Impulse Control, Diabetes-Specific Self-Efficacy, and Diabetes Management Among Emerging Adults With Type 1 Diabetes

The developmental period of emerging adulthood is considered a critical time for those with type 1 diabetes (Peters & Lafell, 2011; Weissberg-Benchell, Wolpert, & Anderson, 2007), and this period is known for poor diabetes outcomes (Wysocki, Hough, Ward, & Green, 1992). Emerging adulthood is marked by increasing freedom (Arnett, 2000) and by numerous transitional events such as leaving the parental home or attending college (Arnett, 2000; Furstenberg, Rumbaut, & Settersten, 2005). This transitional period is proposed to be challenging relative to potential indicators of success or difficulties reflected in diabetes outcomes (Hanna, 2011). Indeed, the diabetes outcome of glycemic control declines during this period (Bryden et al., 2001; Insabella, Grey, Knafl, & Tamborlane, 2007) and is linked to diabetes management (Hood, Peterson, Rohan, & Drotar, 2009). Studies have confirmed that diabetes management is important to target when trying to maintain glycemic control during challenging transitions known to disrupt diabetes care routines (Balfe, 2009; Ramchandani et al., 2000). Diabetes management is proposed to be associated with impulse control in the emerging adulthood framework guiding this study (Hanna, 2011). Impulse control is the ability to delay gratification to achieve goals (Casey, Getz, & Galvan, 2008), the inhibitory control element of executive functioning (Garner, 2009), and particularly important developmentally during emerging adulthood (Steinberg, 2008). This developmental cognitive process is associated with biological changes in the prefrontal cortex, which is immature into the mid to late 20 s (Casey et al., 2008). Developmental changes occur in the balance between impulsivity and impulse control during the transition from adolescence into young adulthood (Steinberg, 2007). Impulsivity, the tendency to put greater emphasis on rewards related to immediate outcomes, occurs due to motivated reward-seeking in the absence of impulse control, the ability to value a delayed, potentially larger reward (Monterosso & Ainslie, 1999; Solnick, Kannenberg, Eckerman, & Waller, 1980). Impulsivity implies heightened reactivity to proximal cues, which may compete with behaviors relative to outcomes that may seem equivocal and distal (Steinberg, 2007; Steinberg et al., 2008). For example, in the case of diabetes management, an emerging adult enrolled in college might be distracted by proximal cues related to a social event and forget about checking his or her blood glucose level, which is needed for the distal outcome of glycemic control. Support for the importance of this developmental process to health behaviors is documented in the general youth literature indicating that less self-control is associated with behaviors that risk one’s health (Patock-Peckham, Cheong, Balhorn, & Nagoshi, 2001; Piquero, Gibson, & Tibbetts, 2002; Steinberg, 2008; Tangney, Baumeister, Boone, 2004). Further, executive functioning has been reported to be associated with diabetes management among youth with type 1 diabetes (McNally, Rohan, Pendley, Delemater, & Droter, 2010; Graziano et al., 2011), supporting the importance of cognitive functioning for youth with diabetes. However, impulse control has garnered less attention for its relationship with diabetes management. Diabetes management is also proposed to be associated with diabetes-specific self-efficacy in this emerging adulthood framework (Hanna, 2011). Self-efficacy is one’s perceived confidence in one’s abilities to perform specific behaviors (Bandura, 1997), in this case, diabetes management. This individual characteristic is assumed to be especially salient for these autonomous youth (Hanna, 2011) who have great freedom (Arnett, 2000) and primary responsibility for diabetes care (Hanna et al., 2011). Indeed, diabetes self-efficacy is well-known to be associated with diabetes management among youth with diabetes (Berg et al., 2011; Helgeson, Honcharuk, Becker, Escobar, & Siminerio, 2011; Iannotti et al., 2006; Johnston-Brooks, Lewis, & Garg, 2002; Ott, Greening, Palardy, Holderby, & DeBell, 2000; Stewart et al., 2003). In addition, diabetes self-efficacy is considered an important variable to target in interventions to improve management (Iannotti et al., 2006) and may be particularly important for youth in this developmental period. Impulse control, a neurocognitive developmental process (Steinberg et al., 2008), may be a challenging factor on which to intervene; however, diabetes management may be amenable to interventions through self-efficacy, a learned behavior (Bandura, 1977). From a social cognitive perspective, diabetes-specific self-efficacy may represent a mechanism to “balance” the demands of diabetes management and the enhanced sensation-seeking and impulsivity associated with the transition from adolescence to adulthood. For example, when emerging adults with lower impulse control are introduced to a new situation with novel proximal cues, they may be especially challenged in their diabetes management. This, in turn, may lead them to develop poor diabetes-specific self-efficacy and negatively impact their diabetes management. On the other hand, youth with high self-control may have had greater success in managing diabetes in the past and developed greater confidence in their skills, which serve them well in managing diabetes in novel (for them) social situations such as a fraternity party. This suggests a model in which diabetes-related self-efficacy mediates the relationship between impulse control and diabetes management. Although no studies have been conducted looking specifically at relationships among impulse control, diabetes-specific self-efficacy, and diabetes management behavior, there is evidence suggesting such an inter-relationship in other youth behaviors. For example, self-efficacy has been found to fully mediate the relationship between impulsivity and marijuana use among youth, with higher levels of self-efficacy reducing the association of impulsivity to marijuana use (Hayaki et al., 2011). Because there is little research in the diabetes area on the relationships among developmental cognitive processes, specifically impulse control, diabetes self-efficacy, and diabetes management, this is an exploratory study. The purposes of this study were to (a) examine the relationship between impulse control and diabetes management and (b) test diabetes-specific self-efficacy as a mediator of this relationship. A better understanding of these relationships may inform diabetes management interventions around diabetes-specific self-efficacy and impulse control, salient for youth during this developmental period.