Disentangling the roles of parental monitoring and family conflict in adolescents' management of type 1 diabetes.

Type 1 diabetes is a chronic condition that impacts two of every 1000 youth in the United States (Liese et al., 2006). The complex, demanding regimen for diabetes self-care requires frequent blood glucose (BG) monitoring and management of insulin, nutritional intake, and physical activity (Silverstein et al., 2005). Common declines in adolescents’ self-care and disease control (Helgeson, Siminerio, Escobar, & Becker, 2009; Luyckx, Seiffge-Krenke, & Hampson, 2010) elevate the risk for complications, lead to greater healthcare utilization, and result in higher medical costs (Menzin, Langley-Hawthorne, Friedman, Boulanger, & Cavanaugh, 2001; Wagner et al., 2001). Ideally, youth with diabetes and their parents complete diabetes management jointly (Anderson, 2004; Silverstein et al., 2005), and family interactions related to diabetes can impact youths’ diabetes self-care and glycemic outcomes (Anderson, Ho, Brackett, Finkelstein, & Laffel, 1997). Parental involvement in diabetes management can take the form of parental responsibility, in which parents complete particular tasks for youth, or of parental monitoring, in which parents supervise youths’ independent completion of self-care tasks. Both forms of involvement are associated with better glycemic control via their beneficial impact on adolescents’ self-care (Anderson et al., 1997; Ellis et al., 2007). In early adolescence, increasing autonomy is typical (Beyers, Goossens, Vansant, & Moors, 2003) and parents’ expectations for teens’ diabetes self-care tend to increase while their direct participation in diabetes management often decreases (Palmer et al., 2004; Wysocki et al., 1996). During this period, parental involvement may begin to transition from responsibility to monitoring. The shift in disease management responsibility from parents to youth is one factor associated with the common deterioration in diabetes outcomes in adolescence (Holmes et al., 2006; Grey, Boland, Yu, Sullivan-Bolyai, & Tamborlane, 1998; Palmer et al., 2004), although greater parental monitoring appears to minimize this risk (Ellis et al., 2007). Conflict between teens and their parents about diabetes is another factor associated with worsening diabetes outcomes in adolescence. Diabetes-related conflict is of significant concern given that even minimally elevated conflict can negatively impact glycemic control (Hood, Anderson, Butler, & Laffel, 2007), in part by detracting from diabetes self-care (Hilliard, Guilfoyle, Dolan, & Hood, 2011). For example, some adolescents who are distressed, angry, or frustrated about family conflict may be less inclined or less able to complete diabetes tasks. Others might limit their completion of diabetes self-care tasks to avoid arguments (e.g., related to BG values). While previous studies have identified family conflict and lower parental monitoring as independent risk factors for suboptimal self-care and ultimately poorer glycemic outcomes (Ellis et al., 2007; Hilliard et al., 2011), it remains unclear how these two important family characteristics are related to one another in the context of diabetes management and glycemic control. There are likely reciprocal relations between them, such that the amount and nature of parental monitoring may impact family conflict, and family conflict may impact how much and in what ways parents are involved in adolescents’ daily diabetes self-care. Greater parental responsibility for and monitoring of diabetes self-care often are encouraged to improve adolescents’ diabetes management and glycemic outcomes (Anderson et al., 1997; Ellis et al., 2007). Yet, clinically it is apparent that some aspects of parent involvement in adolescents’ diabetes self-care, including parental monitoring, may inadvertently foster conflict. For example, frequent reminders or questions about diabetes self-care might irritate teens and lead to or exacerbate conflict. Among youth without diabetes, those with more family conflict want less parental supervision (Laird, Pettit, Dodge, & Bates, 2003) and this preference likely is mirrored in teens with diabetes, who often want less frequent or less intrusive parental involvement in their diabetes self-care (Hanna & Guthrie, 2001; Weinger, O’Donnell, & Ritholz, 2001). Conflict also may detract from diabetes management and glycemic control through its impact on the amount and ways that parents participate in their adolescents’ self-care (Weinger et al., 2001). For example, in order to avoid conflict some parents might decrease their monitoring or oversight of diabetes management (Palmer et al., 2004). Parents who argue frequently with their teens about diabetes may refrain from asking questions or be hesitant to offer assistance with diabetes tasks. Other parents may increase or become more persistent in their monitoring to ensure their teens follow directions. Additionally, adolescents themselves may avoid discussions about diabetes with their parents as a means to avoid conflict. Any of these scenarios could detract from self-care and negatively impact glycemic control. Given the developmentally normative changes in parent-youth relationships at the entry to adolescence and their potential impact on diabetes self-care and glycemic control, a better understanding of how family conflict and parental monitoring relate to each other and to diabetes self-care and glycemic outcomes is valuable. Thus, this paper aims to examine the associations among family conflict, parental monitoring, diabetes self-care, and glycemic control. More family conflict and less parental monitoring were hypothesized to be correlated and to each have a direct association with poorer glycemic control. Given previous evidence of self-care as a mediator of the separate relations of parental monitoring (Ellis et al., 2007) and family conflict (Hilliard et al., 2011) with glycemic control, poorer self-care was hypothesized to mediate these associations. Confirmation of this model would indicate that interventions to improve adolescents’ glycemic control should address multiple aspects of the parent-adolescent relationship related to diabetes and directly address teens’ diabetes self-care behaviors.