004. p170-179.
  23. 23. La Greca A, Harrisson HM. Adolescent Peer Relations, Friendships, and Romantic Relationships: Do They Predict Social Anxiety and Depression? Journal of Clinical Child and Adolescent Psychology 2005;34(1) 49-61.
  24. 24. Yeo M, Sawyer S. Chronic illness and disability 2005;330 721-723.
  25. 25. Silva GR, Cruz NR, Coelho EB. Perfil nutricional, consumo alimentar e prevalência de sintomas de anorexia e bulimia nervosa em adolescentes de uma escola da rede pública no município de Ipatinga, M. G. Revista Digital de Nutrição 2008;2(3) 1-15.
  26. 26. Ribeiro C, Rosendo I. Saúde do adolescente em Medicina Geral e Familiar. Revista Portuguesa Clinica Geral 2011;27 184-186.
  27. 27. Almeida P, Pereira MG. Família, Suporte Social e diabetes tipo 1 na adolescência. In: Pereira MG. (ed.) Psicologia da Saúde Familiar: aspectos teóricos e investigação. Lisboa: Climepsi Editores; 2007. p135-162.
  28. 28. Hilliard ME, Herzerb M, Dolanc LM, Hood KK. Psychological screening in adolescents with type 1 diabetes predicts outcomes one year later. Diabetes Research and Clinical Practice 2011;94(1) 39-44.
  29. 29. Wagner JA, Abbott G, Lett S. Age related differences in individual quality of life domains in youth with type 1 diabetes. Health and Quality of Life Outcomes 2004;2(54). doi:10.1186/1477-7525-2-54.
  30. 30. Schiffrin A. Psychosocial issues in pediatric diabetes. Current Diabetes Reports 2001;1(1) 33-40.
  31. 31. Lehmkuhl HD, Merlo LJ, Devine K, Gaines J, Storch EA, Silverstein JH, et al. Perceptions of Type 1 Diabetes among Affected Youth and their Peers Journal of Clinical Psychology in Medical Settings 2009;16(3) 209-215.
  32. 32. Dias AM, Cunha M, Santos A, Neves A, Pinto A, Silva A, et al. Adesão ao regime Terapêutico na Doença Crónica: Revisão da Literatura. Millenium 2011;40 201-219.
  33. 33. Sousa S, Pires A, Conceição C, Nascimento T, Grenha A, Braz L. Polimedicação em doentes idosos: adesão à terapêutica. Revista Portuguesa de Clínica Geral 2011;27(2) 176-182.
  34. 34. Leite M. Programa de promoção da adesão terapêutica em crianças diabéticas. In: Guerra M, Lima L. (eds.) Intervenção Psicológica em Grupos em Contextos de Saúde. Lisboa: Climepsi Editores; 2005. p155-174
  35. 35. Kakleas K, Kandyla B, Karayianni C, Karav K. Psychosocial problems in adolescents with type 1 diabetes mellitus. Diabetes & Metabolism 2009;35(5) 339-350.
  36. 36. Catela A, Amendoeira J. Viver a Adesão ao Regime Terapêutico – Experiências Vividas do Doente Submetido a Transplante Cardíaco. Pensar Enfermagem 2010;14(2) 39-54.
  37. 37. Sousa M, Peixoto M, Martins T. Satisfação do doente diabético com os cuidados de enfermagem: influência na adesão ao regime terapêutico. Revista Referência 2008;2(8) 59-67.
  38. 38. Silveira L, Ribeiro V. Grupo de adesão ao tratamento: espaço de “ensinagem” para profissionais de saúde e pacientes. Interface - Comunicação, Saúde e Educação 2005;9(16) 91-104.
  39. 39. Gimenes H, Zanetti M, Haas V. Fatores relacionados à adesão do paciente diabético à terapêutica medicamentosa. Revista Latino-Americana de Enfermagem 2009;17(1) 46-51.
  40. 40. Almeida H, Versiani E, Dias A, Novaes M, Trindade E. Adesão a tratamentos entre idosos. Comunicação em Ciências da Saúde 2007;18(1) 57-67.
  41. 41. World Health Organization (WHO). Adherence to long-term therapies - Evidence for action. Switzerland: WHO; 2003.
  42. 42. Fragoso L, Araújo M, Lima A, Freitas R, Damasceno M. Vivências cotidiana de adolescentes com diabetes mellitus tipo 1. Texto & Contexto Enfermagem 2010;19(3) 443-451.
  43. 43. Court J, Cameron F, Berg-Kelly K, Swift P. Diabetes in adolescence. Pediatric Diabetes 2009;10(Suppl. 12) 185-194.
  44. 44. Genuth S. Relationship Between Metabolic Control and Complications in Diabetes: Therapeutic Implications of the Diabetes Control and Complications Trial. In: Sperling MA. (ed.) Type 1 Diabetes. Etiology and Treatment. New Jersey: Humana Press; 2003. p215-232
  45. 45. Kennedy L, Idris I, Gazis A. Problem Solving in Diabetes. Oxford: Atlas Medical Publishing; 2006.
  46. 46. Novato T, Grossi S, Kimura M. Qualidade de Vida e Auto-estima de adolescentes com diabetes mellitus. Acta Paulista de Enfermagem 2008;21(4) 562-567.
  47. 47. Werther GA, Cameron FJ, Court JM. The Adolescent with Type 1 Diabetes. In: Sperling MA. (ed.) Type 1 Diabetes. Etiology and Treatment. New Jersey: Humana Press. 2003. p307-320.
  48. 48. Alencar D, Alencar A. O papel da família na adaptação do adolescente diabético. Revista Rene. 2009;10(1) 19-28.
  49. 49. Kyngäs A. Predictors of good adherence of adolescents with diabetes (insulin-dependent diabetes mellitus). Chronic Illness 2007;3(1) 20-28.
  50. 50. La Greca A. Issues in Adherence With Pediatric Regimens. Journal of Pediatric Psychology 1990;15(4) 423-436.
  51. 51. Mulvaney S, Mudasiru E, Schlundt D, Baughman C, Fleming M, Vanderwoude A, et al. Self-management in Type 2 Diabetes: The Adolescent Perspective. Diabetes Educator 2008;34(4) 674-682.
  52. 52. Tilden B, Charman D, Sharples J, Fosbury J. Identity and Adherence in a Diabetes Patient: Transformations in Psychotherapy. Qualitative Health Research 2005;15(3) 312-324.
  53. 53. Assunção T, Ursine P. Estudo de factores associados à adesão ao tratamento não farmacológico em portadores de diabetes mellitus assistidos pelo Programa Saúde da Família, Ventosa, Belo Horizonte. Ciência & Saúde Colectiva 2008;13(2) 2189-2197.
  54. 54. Pais Ribeiro JL. Introdução à Psicologia da Saúde. 2nd ed. Coimbra: Quarteto; 2007.
  55. 55. Osterberg L, Blaschke T. Adherence to Medication. The new england journal of medicine 2005;353 487-497.
  56. 56. Henriques M. Adesão ao regime medicamentoso em idosos na comunidade. Eficácia das intervenções de enfermagem. PhD thesis. University of Lisbon; 2011.
  57. 57. Bugalho A, Carneiro AV. Intervenções para aumentar a adesão terapêutica em patologias crónicas. NOC de Adesão Terapêutica. Lisboa: CEMBE; 2004.
  58. 58. Salamon S, Allen A, Fleischman M, Davies H, Kichler J. Improving adherence in social situations for adolescents with type 1 diabetes mellitus (T1DM): a pilot study. Primary care diabetes 2010;4(1) 47-55.
  59. 59. Farrell P. Diabetes, Exercício Físico e Esportes de Competição. Sports Science Exchange 2004;16(3), Disponível em: Accessed 30 June 2012]
  60. 60. Carmo T. Melhoria da adesão ao tratamento medicamentoso por meio da atenção farmacêutica. In: UNIMEP. (ed.) 5th Amostra Académica UNIMEP 9º Seminário de Extensão: Educação Brasileira: Extinção ou Sustentabilidade na Universidade 23-25 de October 2007; Piracicaba. Brazil.
  61. 61. Pietropaolo M, Trucco M. Genetics of Type 1 Diabetes. In: Sperling MA. (ed.) Type 1 Diabetes. Etiology and Treatment. New Jersey: Humana Press; 2003. p23-54.
  62. 62. Masharani U. Diabetes Desmystified. A self-teaching guide. New York: McGraw-Hill; 2008.
  63. 63. Kyngäs HA, Kroll T, Duffy ME. Compliance in Adolescents With Chronic Diseases: A Review. Journal of Adolescent Health 2000;26(6) 379-388.
  64. 64. Civita M, Dobkin P. Pediatric Adherence as a Multidimensional and Dynamic Construct, Involving a Triadic Partnership. Journal of Pediatric Psychology 2004;29(3) 157-169.
  65. 65. Garrett S. Adesão ao tratamento da diabetes em adolescentes: factores motivacionais. Master Thesis. University of Oporto; 2007.
  66. 66. Shaw R. Treatment Adherence in Adolescents: Development and Psychopathology. Clinical Child Psychology and Psychiatry 2001;6(1) 1359–1045.
  67. 67. Greening L, Stoppelbein L, Reeves C. A Model for Promoting Adolescents’Adherence to Treatment for Type 1 Diabetes Mellitus. Children's Health Care 2006;35(3) 247-267.
  68. 68. Jacobson A, The Diabetes Control and Complications Trial Research Group. The Diabetes Quality of Life Measure. In: Bradley C. (ed.) Handbook of Psychology and Diabetes. New York: Psychology Press; 2006. p65-88.
  69. 69. Dashiff C, McCaleb A, Cull V. Self-care of young adolescents with type 1diabetes. Journal Pediatric Nursing 2006;21(3) 222-232.
  70. 70. Wysocki T, Taylor A, Hough BS, Linscheid TR, Yeates KO, Naglieri JA. Deviation From Developmentally Appropriate Self-Care Autonomy. Diabetes Care 1996;19(2) 119-125.
  71. 71. Santos E, Zanetti M, Otero L, Santos M. O cuidado sob a ótica do paciente diabético e de seu principal cuidador. Revista Latino-Americana de Enfermagem 2005;13(3) 397-406.
  72. 72. Alcântara K, Zanetti R, Oliveira S. O adolescentes diabético numa visão psicossomática. Revista Académica Digital do Grupo POLIS Educacional 2008;4(5) 15. ISSN 1679-8902
  73. 73. Pereira MG, Berg-Cross L, Almeida P, Machado J. Impact of Family Environment and Support on Adherence, Metabolic Control, and Quality of Life in Adolescents with Diabetes. International Journal of Behavioral Medicine 2008;15 187-193.
  74. 74. Kovacs M, Iyengar S, Goldston D, Stewart J, Obrosky DS, Marsh J. Psychological functioning of children with insulin-dependent diabetes mellitus: a longitudinal study. Journal of Pediatric Psychology 1990;15(5) 619-632.
  75. 75. Holmbeck GN, Kendall PC. Introduction to the Special Section on Clinical Adolescent Psychology: Developmental Psychopathology and Treatment. Journal of Consulting and Clinical Psychology 2002;70(1: 3-5.
  76. 76. Hirschberg SL. The self-regulation of health behavior in children with insulin-dependent diabetes mellitus. Master Thesis. Faculty of Pacific Graduate School of Psychology; 2001.
  77. 77. Garay-Sevilla ME, Nava LE, Malacara JM, Huerta R, León JD, Mena A, et al. Adherence to treatment and social support in patients with non-insulin dependent diabetes mellitus. Journal of Diabetes and Its Complications 1995;9(2) 81-86.
  78. 78. Silva I, Pais Ribeiro J, Cardoso H, Ramos H. Effects of treatment adherence on metabolic control and quality of life in diabetic patients. Psychosomatic Medicine 2002;64 (1) 125-125.
  79. 79. Schwartz D, Cline V, Hansen J, Axelrad M, Anderson BJ. Early risk factors for nonadherence in pediatric type 1 diabetes: A review of the recent literature. Current Diabetes Reviews 2010;6(3) 167-183.
  80. 80. Hanna KG, Guthrie DW. Parental Involvement in Adolescents’ Diabetes Management. Diabetes Spectrum 2003;16(3) 184-187.
  81. 81. Fitzgerald JT, Anderson RM, Davis WK. Gender differences in diabetes attitudes and adherence. Diabetes Educator 1995;21(6) 523-529.
  82. 82. Ribeiro C. Família, Saúde e Doença. O que diz a investigação? Revista Portuguesa Clinica Geral 2007;23 299-306.
  83. 83. Seidl EF, Zannon CC, Tróccoli BT. Pessoas Vivendo com HIV/AIDS: Enfrentamento, Suporte Social e Qualidade de Vida. Psicologia: Reflexão e Crítica 2005;18(2) 188-195.
  84. 84. Castro R, Campero L, Hernández B. La investigación sobre apoyo social en salud: situación actual y nuevos desafíos. Revista de Saúde Pública 1997;31(4) 425-435.
  85. 85. Baptista AD, Neves SV, Baptista MN. Correlação entre suporte familiar, saúde mental e crenças irracionais em idosos religiosos. PSIC - Revista de Psicologia da Vetor Editora 2008;9(2) 155-164.
  86. 86. Baptista MN, Norona APP, Cardoso HF. Relações entre suporte familiar e interesses profissionais. Revista Salud & Sociedad 2010;1(1) 28-40.
  87. 87. Procidano ME, Heller K. Measures of perceived social support from friends and from family: Three validation studies American Journal of Community Psychology 1983;11(1) 1-24.
  88. 88. Pinkerton J, Dolan P. Family support, social capital, resilience and adolescent coping. Child & Family Social Work 2007;12(3) 219-228.
  89. 89. Weinstein SM, Mermelstein RJ, Hedeker D, Hankin BL, Flay BR. The Time-Varying Influences of Peer and Family Support on Adolescent Daily Positive and Negative Affect. Journal of Clinical Child & Adolescent Psychology 2006;35(3) 420-430.
  90. 90. Zanetti ML, Biagg MV, Santos MA, Péres DS, Teixeira CS. O cuidado à pessoa diabética e as repercussões na família. Journal of Clinical Child & Adolescent Psychology 2006;35(3) 420-430.
  91. 91. Kirk RH. Family support: the roles of early years' centers. Children & Society 2003;17(2) 85-99.
  92. 92. Souza MS, Baptista MN. Associações entre Suporte Familiar e Saúde Mental. Psicologia Argumento 2008;26(54) 207-215.
  93. 93. Baptista MN. Inventário de Percepção de Suporte Familiar (IPSF): Estudo Componencial em duas Configurações. Psicologia Ciência e Profissão 2007;27(3) 496-509.
  94. 94. Siqueira AC, Betts MK, Dell’Aglio DD. A Rede de Apoio Social e Afetivo de Adolescentes Institucionalizados no Sul do Brasil. Revista Interamericana de Psicología 2006;40(2) 149-158.
  95. 95. Silver EJ, Westbrook LE, Stein RK. Relationship of Parental Psychological Distress to Consequences of Chronic Health Conditions in Children. Journal of Pediatric Psychology 1998;23(1) 5-15.
  96. 96. Castro EK, Piccinini CA. Implicações da Doença Orgânica Crônica na Infância para as Relações Familiares: Algumas Questões Teóricas. Psicologia: Reflexão e Crítica 2002;15(3) 625-635.
  97. 97. Fisher L, Chesla CA, Skaff MM, Gilliss C, Mullan JT, Bartz RJ, et al. The Family and Disease Management in Hispanic and European-American Patients With Type 2 Diabetes. Diabetes Care 2000;23(3) 267-272.
  98. 98. Pace A, Nunes P, Ochoa-Vigo K. O Conhecimento dos Familares acerca da Problemática do Portador de Diabetes Mellitus. Revista Latino-Americana de Enfermagem 2003;11(3) 312-319.
  99. 99. Santos MA, Alves RP, Oliveira VA, Ribas CP, Teixeira CS, Zanetti ML. Representações sociais de pessoas com diabetes acerca do apoio familiar percebido em relação ao tratamento. Revista da Escola de Enfermagem USP 2011;45(3) 651-658.
  100. 100. Beveridge RM, Berg CA, Wiebe DJ, Palmer DL. Mother and Adolescent Representations of Illness Ownership and Stressful Events Surrounding Diabetes. Journal of Pediatric Psychology 2006;31(8) 818-827.
  101. 101. Lewin AB, Heidgerken AD, Geffken GR, Williams LB, Storch EA, Gelfand KM, et al. The Relation Between Family Factors and Metabolic Control: The Role of Diabetes Adherence. Journal of Pediatric Psychology 2006;31(2) 174-183.
  102. 102. La Greca AM, Thompson KM. Family and friend support for adolescents with diabetes. Análise Psicológica 1998;1(16) 101-113.
  103. 103. Stern M, Zevon MA. Stress, Coping, and Family Environment: The Adolescent's Response to Naturally Occurring Stressors. Journal of Pediatric Psychology 1990;5(3) 290-305.
  104. 104. Harris MA, Mertlich D, Rothweiler J. Parenting Children With Diabetes. Diabetes Spectrum 2001;14(4) 182-184.
  105. 105. Maia F, Araújo LR. Aspectos Psicológicos e Controle Glicêmico de Um Grupo de Pacientes Com Diabetes Mellitus Tipo 1 em Minas Gerais. Arquivos Brasileiros Endocrinologia & Metabologia 2004;48(2) 261-266.
  106. 106. Skinner TC, John M, Hampson SE. Social Support and Personal Models of Diabetes as Predictors of Self-care and Well-Being: a Longitudinal Study of Adolescents with Diabetes. Journal of Pediatric Psychology 2000;25(4) 257-267.
  107. 107. Pereira M, Almeida A, Rocha L, Leandro E. Predictors of Adherence, Metabolic Control and Quality of Life in Adolescents with Type 1 Diabetes. In: Liu C-P, (ed.) Type 1 Diabetes – Complications, Pathogenesis, and Alternative Treatments. Rijeka: InTech; 2011. p119-140.
  108. 108. Pereira MG, Almeida A, Leandro E. Papel do Apoio Escolar e Suporte Familiar em Crianças com Diabetes Tipo 1. In: Psicosoma. (ed.) VII Congresso Internacional de Neurociências e Educação Especial 19-20 May 2012; Viseu, Portugal.
  109. 109. Mellin AE, Neumark-Sztainer D, Patterson JM. Parenting Adolescent Girls with Type 1 Diabetes: Parents’ Perspectives. Journal of Pediatric Psychology 2004;29(3) 221-230.
  110. 110. Weinger K, O'Donnell KA, Ritholz MD. Adolescent Views of Diabetes-Related Parent Conflict and Support: A Focus Group Analysis. Journal of Adolescent Health 2001;29(5) 330-336.
  111. 111. Heleno MV, Vizzotto MM, Mazzotti T, Cressoni-Gomes R, Modesto SF. Acampamento de Férias para Jovens com Diabetes Mellitus tipo 1: Achados da Abrodagem Psicológica. Boletim de Psicologia 2009;59(130) 77-90.
  112. 112. Piccinini CA, Castro EK, Alvarenga P, Vargas S, Oliveira VZ. A doença crônica orgânica na infância e as práticas educativas maternas. Estudos de Psicologia 2003;8(1) 75-83.
  113. 113. Folkman S, Lazarus RS. If It Changes It Must Be a Process: Study of Emotion and Coping During Three Stages of a College Examination. Journal of Personality and Social Psychology 1985;48(1) 150-170.
  114. 114. Pais-Ribeiro J, Santos C. Estudo conservador de adaptação do Ways of Coping Questionnaire a uma amostra e contexto portugueses. Análise Psicológica 2001;4(19) 491-502.
  115. 115. Folkman S, Lazarus RS. Coping as a Mediator of Emotion. Journal of Personality and Social Psychology 1988;54(3) 466-475.
  116. 116. Pais Ribeiro JL, Rodrigues AP. Questões àcerca do coping: a propósito do estudo de adaptação do Brief COPE. Psicologia, Saúde & Doenças 2004;5(1) 3-15.
  117. 117. Vivan S, Argimon IL. Estratégias de enfrentamento, dificuldades funcionais e fatores associados em idosos institucionalizados. Cadernos de Saúde Pública 2009;25(2) 436-444.
  118. 118. Correia AR. Coping e Auto-eficácia em Pais de Crianças e Adolescentes com Diabetes tipo 1. Master Thesis. University Fernando Pessoa; 2010.
  119. 119. Tuncay T, Musabak I, Gok DE, Kutlu M. The relationship between anxiety, coping strategies and characteristics of patients with diabetes. Health and Quality of Life Outcomes 2008;6(79) 9. diabwte:10.1186/1477-7525-6-79.
  120. 120. Sousa MG, Landeiro ML, Pires R, Santos C. Coping e adesão ao regime terapêutico. Revista de Enfermagem Referência 2011;3 (4) 151-160.
  121. 121. Lisboa C, Koller SH, Ribas FF, Bitencourt K, Oliveira L, Porciuncula LP, et al. Estratégias de Coping de Crianças Vítimas e Não Vítimas de Violência Doméstica. Psicologia: Reflexão e Crítica 2002;15(2) 345-362.
  122. 122. Folkman S. Personal Control and Stress and Coping Processes: A Theoretical Analysis. Journal of Personality and Social Psychology 1984;46(4) 839-852.
  123. 123. Vaz Serra A. A vulnerabilidade ao stress. Psiquiatria Clínica 2000;21(4) 261-278.
  124. 124. Barros DS. Estratégias de Coping em Crianças Vítimas de Abuso Sexual. Master Thesis. University Fernado Pessoa; 2009.
  125. 125. Nascimento CM, Nunes S. O Conceito de Enfrentamento e a sua Relevância na Prática da Psiconcologia. Encontro: Revista de Psicologia 2010;13(19) 91-102
  126. 126. Antoniazzi AS, Dell’Aglio DD, Bandeira DR. O conceito de coping: uma revisão teórica. Estudos de Psicologia 1998;3(2) 273-294.
  127. 127. Monteiro M, Matos AP, Coelho R. A adaptação psicológica de mães cujos filhos apresentam Paralisia Cerebral: Revisão da literatura. Revista Portugesa de Psicossomática 2002;4(2) 149-178.
  128. 128. Amorim ML. Para lá dos números… Aspectos psicossociais e qualidade de vida do indivíduo com diabetes mellitus tipo 2. PhD Thesis. Institute of Biomedical Sciences Abel Salazar, University of Oporto; 2009.
  129. 129. Coletto M, Câmara S. Estratégias de coping e percepção da doença em pais de crianças com doença crônica: o contexto do cuidador. Revista Diversitas - Perspectivas en Psicología 2009;5(1) 97-110.
  130. 130. Macrodimitris SD, Endlen NS. Coping, Control, and Adjustment in Type 2 Diabetes. Health Psychology 2001;20(3) 208-216.
  131. 131. Kovacs M, Finkelstein R, Feinberg TL, Crouse-Novak M, Paulauskas S, PollockM. Initial Psychologic Responses of Parents to the Diagnosis of Insulin-dependent Diabetes Mellitus in Their Children. Diabetes Care 1985;8(6) 568-575.
  132. 132. Manuel J. Risk and Resistance Factors in the Adaptation in Mothers of Children with Juvenile Rheumatoid Arthristis. Journal of Pediatric Psychology 2001;26(4) 237-246.
  133. 133. Souza IB, Marques DA, Lacerda OM, Collet N. Percepção das Mães Frente ao Diagnóstico do Filho com Diabetes Mellitus tipo 1. Cogitare Enfermagem 2011;16(1) 43-48.
  134. 134. Zanetti ML, Mendes IC. Análise das Dificuldades Relacionadas às Atividades Diárias de Crianças e Adolescente com Diabetes Mellitus tipo 1: Depoimento de Mães Revista Latino-Americana de Enfermagem 2001;9(6) 25-30.
  135. 135. Nunes, Dupas. Entregando-se à vivência da doença com o filho: a experiência da mãe da criança/adolescente diabético. Texto & Contexto Enfermagem 2004;13(1) 83-91.
  136. 136. Brito TB, Sadala MA. Diabetes mellitus juvenil: a experiência de familiares de adolescentes e pré-adolescentes. Ciência & Saúde Coletiva 2009;14(3) 947-960.
  137. 137. Lehmkuhl H, Nabors L. Children with Diabetes: Satisfaction with School Support, Illness Perceptions and HbA1C Levels. Journal of Developmental and Physical Disabilities 2008;20 101-114.
  138. 138. Wang Y-L, Brown SA, Horner SD. School-Based Lived Experiences of Adolescents With Type 1 Diabetes: A Preliminary Study. Journal of Nursing Research 2010;18(4) 258-265.
  139. 139. Santana EA, Silva SS. Educação Física escolar para alunos com diabetes mellitus tipo 1. Motriz Revista de Educação Física UNESP 2009;15 (3) 669-676.
  140. 140. Jameson PL. Developing Diabetes Training Programs for School Personnel. School Nurse News 2004;21(4) 14-17.
  141. 141. Amillategui B, Mora E, Calle JR, Giralt P. Special needs of children with type 1 diabetes at primary school: perceptions from parents, children, and teachers. Pediatric Diabetes. 2009;10(1): 67-73.
  142. 142. Hayes-Bohn R, Neumark-Sztainer D, Mellin AE, Patterson JM. Adolescents and Parent Assessments of Diabetes Mellitus Management at School. Journal of School Health 2004;74(5) 166-169.
  143. 143. Wilson V, Beskine D. Children and young people with type 1 diabetes: Managing at school. Journal of Diabetes Nursing 2007;11(10) 392-398.
  144. 144. Nascimento LC, Amaral MJ, Sparapani VC, Mara L, Fonseca M, Nunes MR, et al. Diabetes mellitus tipo 1: evidências da literatura para seu manejo adequado, na perspectiva de crianças. Revista da Escola de Enfermagem USP 2011;45(3) 764-769.
  145. 145. Olson AL, Seidler AB, Goodman D, Gaelic S, Nordgren R. School Professionals’ Perceptions About the Impact of Chronic Illness in the Classroom. Archives of Pediatrics & Adolescent Medicine 2004;158(1) 53-58.
  146. 146. Nabors L, Troillett A, Nash T, Masiulis B. School Nurse Perceptions of Barriers and Supports for Children With Diabetes. Journal of School Health 2005;75(4) 119-124.
  147. 147. Wagner JA, Abbott G, Lett S. Age related differences in individual quality of life domains in youth with type 1 diabetes. Health and Quality of Life Outcomes 2004;2(54): 9 doi:10.1186/1477-7525-2-54.
  148. 148. Nabors L, Lehmkuhl H, Christos N, Andreone T. Children with Diabetes: Perceptions of Support for Self-Management at School. Journal of School Healt. 2003;73(6) 216-221.
  149. 149. Brener ND, Wheeler L, Wolfe LC, Vernon-Smiley M, Caldart-Olson L. Health Services: Results From the School Health Policies and Programs Study 2006. Journal of School Health 2007;77(8) 464-485.
  150. 150. La Greca A, Auslander WF, Greco P, Spetter D, Fisher EB Jr, Santiago JV. I Get by with a little help from my Family and Friends: Adolescents' Support for Diabetes Care. Journal of Pediatric Psychology 1995;20(4) 449-476.
  151. 151. Greco P, Pendley JS, McDonell K, Reeves G. A Peer Group Intervention for Adolescents With Type 1 Diabetes and Their Best Friends. Journal of Pediatric Psychology 2001;26(8) 485-490.
  152. 152. Bearman KJ, La Greca A. Assessing Friend Support of Adolescents' Diabetes Care: The Diabetes Social Support Questionnaire-Friends Version. Journal of Pediatric Psychology 2002;27(5) 417-428.
  153. 153. Wysocki T, Greco P. Social Support and Diabetes Management in Childhood and Adolescence: Influence of Parents and Friends. Current Diabetes Reports 2006;6 117-122.
  154. 154. Karlsson A, Arman M, Wikblad K. Teenagers with type 1 diabetes—a phenomenological study of the transition towards autonomy in self-management. International Journal of Nursing Studies 2008;45(4) 562-570.
  155. 155. Ferreira BS, Garcia A. Aspectos da amizade de adolescentes portadores de diabetes e câncer. Estudos de Psicologia 2008;25(2) 293-301.
  156. 156. Helgeson VS, Siminerio L, Escobar O, Becker D. Predictors of Metabolic Control among Adolescents with Diabetes: A 4-Year Longitudinal Study. Journal of Pediatric Psychology 2009;34(3) 254-270.
  157. 157. Frey MA, Guthrie B, Loveland-Cherry C, Park PS, Foster CM. Risky Behavior and Risk in Adolescents with IDDM. Journal of Adolescent Health 1997;20(1) 38-45.
  158. 158. Silverstein JH, Klingensmith G, Copeland K, Plotnick L, Kaufman F, Laffel L, et al. Care of Children and Adolescents With Type 1 Diabetes. A statement of the American Diabetes Association. Diabetes Care 2005;28(1) 186-212.
  159. 159. Thomas AM, Peterson L, Goldstein D. Problem Solving and Diabetes Regimen Adherence by Children and Adolescents with IDDM in Social Pressure Situations: A Reflection of Normal Development. Journal of Pediatric Psychology 1997;22(4) 541-561.
  160. 160. Hains AA, Berlin KS, Davies WH, Smothers MK, Sato AF, Alemzadeh R. Attributions of Adolescents with Type 1 Diabetes Related to Performing Diabetes Care around Friends and Peers: The Moderating Role of Friend Support. Journal of Pediatric Psychology 2007;32(5) 561-570.
  161. 161. Davidson M, Penney ED, Muller B, Grey M. Stressors and Self-Care Challenges Faced by Adolescents Living With Type 1 Diabetes. Applied Nursing Research 2004;17(2) 72-80.
  162. 162. Michaud P-A, Suris J-C, Thomas LR, Kahlert C, Rudin C, Cheseaux J-J. To Say or Not to Say: A Qualitative Study on the Disclosure of Their Condition by Human Immunodeficiency Virus–Positive Adolescents. Journal of Adolescent Health 2009;44(4) 356-362.
  163. 163. Burke H, Dowling M. Living with diabetes: Adolescents’ perspectives. Journal of Diabetes Nursing 2007;11(3) 90-96.
  164. 164. Berlin KS, Davies WH, Jastrowski KE, Hains AA, Parton EA, Alemzadeh R. Contextual Assessment of Problematic Situations Identified by Insulin Pump Using Adolescents and Their Parents. Families, Systems, & Health 2006;24(1) 33-44.
  165. 165. Di Battista AM, Hart TA, Greco L, Gloizer J. Type 1 diabetes among adolescents: reduced diabetes self-care caused by social fear and fear of hypoglycemia. Diabetes Educator 2009;35(3) 465-475.
  166. 166. Sparapani VC, Borges AV, Dantas IO, Pan R, Nascimento LC. A criança com Diabetes Mellitus Tipo 1 e seus amigos: a influência dessa interação no manejo da doença. Revista Latino-Americana de Enfermagem 2012;20(1) 117-125.

Written By

A. Cristina Almeida, M. Graça Pereira and Engrácia Leandro

Submitted: 03 May 2012 Published: 27 February 2013