From Caregiver Psychological Distress to Adolescent Glycemic Control: The Mediating Role of Perceived Burden around Diabetes Management

Type 1 diabetes is a common chronic disease, affecting one in 500 youth (SEARCH for Diabetes in Youth Study Group, 2006; The National Institute of Diabetes and Digestive and Kidney Diseases, 2005) with approximately 15,000 new diagnoses annually in the United States (Dabelea et al., 2007). Treatment of type 1 diabetes includes insulin administration, blood glucose monitoring (BGM), and close attention to dietary intake and physical activity. Although significant advancements in treatment approaches and technologies have been made (Tamborlane et al., 2008), adolescents with type 1 diabetes continue to exhibit suboptimal glycemic control (Danne et al., 2001; Springer et al., 2006). A number of individual (e.g., growth, psychological functioning) and family factors contribute to suboptimal control (Amiel, Sherwin, Simonson, Lauritano, & Tamborlane, 1986; Moreland et al., 2004). However, few investigations have examined the role of caregiver psychological factors in relation to adolescent glycemic control (Anderson, Ho, Brackett, Finkelstein, & Laffel, 1997; La Greca et al., 1995). A wealth of empirical evidence in the literature has linked caregiver psychological factors to poor child outcomes. The child outcomes cut across academic, behavioral, and emotional domains (Cicchetti, Rogosch, & Toth, 1998; Cytryn et al., 1984; Hay, Pawlby, Angold, Harold, & Sharp, 2003; Lyons-Ruth, Connell, Grunebaum, & Botein, 1990; Orvaschel, Weissman, & Kidd, 1980; Radke-Yarrow, Zahn-Waxler, Richardson, Susman, & Martinez, 1994; Silverstein, Augustyn, Cabral, & Zuckerman, 2006; Walker et al., 2007). For example, Larson and colleagues (2008) found that multiple social risks, including “low maternal mental health,” predicted poor child health in the 2003 National Survey of Children’s Health. In addition, caregiver depressive symptoms have been linked with negative health outcomes in adolescents. In a large sample of inner-city adolescents with asthma, there was a twofold increase in child hospitalization in the presence of caregiver depressive symptoms (Weil et al., 1999). Furthermore, while not specifically examining health outcomes in a younger age group with type 1 diabetes, maternal depressive symptoms were related negatively to child quality of life and other indicators of family functioning (Jaser, Whittemore, Ambrosino, Lindemann, & Grey, 2008). Additionally, Cameron, Young, and Weibe (2007) found that elevated levels of caregiver anxiety symptoms were related to suboptimal glycemic control in adolescents with type 1 diabetes. Specifically, maternal trait anxiety was associated with higher A1c levels and greater absenteeism from school and social activities due to diabetes during the subsequent 3 months in younger adolescents. Considered together, both maternal anxiety and depressive symptoms were shown to be associated with negative child health outcomes, although data have been limited in adolescents with type 1 diabetes. Caregivers play critical roles in managing type 1 diabetes in their adolescents, setting up the potential for caregiver psychological status to affect diabetes-specific health outcomes (Anderson et al., 2009; Berg et al., 2008). For example, a caregiver with depressive symptoms may feel overwhelmed and be uninvolved in critical parts of management. Alternatively, a caregiver experiencing anxiety symptoms may be overly attentive (i.e., hypervigilant) to diabetes care and may engage in constant monitoring. These experiences can be captured as perceived burden specific to diabetes management (Butler et al., 2008; Polonsky et al., 1995). Increases in perceived diabetes-specific burden may subsequently transfer to the adolescent and result in poor health outcomes (i.e., suboptimal glycemic control). For example, a caregiver who had negative feelings about adolescents’ BGM was more likely to have higher levels of perceived diabetes-specific burden (Butler et al., 2008). Interestingly, this investigation also found that perceived burden specific to diabetes management, rather than general caregiver negative affect, was directly related to glycemic control, when controlling for other sociodemographic and diabetes-specific variables. Thus, Butler and colleagues (2008) highlight that a caregiver variable, perceived diabetes-specific burden, is linked to an adolescent’s diabetes-specific health outcome. Also, there is literature linking perceived caregiver burden to caregiver distress in youth with medical conditions, including type 1 diabetes (Canning, Harris, & Kelleher, 1996). The purpose of the current study was to examine the role of diabetes-specific burden perceived by caregivers as a mediating variable between measures of caregiver psychological distress and adolescents’ glycemic control. Testing this mediation model in a longitudinal dataset provides an opportunity to more strongly infer predictive relationships in contrast to a cross-sectional design where measures are collected concurrently. Specifically, we hypothesized that higher levels of general caregiver distress (e.g., anxiety or depressive symptoms) would lead to higher levels of perceived diabetes-specific burden around diabetes management, which would ultimately lead to suboptimal glycemic control.