Examining the interaction of parental involvement and parenting style in predicting adherence in youth with type 1 diabetes.

Youth with type 1 diabetes (T1D) face the daunting task of managing a complex medical regimen on a daily basis. A key factor in adhering to this regimen is parental involvement, a term used to capture behaviors such as physically assisting children with disease management tasks, supervising, and showing support. The prevailing notion amongst researchers is that children and adolescents benefit physically and emotionally from this involvement. In the T1D literature, numerous aspects of parental involvement, including performing blood glucose checks and administering insulin (Anderson, Ho, Brackett, Finkelstein & Laffel, 1997), monitoring illness-related tasks (Berg et al., 2008; Ellis et al., 2007; Palmer et al., 2011), and sharing responsibility for diabetes care (Ingerski et al., 2010; Vesco et al., 2010) have been associated with improved adherence in adolescents, while sharing responsibility has also been associated with improved adherence in studies including both children and adolescents (Anderson et al., 2002). Prior research has demonstrated that parents are most involved when children are young, and that during the transition through adolescence, parental involvement (e.g., behavioral involvement; monitoring) declines while adherence worsens (King et al., 2014; Wu et al., 2014). Despite the evidence presented, there are a myriad of findings that challenge the seemingly direct relationship between parental involvement and treatment adherence. One study that sampled young adolescents ages 10–14 years reported that greater parent responsibility for diabetes management was associated with worse adherence (Helgeson, Reynolds, Siminerio, Escobar, & Becker, 2008). Another study examined a slightly younger age group (ages 9–12 years) and found no significant relationship between paternal involvement, defined as assistance with T1D-related tasks, and blood glucose monitoring frequency (Hilliard et al., 2011). Wiebe et al. (2005) found no relationship between maternal responsibility for T1D-related tasks and adherence in a sample of youth ages 10–15 years. In a sample of young adolescents, Berg et al. (2011) found no association between parental frequency of help and adherence but significant positive associations between diabetes-related monitoring and adherence. When considering possible explanations for these mixed findings, researchers have pointed to several factors. Wiebe et al. (2014) suggest that the decline in parental involvement during adolescence may not necessarily predict a decline in adherence, though they often occur around the same time. The authors assert that the transfer of responsibility from parents to children can be problematic if it occurs before children are ready and that studies have not thoroughly explored when, how, and under what conditions that transfer should take place. A second insight comes from Palmer et al. (2011), who acknowledge the varied ways in which parental involvement has been measured. While some researchers operationalize involvement using singular constructs such as responsibility or monitoring, others use composite variables that capture numerous facets of involvement. Thus, the constructs being measured and the instruments measuring them differ from one study to the next, making it difficult to determine which aspects of involvement are related to adherence. Although each of the factors described above may contribute to the mixed findings, it is also likely that the relationship between parental involvement and adherence is dependent upon parenting style. Skinner, Johnson, and Snyder (2005) posit that parenting styles are made up of a combination of the six core dimensions of warmth, rejection, structure, chaos, autonomy support, and coercion. While a parent’s degree of involvement may vary from one situation to the next, parenting style tends to be consistent across domains and dictate the overarching tone of parent-child encounters (Darling & Steinberg, 1993). Thus, parenting style may positively or negatively affect the relationship between a parent’s involvement and the child’s illness management. Warm and accepting parenting has been correlated with more positive outcomes in children with T1D (Butler, Skinner, Gelfand, Berg, & Wiebe, 2007; Davis et al., 2001; Wiebe et al., 2005), while the use of coercive strategies, such as restrictive or punitive disciplinary measures to assert control over children’s actions, has been identified as having a negative effect on health and well-being (Duke et al., 2008; Patton, Dolan, & Powers, 2006). Because coercive parenting can be so detrimental, it stands to reason that a coercive parent who is heavily involved in his or her child’s illness management might have more of a negative effect on the child than one who is largely hands-off. Therefore, it is possible that children with equally involved parents might have different illness management experiences based on specific factors related to parenting style. The findings outlined above highlight the need for parents to stay involved in children’s illness management in a supportive, developmentally-appropriate way that respects the child’s increasing need for autonomy while ensuring the effective management of serious medical conditions. Information about the interaction between parental involvement and parenting style in predicting adherence may shed light on how best to approach this complex task. Anderson (2011) explicitly suggests considering parenting style as a moderator of the relationship between involvement and adherence, but to our knowledge, this interaction has not been tested. Young et al. (2014) provide a comprehensive review of the studies that have addressed the significance of both the quantity (e.g. degree of involvement) and quality (e.g. style) of parental participation in diabetes management, but the majority of these studies drew insights based on main effects rather than interactions between variables. Of the handful of studies that have addressed the possibility of an interaction between involvement and style, some have conflated the two variables (Ellis et al., 2007; Palmer et al., 2011; Wiebe et al., 2005), which makes it impossible to determine which factors are driving the interaction. Other studies have assessed aspects of both parenting style and parental involvement but did not examine the interaction between them (King et al., 2014; Wu et al., 2014). Although each of these studies provides support for the hypothesis that the context in which parental involvement occurs is important for effective illness management, none focus specifically on parsing out involvement from style and studying the interactions between them in predicting adherence. Since children’s health and well-being can be heavily influenced by parents, it is essential to tease out these factors and explore their effect on adherence to identify the optimal form of parental involvement in diabetes management. For the present study, we examined both main effects of parental involvement and aspects of parenting style on adherence, as well as the interaction of involvement and parenting style, in 8–16 year olds with T1D. We conceptualized parental involvement as the degree of responsibility for illness-related tasks, which is cited as a commonly used method of measuring involvement (Wiebe et al., 2005; Young et al., 2014) and is similar to the approach taken by Anderson et al. (1997) and Leonard, Garwick, and Adwan (2005). For the main effects we hypothesized that more parental involvement, warmth, and autonomy support and lower coercion would be associated with better adherence. We also hypothesized that parenting style would moderate the association between parental involvement and adherence, such that involvement would be most strongly associated with adherence when warmth and autonomy support were high and coercion was low.