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Parental separation anxiety and diabetes self-management of older adolescents: a pilot study.

Separation anxiety, the discomfort, fear, or guilt experienced when someone is separated from a significant other person, has been widely acknowledged and studied among parents of young children, and in infants and young children (Dashiff & Weaver, 2008). Separation is also regarded as a normative experience among adolescents seeking autonomy (Berman & Sperling, 1991). Parents of adolescents experience separation-related distress, possibly because it is challenging to maintain connections with adolescents who spend increasing amounts of time outside the family (Larson, Richards, Moneta, Hombeck, & Duckett, 1996).

Parents of youth with type 1 diabetes mellitus (T1D) are especially confronted with numerous additional challenges that may evoke separation anxiety during adolescent years. Poorly controlled diabetes can result in major organ damage and shortened life expectancy (Silverstein et al., 2005). Parental awareness of these long-term serious and life-limiting complications related to poor disease management, as well as declines in adherence and glycemic control that occur as adolescence progresses (Pasquier-Fediaevsky, Chawlow, & Tubiana-Rufi, 2005; Urbach et al., 2005), can evoke concerns about the adolescent's well-being. Deterioration in self-management behaviors and glycemic control appears to peak between the ages of 14 to 18 years, when adolescents spend more time away from parents, and parents prepare to launch the adolescent out of the parental home (Hanna, Juarez, Lenss, & Guthrie, 2003; Urbach et al., 2005; Wysocki, Hough, Ward, & Green, 1992).

Fears about diabetes complications, awareness of declines in disease management, and fewer opportunities to directly validate the adequacy of the adolescent's diabetes management may heighten parental anxiety about separation. High levels of parental separation anxiety during this time might impede effective self-management and diabetes control by disrupting supportive communication and the goal-corrected partnership needed to advance adolescent development and health behaviors (Allen & Land, 1999).

Separation anxiety, an emotion tied to adolescent developmental processes (Dashiff, 1995; Dashiff & Weaver, 2008), has not been previously investigated in parents of adolescents with T1D, although it may influence self-management and glycemic control by interfering with the parents' ability to support effective adolescent self-management. The purpose of this exploratory study was to investigate whether there were relationships among mothers' and fathers' separation anxiety, adolescent self-management, and glycemic control in high school seniors 16 to 18 years of age.

Theoretical Framework

Attachment theory provides a conceptual framework for understanding anxiety as experienced by parents during times of separation from their offspring. Bowlby (1973) postulated that separation or threats of separation from an attachment figure might evoke, in either a child or an adult, feelings of apprehension and anxiety. Separation anxiety is indicative that an attachment relationship exists. Although parental reactions to separation threats are primed to some extent by the parents' previous experiences with their own attachment figures, they can also be altered by current circumstances (Bowlby, 1973). Parents experience separation anxiety when they perceive threats to life or bodily harm of their child, such as when an adolescent with T1D has less than optimal adherence to the diabetes management regimen or poor glycemic control.

Bowlby (1969) regarded illness as a "strange situation," and strange situations evoke separation anxiety, as well as attachment and caregiving behaviors. Allen and Land (1999), who extended the discussion and study of attachment theory to the adolescent developmental stage, indicated that among adolescents, autonomy seeking overrides the adolescent's attachment system in relation to parents. This contrasts with the parents' attachment system, which is more active and oriented to protecting the adolescent. Thus, the parent wants to protect the adolescent under threatening conditions of illness or risky behavior, seeks proximity rather than distance (George & Solomon, 1999), and consequently, may communicate in a way that inhibits the development and exercise of autonomy necessary for diabetes management and glycemic control.

Review of Literature

Parental Separation Anxiety

Numerous studies indicate that parental involvement is necessary for effective disease management among adolescents with diabetes (Anderson, Ho, Brackett, Finkelstein, & Laffel, 1999; Ellis et al., 2008; Helgeson, Reynolds, Siminerio, Escobar, & Becker, 2008; Laffel et al., 2003; Wiebe et al., 2005; Wysocki et al., 2009). A comprehensive review of parent-adolescent communication and diabetes revealed that parental involvement was consistently linked to better metabolic control (Dashiff, Hardeman, & McLain, 2008). Wiebe et al. (2005) found that both adherence to the diabetes regimen and glycemic control were better when adolescents viewed their parents as collaborators in disease management and decision making. Wysocki et al. (2009) found that the collaborative involvement of the parent who was a primary caregiver was especially important to a variety of positive diabetes outcomes, including better diabetes self-efficacy, quality of life, better self-management, less fear of hypoglycemia, and less depression. However, less attention has been directed to parental emotions, such as separation anxiety, that might disrupt development of collaborative involvement necessary for positive disease outcomes.

In this regard, the potential significance of parental separation anxiety in relation to adolescents and adolescents with diabetes is highlighted by several findings. In a community sample of adolescents, parental psychological control, demonstrated by a reluctance to be separated from their adolescent, interfered with adolescent attachment and autonomy development (Barber & Harmon, 2002). Further, parents of adolescents who had higher parental separation anxiety experienced a less positive relationship with their adolescent (Dashiff & Weaver, 2008). Among adolescents with T1D, those who perceived their parents as more overprotective were found to have less autonomous motivation for diabetes self-management (Cameron, Young, & Wiebe, 2007). Such overprotection can result from parental separation anxiety.

Although separation anxiety of mothers of infants (DeMeis, Hock, & McBride, 1986; Hock, DeMeis, & McBride, 1988; Hock, McBride & Gnezda, 1989; Lutz & Hock, 1995) and among children (Hock, Shirtzinger, & Lutz, 1992) has received long-standing attention, the examination of separation anxiety in later stages of child development, such as adolescence (Hock, Eberly, Bartle-Haring, Ellwanger, & Widaman, 2001), has been more recent. Some degree of separation anxiety appears to be normative among parents of adolescents. Parents may naturally become more anxious about physical separation as the adolescent gets older because of the difficulty in closely monitoring their activities (Hock et al., 2001).

Nevertheless, the parents' anxiety about separation can affect the security, competence, and adjustment of the adolescent (Dashiff & Weaver, 2008). For example, Dashiff and Weaver (2008) found that greater separation anxiety among mothers was associated with less self-governance of older adolescent males with T1D. However, in contrast, Dashiff and Weaver (2008) also found that fathers' greater separation anxiety was associated with higher self-governance among adolescent daughters. Further, Bartle-Haring, Bruckner, and Hock (2002) studied healthy, older adolescents and found increased levels of separation anxiety experienced by fathers appeared to negatively impact their adolescent daughters' identity development, but their separation anxiety did not have this effect on their sons' identity development. Thus, there is indication that separation anxiety of mothers and fathers may have different effects on different outcomes at different times based on adolescent gender.

The relationship of parental separation anxiety to adherence or diabetes self-management among adolescents has received some attention; however, efforts have centered on the investigation of maternal separation anxiety. Although Dashiff, Vance, Abdullatif, and Wallander (2009) did not find a relationship between maternal separation anxiety and diabetes adherence in a study of 11- to 15-year-old adolescents, Cameron et al. (2007) examined the relationships of a different type of anxiety in mothers with the diabetes regulation of 13- to 18-year-old adolescents. Maternal trait anxiety was associated with beliefs about the adolescent's diabetes management skills, beliefs of mothers about their involvement in diabetes, parental overprotectiveness, and adolescent beliefs about maternal control of diabetes. These previous reports did not examine the relationship between parental separation anxiety and disease-related outcomes specifically in older adolescents, nor was separation anxiety of fathers addressed.

Adolescent Self-Management

The transfer of diabetes management from parents to the adolescent can be a difficult transition as parents raise their expectations regarding the adolescent's self-management of their diabetes (Anderson, Auslander, Jung, Miller, & Santiago, 1990; Dashiff, 2003; La Greca et al., 1995; La Greca, Follensbee, & Skylar, 1990; Schilling, Knafl, & Grey, 2006). Further, parents do not necessarily transfer management skills to the adolescent based on awareness of the adolescent's capacities (Anderson et al., 1999; Palmer et al., 2009). The amount and timing of parental support appears to play a key role in the effectiveness of the transfer of diabetes care responsibility to the adolescent so adequate glycemic control can be attained (Anderson et al., 1990; Helgeson & Novak, 2007; La Greca et al., 1995; Leonard, Garwick, & Adwan, 2005; Wiebe et al., 2005). Schilling et al. (2006) found that adolescents were managing almost all of their diabetes care by middle adolescence (15 to 17 years of age); however, there was great variation in parental involvement in this age group. By late adolescence (17 to 19 years of age), adolescents were carrying out diabetes management tasks with little to no supervision or oversight. Nevertheless, parental collaborative involvement marked by enjoyment is important, and it is related to better adherence to the management regimen, regardless of age (Berg, Schindler, & Maharajh, 2008). A parent's anxiety can interfere with his or her ability to engage in the collaboration that contributes to adolescent adherence to the diabetes regimen.

Glycemic Control

Glycemic control often declines during adolescence (Greening, Stoppelbein, Konishi, Jordan, & Moll, 2007; Leonard, Jang, Savik, & Plumbo, 2005), and it is generally poorer than glycemic control achieved during childhood or adulthood (Diabetes Research in Children Network [DirecNet] Study Group, 2005; Greening et al., 2007). Several studies suggest that male youths have poorer glycemic control and adherence than female youth (Bearman & La Greca, 2002; Grey, Lipman, Cameron, & Thruber, 1997; Naar-King et al., 2006; Perwien, Johnson, Dymtrow, & Silverstein, 2000), but a recent multicenter study of diabetes in youth indicated glycemic control was worse for females, although the difference in hemoglobin (HbA1c) between genders was small (Petitti et al., 2009).

Adolescents who have been diagnosed with diabetes longer tend to have worse control than those with diabetes of shorter duration, due in part to the progressive loss of function of beta cells (Ohmann et al., 2010; Petitti et al., 2009). However, some studies do not support this link (Hassan, Loaf, Anderson, & Heptulla, 2006). In addition, youth from higher socioeconomic status (SES) families have better glycemic control than lower SES families (Hassan et al., 2006). While no study was located that addressed the relationship of parental separation anxiety with glycemic control, Cameron et al. (2007) found that maternal trait anxiety strongly influenced glycemic control and diabetes complications only in younger adolescents, whereas it was associated with less autonomous motivation for diabetes self-management and less positive effect in older adolescents.

Other investigators applied attachment theory and found that maternal perceptions of secure parent-adolescent attachment were related to better glycemic control in adolescents with T1D after controlling for covariates of maternal age and adolescent age and gender (Rosenberg & Shields, 2009). In contrast, fathers' and adolescents' perceptions of security of parent-adolescent attachment were not associated with glycemic control. Hood, Peterson, Rohan, and Drotar (2009) conducted a meta-analysis of studies reporting an association of adherence with glycemic control among youth younger than 19 years of age. Results supported that glycemic control improves as adherence increases.



Following Institutional Review Board approval, eligible families were recruited from an outpatient endocrinology clinic of a children's hospital in Alabama over a three-month period. Letters signed by the adolescent's endocrinologist as well as by the primary investigator were mailed to potential participants. Personal contacts were made in the clinic by the research team only when eligible families demonstrated interest. Participation of at least one parent and the adolescent were required for the family to be eligible to enroll in the study, and both residential parents were contacted in an effort to promote father involvement. Eligible families were those who had been residing together for at least 12 months and had an adolescent who was 1) diagnosed with T1D for longer than one year, 2) 16 to 18 years of age, 3) enrolled or preparing to enroll in the 12th grade, and 4) without any other chronic medical conditions, including pregnancy. Parents were also required to be able to read, write, and speak English, and not have any developmental disability or major psychiatric illness. Substitute parental figures, such as grandparents, were included if they were legally responsible for the adolescent and met all other inclusion criteria.

The research team obtained informed consent from each participating parental figure and assent from the adolescent during recruitment. A total of 24 families (80% of eligible families approached) were enrolled. The major reason cited for non-participation was time and distance to the data collection site. After consenting to participate in the study, one family withdrew after reporting the adolescent moved out of the state to live with a family member. Twenty-three families completed the interviews. Each participant received a $50.00 incentive for the assessment and interview, and each family unit was provided a stipend for travel and meals.


Data collection took place in a research center in close proximity to the adolescent's endocrinology clinic within three weeks of a clinic visit. Adolescents and parents completed separate paper-and-pencil measures with the oversight of research staff. In addition, research staff members conducted an audiotaped, separate, structured interview (discussed below) with the adolescent to evaluate self-management behaviors. Qualitative interviews were also conducted with parents and adolescents, but were not included as part of this report. Information pertaining to the adolescent's glycemic control was ascertained from medical records after all interviews were completed. The HbA1c value in closest proximity to the data collection date was utilized in analysis.


Parental separation anxiety. Separation anxiety of mothers and fathers was assessed by two separate scales: the Parental Separation Anxiety Scale (PSAS) and the Anxiety about Adolescent Distancing Scale (AAD). The PSAS is an 18-item questionnaire (Dashiff & Weaver, 2008) adapted from the Maternal Separation Anxiety Scale (Hock et al., 1989), which assesses universal feelings of distress regarding separation from an adolescent offspring, such as being upset or lonely, missing the other person, and/or being concerned or wondering about the other person. The scale was modified to detect variation in parental separation anxiety among gender-specific parent-adolescent dyads. Initial internal consistency reliability reports ranged from 0.90 to 0.93 for mothers and 0.88 to 0.91 for fathers (Dashiff & Weaver, 2008). Differences in maternal and paternal separation anxiety in relation to adolescent cognitive autonomy development based on the adolescent's age and gender were detected. Cognitive autonomy development is essential for the establishment of effective relationships and reasoning skills, as well as the development of self-sufficiency and initiative. Higher maternal separation anxiety was associated with less cognitive autonomy of older adolescent sons, while higher paternal separation anxiety was associated with higher cognitive autonomy in younger adolescent daughters. Factor analysis of the items yielded different factors for mothers and fathers. For mothers, separation anxiety was typified by a factor reflective of perceived adolescent distress with separation. For fathers, distance from the adolescent appeared to be the crucial factor. Additionally, increased levels of parental separation anxiety were associated with a more negative global quality relationship and were found in families reporting a more negative parent-adolescent relationship.

The Parents of Adolescents Separation Anxiety Scale (PASAS) and the Anxiety Adolescent Distancing Subscale (AAD) (Hock et al., 2001) differ from the above PSAS scale. The PASAS consists of 21 items reflecting parents' feelings of discomfort or loss associated with their adolescent's decreasing involvement with parents and increasing affiliation with others, as opposed to discomfort related to physical separation in the PSAS. High scores on this scale appear to indicate jealousy and possessiveness, and occur in parents who inhibit adolescent age-appropriate autonomous behavior. The AAD had an internal consistency ranging from 0.86 to 0.88 for mothers and 0.64 for fathers (Hock et al., 2001).

Adolescent diabetes self-management. The Diabetes Self-Management Profile (DSMP) is an adaptation of the diabetes adherence instrument developed by Hanson, Henggeler, and Burghen (1987) and later modified by Harris et al. (2000) in an effort to assess self-management skills necessary for glycemic control for patients with T1D. The DSMP in this study was completed by adolescents. The 25-item structured interview produces a total score addressing five aspects of competent diabetes care: diet, exercise, hypoglycemia management, glucose monitoring, and insulin administration. The instrument is available in two versions based on the prescribed diabetic regimen: conventional versus flexible. Previous works have reported internal reliability ranging from [alpha] = 0.47 to 0.79 for youth (DirecNet Study Group, 2005; Harris et al., 2000). Inter-rater agreement ranged from 0.94 to 0.95. Concurrent validity was indicated by significant correlations of the DSMP with Diabetes Quality of Life of Mothers (r = -0.27) and correlations of the DSMP with Diabetes Quality of Life of Adolescents (r = -0.27) but not with fathers. Predictive validity was demonstrated by correlations of the DSMP total with glycemic control ([A.sub.x]) (r = -0.28, p < 0.01). Although the DSMP accounted for only 8% of the variance in [Hb.sub.AlC], this is a stronger association than reported previously for other instruments. Moreover, good parent-adolescent agreement (r = 0.61) and the similarity of DSMP scores for adolescents interviewed alone and those who knew their parent was also being interviewed indicated that interviewing adolescents alone was a sound measure of diabetes self-management among those who were older than 11 years of age.

In this study, internal consistency reliability of the conventional version yielded a Cronbach's Alpha of 0.80, while the flexible instrument's Cronbach's Alpha was lower at 0.59. Conventional diabetes management requires a prescribed diet, scheduled glucose monitoring, and routine insulin doses prescribed by a health care provider. In contrast, the flexible diabetes management style allows more individual decision-making regarding diet, glucose monitoring, and insulin administration. Thus, the flexible version of the DSMP may appropriately yield lower internal consistency reliability because it assesses several independent dimensions of diabetes self-management (DirecNet Study Group, 2005). Inter-rater reliability was assessed via audio taping of interview with second member of research team scoring items separately. Inter-rater reliability was r = 0.92.

Metabolic control. Glycosylated HbA1c is the percentage of glycosylated hemoglobin in whole blood. It is less likely to be influenced by day-today fluctuations than random urine or blood glucose measurements, reliably reflects blood glucose over the previous several weeks, and has been found to be the most useful index of metabolic control for the 6- to 8-week period before testing (Rohlfing et al., 2002). A value less than 7.5% is a goal of therapy for adolescents 13 to 19 years of age (Silverstein et al., 2005). Immunoassays were performed by technicians with the Ames DCA 2000 automated analyzer system.


Description of the Sample

The sample consisted of 23 biological, step-parent, and single-parent families who were primarily middle-class and Caucasian. A similar number of adolescent males and females participated. Length of time since diabetes onset demonstrated a wide range with a mean of 50.64 months (see Table 1).

Family structure and SES, adolescent gender, and number of years since diabetes diagnosis were assessed to evaluate their relationship with the primary study variables (for example, prostate-specific antigen [PSA]), adolescent self-management, and glycemic control). Maternal (but not paternal) separation anxiety was positively correlated with race (r = 0.492, p = 0.020); African-American mothers reported higher levels of separation anxiety than their Caucasian counterparts. Diabetes self-management was positively related to SES (r = 0.410, p = 0.05); adolescents from higher SES families demonstrated better diabetes self-management. The number of years since the diabetes diagnosis was significantly related to glycemic control (r = 0.448, p = 0.32). Glycemic control declined as these older adolescents had greater durations of T1D. No other significant relationships were demonstrated between the demographic and primary study variables.

Parental Separation Anxiety And Adolescent Diabetes Self-Management

Parental separation anxiety was assessed using two measures: the PSAS and the AAD. Each scale taps a slightly different theoretical conceptualization of parental separation anxiety. Both instruments assess parental separation anxiety of the mother and the father. Correlation of the PSAS and the AAD for mothers (r = 0.560, p = 0.007) and fathers (r = 0.639, p = 0.008) was moderate.

Neither maternal (r = -0.307, p = 0.165) nor paternal (r = 0.303, p = 0.253) separation anxiety, as assessed by the PSAS, was significantly correlated with the adolescent's report of diabetes self-management. Maternal separation anxiety (r = 0.007, p = 0.976) and paternal separation anxiety (r = -0.092, p = 0.735), as assessed by the AAD scale, were also not significantly correlated with the adolescent's perceived self-management.

Parental Separation Anxiety And Glycemic Control

Maternal separation anxiety as assessed by the PSAS was not significantly correlated with HbA1c; however; paternal separation anxiety was inversely correlated with HbA1c (r = -0.716, p = 0.002). Partial correlations revealed that the relationship between paternal separation anxiety and [Hb.sub.A1C] remained significant even when the number of years since the diagnosis of diabetes was controlled (r = -0.701, p = 0.004).

Maternal separation anxiety as assessed by the AAD scale was not significantly correlated with A1C (r = 0.181, p = 0.419); however, paternal separation anxiety displayed a significant negative correlation with A1C (r = -0.524, p = 0.037). The significance of the relationship, however, was negated (r = -0.489, p = 0.064) after a partial correlation was performed that controlled for the number of years since diagnosis of diabetes.

Adolescent Diabetes Self-Management And Glycemic Control

Bivariate correlations indicated a marginal inverse correlation between adolescent self-management and glycemic control (r = -0.370, p = 0.08). Partial correlations of diabetes self-management and glycemic control were significant (r = -0.433, p = 0.04) when the number of years since the diagnosis of diabetes was controlled (see Table 2).


The sample in this exploratory pilot study was diverse with respect to race, family structure, SES, and T1D duration. Although the number of minority families participating in the study was small, this appropriately reflects the epidemiology of T1D. Approximately 16 per 100,000 African-American adolescents are diagnosed with T1D, while the rate is almost double for non-Hispanic Caucasians (Centers for Disease Control and Prevention, 2007).

Certain characteristics of the sample demonstrated significant relationships to the study variables, and this was congruent with findings of other studies. In the present study, adolescents with longer durations of T1D were more likely to have worse glycemic control. Although similar results have been found in other studies (Dashiff, 2003; Dashiff, Bartolucci, Wallander, & Abdullatif, 2005; Frey & Denyes, 1989; Leonard et al., 2005), none of these studies specifically addressed a 16- to 18-year-old age group. Adolescents who have been grappling with self-management of diabetes for longer periods of time may be at greater risk for problems with glycemic control as they transition to later adolescence. Similar to other studies, adolescents from families of higher SES had better diabetes self-management. Other studies reporting this finding were conducted with broader age groups of adolescents and their families (Hassan et al., 2006). Access to resources to support diabetes self-management may be greater in these families (Paris et al., 2009).

Some findings differ with reports from previous studies. In contrast to earlier studies with broader age groups (Dashiff & Weaver, 2008), a relationship of SES with parental separation anxiety was not found, suggesting access to greater resources and a higher level of education may have less impact on separation anxiety of parents of older adolescents. Although diabetes literature indicates there are gender differences between adolescent girls and boys in diabetes self-management and glycemic control (Helgeson & Novak, 2007; Jacobson et al., 1994; Wiebe et al., 2005), these differences in this sample of a narrower age group in which males and females were nearly equally represented were not found. Further contrasting with other studies (Helgeson, Siminerio, Escobar, & Becker, 2009; La Greca et al., 1995), the duration of T1D was not related to adolescents' reports of diabetes self-management. Problems with self-management may be due to other factors in the older adolescent. Alternatively, the DSMP may not have adequately examined the scope of self-management in this age group. Schilling et al. (2009) suggested the DSMP might not effectively capture the complex processes involved in adolescent self-management that not only include diabetes tasks performance but also collaboration with parents and health care providers. Lastly, counter to previous studies with younger adolescents (Dashiff & Weaver, 2008), a relationship between maternal or paternal separation anxiety and adolescent gender was not found. Differences in adolescent gender-related maternal and paternal separation anxiety may diminish as the adolescent matures, parent/adolescent conflict lessens (Dashiff et al., 2009; Laursen, Kay, & Collins, 1998), and the adolescent assumes primary responsibility for his or her disease management (Schilling et al., 2006). In addition, the finding that African-American mothers, in comparison to Caucasian mothers, may experience greater levels of separation anxiety has not previously been reported; however, inferences should be reserved due to the small number of African-American women represented in this pilot study.

The researchers' failure to find a relationship between parental separation anxiety and adolescent self-management suggests that adolescent diabetes tasks self-management is not directly influenced by parental separation anxiety in adolescents 16 to 18 years of age. These adolescents spend more time outside the purview of parents (Scholte, van Lieshout, & Van Aken, 2001; Shulman & Ben-Artzi, 2003), and as a result, parents have less direct knowledge of older adolescents' self-management. Therefore, parental separation anxiety may not be responsive to the adolescent's concurrent self-management. In other studies, adolescents acknowledged concealing self-management errors or omissions from parents (Kynas & Barlow, 1995). Whether parent and adolescent reports of adolescent diabetes self-management differ, and whether parental separation anxiety is related to parents' own perception of adolescent self-management deserves further investigation.

The finding that fathers with higher separation anxiety had adolescents with better glycemic control was unexpected. It was hypothesized that parental separation anxiety would be higher when glycemic control was worse. Fathers' separation anxiety in this age group of adolescents appears to be either responsive to glycemic control or contributory to glycemic control. These cross-sectional findings do not allow for interpretation of direction of effects. Attachment theory suggests that fathers' separation anxiety reflects attachment. Fathers who experience greater separation anxiety may be those who are more strongly attached and less disengaged from their adolescents. Since fathers of adolescents with diabetes have been reported to use distancing as a way of coping with their distress (Azar & Solomon, 2001; Dashiff, 1993; Dashiff, Morrison, & Rowe, 2008), separation anxiety may be experienced and endorsed by fathers who are more involved with their adolescent. This involvement may contribute to better glycemic control. The character of this involvement deserves further investigation. These findings were stronger with the parental separation anxiety measure based on a more normative view of separation anxiety; thus, additional highlighting of separation anxiety in fathers of these adolescents might serve an adaptive function. The later adolescent years evoke fathers' anxiety about separation from the adolescent, and this may contribute to the adolescent's glycemic control. Further investigation is needed with larger samples to verify this finding. In addition, further investigation is needed to determine the mediating processes involved in the link between fathers' separation anxiety and glycemic control.

The transition of diabetes care from parental management to adolescent self-management occurs during adolescence. Premature transfer of diabetes management from parental figures to the adolescent has shown to yield inadequate glycemic control (LaGreca et al., 1990). While most adolescents have assumed diabetes task responsibilities by middle adolescence (Schilling et al., 2006), the decrease in glycemic control found in this age group suggests the adolescent may not fully possess the developmental capabilities necessary to adequately manage his or her diabetes. However, better self-management was associated with glycemic control and provides some evidence that 16- to 18-year-old adolescents are able to self-manage their diabetes effectively to yield positive results in their glycemic control.

These findings are limited by their cross-sectional and exploratory nature. Important questions are raised about the contribution of fathers' separation anxiety to glycemic control, or alternatively, whether better glycemic control contributes to fathers' separation anxiety. Although maternal separation anxiety was not related to self-management in older adolescents, it may be tied to other significant adolescent outcomes not assessed in this study (Cameron et al., 2007; Dashiff et al., 2009; Dashiff & Weaver, 2008). Replication of these results with larger samples and longitudinal studies is needed to determine the direction of effects. With further information and insight, better anticipatory guidance and therapeutic tactics could be employed to confront the challenges of patients with T1D and their families during adolescence.


In summary, in this sample of 16- to 18-year-old high school students, adolescents who had been managing T1D the greatest number of years demonstrated the worst glycemic control. Adolescent gender, race, and family structure were not related to the adolescent's ability to effectively manage his or her blood glucose. Neither maternal nor paternal separation anxiety influenced the adolescent's self-management of diabetes. Lastly, paternal, but not maternal, separation anxiety was predictive of glycemic control.

Additional Readings

Berg, C.A., Wiebe, D.J., Beveridge, R.M., Palmer, D.L., Korbel, C.D., Upchurch, R., ... Donaldson, D. (2007). Mother-child appraised involvement in coping with diabetes stressors and emotional adjustment. Journal of Pediatric Psychology, 32(8), 995-1005.

Bowlby, J. (1988). Developmental psychiatry comes of age. American Journal of Psychiatry, 145, 1-10.

Pomerantz, E., & Eaton, MM. (2000). Developmental differences in children's perceptions of parental control: They love me, but they make me feel incompetent. Merrill-Palmer Quarterly, 46, 140-167.

Steinburge, L., & Silverberg, S. (1986). The vicissitudes of autonomy in early adolescence. Child Development, 57, 841-851.


Allen, J.P., & Land, D. (1999). Attachment in adolescence. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 319-335). New York: Guilford.

Anderson, B., Auslander, W., Jung, K., Miller, P, & Santiago, J. (1990). Assessing family sharing of diabetes responsibilities. Journal of Pediatric Psychology, 15(4). 477-492.

Anderson, B., Ho, J., Brackett, J., Finkelstein, D., & Laffel, D. (1999). Parental involvement in diabetes management tasks: Relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus. Journal of Pediatrics, 130, 257-265.

Azar, R., & Solomon, C.R. (2001). Coping strategies of parents facing child diabetes mellitus. Journal of Pediatric Nursing, 16, 418-428.

Barber, B.K., & Harmon E.L (2002). Violating the self. Parental psychological control of children and adolescents. In B.K Barber (Ed.), Intrusive parenting: How psychological control impacts children and adolescents (pp. 15-52). Washington, DC: American Psychological Association.

Bartle-Haring, P., Bruckner, R, & Hock, E. (2002). The impact of parental separation anxiety on identity development in late adolescence and early adulthood. Journal of Adolescent Research, 17(5), 439-450.

Bearman, K.J., & La Greca, A.M. (2002). Assessing friend support of adolescents' diabetes care: The diabetes social support questionnaire-friends version. Journal of Pediatric Psychology, 27, 417-428.

Berg, C.A., Schindler, I., & Maharajh, S. (2008). Adolescents' and mothers' perceptions of the cognitive and relational functions of collaboration and adjustment in dealing with type 1 diabetes. Journal of Family Psychology, 22(6), 865-874.

Berman, W.H., & Sperling, M.B. (1991). Parental attachment and emotional distress in the transition to college. Journal of Youth and Adolescence, 20, 427-440.

Bowlby, J. (1969). Attachment and loss-Volume 1: Attachment. New York: Basic Books.

Bowlby, J. (1973). Attachment and loss-Volume 2: Separation. New York: Basic Books.

Cameron, L.D., Young, M.J., & Wiebe, D. (2007). Maternal trait anxiety and diabetes control in adolescents with type 1 diabetes. Journal of Pediatric Psychology, 32(7), 733-744.

Dashiff, C.J. (1993). Parents' perceptions of the impact on the family of diabetes in adolescent daughters. Journal of Pediatric Nursing, 8, 361-369.

Centers for Disease Control and Prevention (CDC). (2007). National diabetes fact sheet. Retrieved from http://www.cdc. gov/diabetes/pubs/pdf/ndfs-2007.pdf

Dashiff, C.J. (1995). Understanding separation anxiety disorder. Journal of Child & Adolescent Psychiatric Nursing, 8, 27-38.

Dashiff, C.J. (2003). Self and dependent-care responsibility of adolescents with IDDM and their parents. Journal of Family Nursing, 9(2), 166-183.

Dashiff, C., Bartolucci, A., Wallander, J., & Abdullatif, H. (2005). The relationship of family structure, maternal employment, and family conflict with self-care adherence of adolescents with type 1 diabetes. Families, Systems, and Health, 23(1), 66-79.

Dashiff, C., Hardeman, T., & McLain, R. (2008). Parent-adolescent communication and diabetes: An integrative review. Journal of Advanced Nursing, 62, 140-162.

Dashiff, C.J., Morrison, S.A., & Rowe, J. (2008). Fathers of children and adolescents with diabetes: What do we know? Journal of Pediatric Nursing, 23(2), 101-119.

Dashiff, C., Vance, D., Abdullatif, H., & Wallender, J. (2009). Parenting, autonomy and self-care of adolescents with type 1 diabetes. Child Care Health and Development, 35(1), 79-88.

Dashiff, C.J., & Weaver, M. (2008). Development and testing of a scale to measure separation anxiety of parents of adolescents. Journal of Nursing Measurement, 16(1), 61-80.

DeMeis, D.K., Hock, E., & McBride, S.L. (1986). The balance of employment and motherhood: Longitudinal study of mothers' feelings about separation from their first-born infants. Developmental Psychology, 22, 627-632.

Diabetes Research in Children Network (DirecNet) Study Group. (2005). Diabetes self-management profile for flexible insulin regimens: Cross-sectional and longitudinal analysis of psychometric properties in a pediatric sample. Diabetes Care, 28(8), 2034-2035.

Ellis, D.A., Templin, T., Podolski, C., Frey, M., Naar-King, S., & Moltz, K. (2008). The Parental Monitoring of Diabetes Care Scale: Development, reliability and validity of a scale to evaluate parental supervision of adolescent illness management. Journal of Adolescent Health, 42, 146-153.

Frey, M.A., & Denyes, M.J. (1989). Health and illness self-care in adolescents with IDDM: A test of Orem's theory. Advances in Nursing Science, 12, 67-75.

George, C., & Solomon, J. (1999). Attachment and caregiving: The caregiving behavioral system. In J. Cassidy, & RR. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 649-670). New York: The Guilford Press.

Greening, L., Stoppelbein, L., Konishi, C., Jordan, S., & Moll, G. (2007). Child routines and youths' adherence to treatment for type 1 diabetes. Journal of Pediatric Psychology, 32, 437-447.

Grey, M., Lipman, T., Cameron, M.E., & Thruber, F.W. (1997). Coping behaviors at diagnosis and in adjustment one year later in children with diabetes. Nursing Research, 46, 312-317.

Hanna, K., Juarez, B., Lenss, S., & Guthrie, D. (2003). Parental-adolescent communication and support for diabetes management as reported by adolescents with type 1 diabetes. Issues in Comprehensive Pediatric Nursing, 26, 145-158.

Hanson, C.L, Henggeler, W.W., & Burghen, G.A. (1987). Social competence and parental support as mediators of the link between stress and metabolic control in adolescents with insulin-dependent diabetes mellitus. Journal of Consulting and Clinical Psychology, 55, 529-533.

Harris M.A., Wysocki, T., Sadler, M., Wilkinson, K., Harvey, L, Buckloh, L. M., ... White, N.H. (2000). Validation of a structured interview for the assessment of diabetes self-management. Diabetes Care, 23(9), 1301-1304.

Hassan, K., Loar, R., Anderson, B.J., & Heptulla, R.A. (2006). The role of socioeconomic status, depression, quality of life, and glycemic control in type 1 diabetes mellitus. Journal of Pediatrics, 149(4), 526-531.

Helgeson, V., & Novak, S. (2007). Illness centrality and well-being among male and female early adolescents with diabetes. Journal of Pediatric Psychology, 32(3), 260-272.

Helgeson, V.S., Reynolds, K.A., Siminerio, L., Escobar, O., & Becker, D. (2008). Parent and adolescent distribution of responsibility for diabetes self-care: Links to health outcomes. Journal of Pediatric Psychology, 33, 497-508.

Helgeson, V.S., Siminerio, L, Escobar, O., & Becker, D. (2009). Predictors of metabolic control among adolescents with diabetes: A 4-year longitudinal study. Journal of Pediatric Psychology, 34(3), 254-270.

Hock, E., DeMeis, D., & McBride, S.L. (1988). Maternal separation anxiety: Its role in the balance of employment and motherhood in mothers of infants. In A. Gottfried & A. Gottfried (Eds.), Maternal employment and children's development (pp. 191-230). New York: Plenum.

Hock, E., Eberly, M., Bartle-Haring, S, Ellwanger, P., & Widaman, K.F. (2001). Separation anxiety in parents of adolescents: Theoretical significance and scale development. Child Development, 72, 284-298.

Hock, E., McBride, S.L., & Gnezda, T. (1989). Maternal separation anxiety: Mother-infant separation from the maternal perspective. Child Development, 60, 793-802.

Hock, E., Shirtzinger, M.B., & Lutz, W.J. (1992). Dimensions of family relationships associated with depression in mothers of young children. Psychology of Women Quarterly, 16, 229-241.

Hollingshead, A.B. (1965). Two-factor index of social position. New Haven, CT: Yale Station. Hollingshead.

Hood, K.K., Peterson, C.M., Rohan, J.M., & Drotar, D. (2009). Association between adherence and glycemic control in pediatric type 1 diabetes: A meta-analysis. Pediatrics, 124(6), 1171-1179.

Jacobson, A.M., Hauser, S.T., Lavori, P., Willett, J.B., Cole, C.F., Wolfsdorf, F.I., Wertlieb, D. (1994). Family environment and glycemic control: A four-year prospective study of children and adolescents with insulin-dependent diabetes mellitus. Psychosomatic Medicine, 56, 401-409.

Kynas, H., & Barlow, J. (1995). Diabetes: An adolescent's perspective. Journal of Advanced Nursing, 22, 941-947.

La Greca, A.M., Auslander, W.F., Greco, P. Spetter, D., Fisher, E.B., & Santiago, J.V. (1995). I get by with a little help from my family and friends: Adolescents' support for diabetes care. Journal of Pediatric Psychology, 20, 449-476.

La Greca, A.M., Follensbee. D.K., & Skylar, J.S. (1990). Developmental and behavioral aspects of diabetes management in children and adolescents. Children's Health Care, 19, 132-139.

Laffel, L.M., Vangsness, L., Connell, A., GoebeI-Fabbri, A., Butler, D., & Anderson, B. J. (2003). Impact of ambulatory, family-focused teamwork intervention on glycemic control in youth with type 1 diabetes. The Journal of Pediatrics, 142, 409-416.

Larson, R.W., Richards, M.H., Moneta, G., Hombeck, G., & Duckett, E. (1996). Changes in adolescents' daily interactions with their families from ages 10-18: Disengagement and transformation. Developmental Psychology, 32(4), 744-754.

Laursen, B., Kay, C., & Collins, A. (1998). Reconsidering changes in parental-child conflict across adolescence: A metal-analysis. Child Development, 69(3), 817-832.

Leonard, B.J., Garwick, A., & Adwan, J.Z. (2005). Adolescents' perceptions of parental roles and involvement in diabetes management. Journal of Pediatric Nursing, 20, 405-414.

Leonard, B.J., Jang, Y.P., Savik, K., & Plumbo, M.A. (2005). Adolescents with type 1 diabetes: Family functioning and metabolic control. Journal of Family Nursing, 11, 102-121.

Lutz, W.J., & Hock, E. (1995). Maternal separation anxiety: Relations to adult attachment representations in mothers of infants. Journal of Genetic Psychology, 156, 57-72.

Naar-King, S., Ellis, D., Frey, M., Templin, T., Cunningham, P.B., & Cakan, N. (2006). Gender differences in adherence and metabolic control in urban youth with poorly controlled type 1 diabetes: The mediating role of mental health symptoms. Journal of Pediatric Psychology, 31(8), 793-802.

Ohmann, S., Popow, C., Rami, B., Konig, M., Blaas, S., Fliri, C., & Schober, E. (2010). Cognitive functions and glycemic control in children and adolescents with type 1 diabetes. Psychological Medicine, 40, 95-103.

Palmer, D.L., Berg, C.A., Butler, J., Fortenberry, K, Murray, M., Lindsay, R., ... Wiebe, D.J. (2009). Mothers', fathers', and children's perceptions of parental diabetes responsibility in adolescence: Examining the roles of age, pubertal status, and efficacy. Journal of Pediatric Psychology, 34(2), 195-204.

Paris C.A. Imperatore G., Klingensmith G., Petitti D., Rodriguez, B., Anderson A. M., Pihoker, C. (2009). Predictors of insulin regimens and impact on outcomes in youth with type 1 diabetes: The SEARCH for diabetes in youth study. Journal of Pediatrics, 155(2), 183-189.

Pasquier-Fediaevsky, L.D., Chawlow, A.J., & Tubiana-Rufi, N. (2005). Is the relationship between adherence behaviors and glycemic control bi-directional at adolescence? A longitudinal cohort study. Diabetic Medicine, 22, 427-433.

Perwien, A.R., Johnson, S.B., Dymtrow, D., & Silverstein, J. (2000). Blood glucose monitoring skills in children with type 1 diabetes. Clinical Pediatrics, 39, 351-357.

Petitti, D.B., Klingensmith, G.J., Bell, R.A., Andrews, J.S., Dabelea, D., Imperatore, G., ... Mayer-Davis, E. (2009). Glycemic control in youth with diabetes: The SEARCH for diabetes in youth study. The Journal of Pediatrics, 155(5), 668-672.

Rohlfing, C.L., Wiedmeyer, H., Little, R.L., England, J.D., Tennell, A., & Goldstein, D. (2002). Defining the relationship between plasma glucose and HbA(1c): Analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial. Diabetes Care, 25(2), 275-278.

Rosenberg, T., & Shields, C.G. (2009). The role of parent-adolescent attachment in the glycemic control of adolescents with type 1 diabetes: A pilot study. Families, Systems, & Health, 27(3), 237-248.

Schilling, L.S., Dixon, J.K., Knafl, K.A., Lynn, M.R., Murphy, S.D., & Grey, M. (2009). A new self-report measure of self-management of type 1 diabetes for adolescents. Nursing Research, 58(4), 228-236.

Schilling, L.S., Knafl, K.A., & Grey, M. (2006). Changing patterns of self-management in youth with type 1 diabetes. Journal of Pediatric Nursing, 6, 412-424.

Scholte, R.H, Van Lieshout, C.F., & Van Aken, M.A. (2001). Perceived relational support in adolescence: Dimensions, configurations, and adolescent adjustment. Journal of Research on Adolescence, 11, 71-94.

Shulman, S., & Ben-Artzi, E. (2003). Age-related differences in the transition from adolescence to adulthood and links with family relationships. Journal of Adult Development, 10(4), 217-236.

Silverstein, J., Klingensmith, G., Copeland, K., Plotnick, L. Kaufman, F., Laffel, L., ... Clark, N. (2005). Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association. (ADA Statements). Diabetes Care, 28, 186-213.

Urbach, S.L., LaFranchi, S., Lambert, L., Lapidus, J.A., Daneman, D., & Becker, T.M. (2005). Predictors of glucose control in children and adolescents with type 1 diabetes mellitus. Pediatric Diabetes, 6, 69-74.

Wiebe, D.J., Berg, C., Korbel, C., Palmer, D., Beveridge, R., Upchurch, R., ... Donaldson, D. (2005). Children's appraisals of maternal involvement in coping with diabetes: Enhancing our understanding of adherence, metabolic control, and quality of life across adolescence. Journal of Pediatric Psychology, 30, 167-178.

Wysocki, T, Hough, B.S., Ward, K.M., & Green, L.B. (1992). Diabetes mellitus in the transition to adulthood: Adjustment, self-care, and health status. Journal of Developmental and Behavioral Pediatrics, 13, 194-201.

Wysocki, T., Nansel, T.R., Holmbeck, G., Chen, R., Laffel, L., Anderson, B.J., & Weissberg-Benchell, J. (2009). Collaborative involvement of primary and secondary caregivers: Associations with youth's diabetes outcomes. Journal of Pediatric Psychology, 34, 869-881.

Acknowledgments: The funding for this study was provided by a Dean's Award from the University of Alabama at Birmingham granted to Dr. Carol Dashiff.

Shannon Morrison, PhD, MSN, APRN-BC, is an Assistant Professor, University of Alabama at Birmingham, Birmingham, AL.

Carol Dashiff, PhD, RN, is a Professor, University of Alabama at Birmingham, School of Nursing, Birmingham, AL.

Hussein Abdullatif, MD, is an Associate Professor of Pediatrics, Children's Park Place, Birmingham, AL.

Elaine Moreland, MD, is an Assistant Professor, Department of Pediatrics, Division of Endocrinology, University of South Carolina Medical School, Greenville Hospital System, Greenville, SC.
Table 1.
Demographics of Sample Background Characteristics

Variable                                Percentage     n

Adolescent Gender
Female                                     47.6       11
Male                                       52.4       12
Adolescent Race
African-American                            9.8        2
Caucasian                                  90.2       21
Family Structure
Two-parent biological                      55.0       12
Biological and one step-parent             35.0        7
Single parent                              10.5        4

                                                      SD       Range

Family Socioeconomic Status               45.79      11.66   22 to 61
Duration of Diabetes in Months    (a)     50.64      34.66   12 to 159

(a) Hollingshead index.

Source: Hollingshead, 1965.

Table 2.
Correlation of Variables

                                 1      2          3         4

 1. Glycemic control             --   -0.370   -0.716 **    0.104
 2. Self-management                     --      0.303      -0.307
 3. PSAS (father)                                 --        0.173
 4. PSAS (mothers)                                           --
 5. AAD (father)
 6. AAD (mother)
 7. SES
 8. Gender
 9. Race
10. Diabetes (number of years)
11. Family structure

                                     5          6          7

 1. Glycemic control             -0.524 *    0.181      -0.135
 2. Self-management              -0.092      0.007       0.410 *
 3. PSAS (father)                 0.639 **   0.080      -0.128
 4. PSAS (mothers)                0.463 *    0.560 **    0.065
 5. AAD (father)                    --       0.127      -0.330
 6. AAD (mother)                                --       0.084
 7. SES                                                    --
 8. Gender
 9. Race
10. Diabetes (number of years)
11. Family structure

                                   8         9          10        11

 1. Glycemic control             -0.062    0.072      0.448 *    0.005
 2. Self-management              -0.009   -0.080      0.039      0.351
 3. PSAS (father)                -0.163   -0.231     -0.202      0.239
 4. PSAS (mothers)               -0.053    0.301      0.259      0.225
 5. AAD (father)                  0.052   -0.216     -0.246      0.176
 6. AAD (mother)                  0.038    0.492 *    0.234      0.371
 7. SES                          -0.016    0.151      0.260      0.012
 8. Gender                         --     -0.041      0.114     -0.046
 9. Race                                     --      -0.204      0.038
10. Diabetes (number of years)                          --       0.273
11. Family structure                                              --

* p [less than or equal to] 0.05

** p < 0.01

Notes: AAD = Anxiety about Adolescent Distancing Scale; PSAS =
Parental Separation Anxiety Scale; SES = socioeconomic status.
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Author:Morrison, Shannon; Dashiff, Carol; Abdullatif, Hussein; Moreland, Elaine
Publication:Pediatric Nursing
Article Type:Report
Geographic Code:1USA
Date:Mar 1, 2012
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