a conceptual framework for studying child adaptation ...

A CONCEPTUAL FRAMEWORK FOR STUDYING CHILD ADAPTATION TO TYPE 1 DIABETES

Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by DePaul University on 02/18/14 For personal use only.

KIM SIARKOWSKI AMER, BSN, MS, PhD DePaul University, Chicago, Illinois, USA

Understanding the challenges of managing a chronic illness, nurses provide a key component of care to patients and families who struggle daily with the demands of self-management and the balance of daily life challenges. Even though nurses empathize with the issues of chronic illness management, the complexity of managing such clients has not been articulated in a theoretical or research base. Hence, the nursing process related to facilitating adaptation to childhood chronic illness remains in a formative stage. My article presents a conceptual framework that can guide the study of children and families coping with children with Type 1 diabetes. The framework also may prove useful for other chronic illnesses.

Many adjustments are required when children are diagnosed with chronic illnesses that affect both the child and the family. The child must cope with biological changes, social and psychological differences related to having a chronic illness, and the ever present fear of being different. Developmental changes in the child continue despite the added stress of managing a chronic illness. Families need to make schedule adjustments, coordinate school activities, and attempt to integrate the child back into the social and ecological environment despite the demands of the illness. For a child with Type 1 diabetes, adapting to the illness involves integrating responses from the physiological, psychological, social, and cultural systems of the individual (Austin, 1990; Betschart, 1993; Bond, 1986; Drotar, 1997; Grey, Cameron, & Thurber 1991; Swift, Seidman, & Stein, 1967). The child adapting to Type 1 diabetes must have one or more insulin injections and frequent blood tests throughout the day, meals with prescribed calories at precise times during the day, and a closely monitored exercise and activity schedule (Betschart, 1993). The internal and external demands of the illness change as the child grows and develops and as interests and activities change. Research to date has not adequately examined, from the child’s perspective, what the experience of having Type 1 diabetes is like and how Received 22 November 1998; accepted 20 March 1999. Address correspondence to Kim Siarkowski Amer, Associate Professor, DePaul University Department of Nursing, 802 W. Belden McGaw Hall 142C, Chicago, IL 60614, USA. Issues in Comprehensive Pediatric Nursing, 22:13–25, 1999 Copyright ã 1999 Taylor & Francis 0146-0862/99 $12.00 + .00

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it affects the child and his or her view of self. The first step in examining this concept is the use of a guiding framework. The perspective of the child is a key component to assessing a family and planning appropriate interventions with the child and family. In studies reviewed, a multitude of approaches were used. This multitude includes a range of study designs and sample sizes with few clear conceptual frameworks. The following discussion of a risk and resistance model and the related literature review of child adaptation to Type 1 diabetes provides clearer definitions for child adaptation, related concepts, and a guiding framework for practice and study of the concept. RESEARCH ON CHILD ADAPTATION TO TYPE 1 DIABETES Children with Type 1 diabetes have been studied in relation to adaptation to chronic illness in the disciplines of nursing, psychology, social work, and medicine. Early studies on child adaptation to Type 1 diabetes focused on the etiology of psychopathology in children and families and used research methods with limited reliability and validity (Swift, Seidman, & Stein, 1967). Recent studies examined many variables, such as age, gender, and socioeconomic status as individual variables, and usually one dependent variable measured child adaptation to chronic illness (Austin, 1988; Burns, Green, & Chase, 1986; Chaney et al., 1997; Grey, Cameron, & Thurber, 1991). In addition, recent studies acknowledged both the direct and indirect relationship between variables that may affect child adaptation to chronic illness. Recent research reports range from descriptions of demographic characteristics in relationship to physiological parameters of a child’s adaptation to Type 1 diabetes (Grey & Thurber, 1991; Hanson, Henggeler, & Burghen, 1987a) to multivariate examinations of the complex relationships between physiological, psychological, social, individual, and family adaptation to the diabetic condition in children (Aikens, Wallander, Bell, & Cole, 1992; Hanson et al., 1990). Related concepts, such as coping and adjustment, were studied as intervening variables in adaptation to Type 1 diabetes (Hanson et al., 1989). RISK AND RESISTANCE MODEL The following model of risk and resistance provides a framework for studying the complexity of the relationships between child, family, and the many other variables that influence adaptation in a child with Type 1 diabetes. The model was developed after an extensive review of the literature and reflection on my clinical experience of managing Type 1


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diabetes. The risk and resistance model (Figure 1) identifies risk and resistance variables that may influence child adaptation to chronic illness or a handicapping condition. The child is the center of the model since his or her perceptions are central in understanding resultant adaptation. The model provides a theoretical basis for exploring the nonlinear and nonunidirectionality of the complex concept of child adaptation to chronic illness. The model includes a representation of the relationships between complex interwoven variables that may affect the child’s adaptation. The stress of illness affects all systems. Stressors related to and beyond the illness are viewed as risk variables. Positive coping strategies, which flow through all systems, provide resistance to stress. Risk variables identified in the model include gender, age, socioeconomic status (SES), development level, lack of social support, duration of

Figure 1. Model of influences on child adaptation to chronic illness.


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illness, and the presence of depression and anxiety. All the risk variables are interdependent and relate to the resistance variables. Resistance variables, if present, can mediate or buffer the effect of risk on the child’s adaptation to chronic illness. Resistance variables include self perception or self esteem, knowledge of disease, and presence of social support. Social ecological variables, which provide resistance to poor adaptation, include family environment, family support, family cohesion and adaptability, family knowledge of disease, and normalization (Knafl & Deatrick, 1986). Child adaptation, the center of the framework, should be measured by the children’s ability to process stress, their cognitive appraisal, coping strategies and physical, social, and psychological well-being. All the resistance variables are intertwined and relate to both the risk variables and the child adaptation outcomes. The model includes select variables that have been studied most frequently in the literature, such as family environment and competence of the child. The child’s adaptation, the center of the model, is conceptualized in a comprehensive manner to include the mental health, social functioning, and physical health. Outcomes, such as the presence or absence of depression, anxiety, level of self-worth and physical health, are influenced by the variables of social ecology of the child’s environment, coping strategies, and cognitive appraisal by the child. The child must not be viewed in isolation since there are complex systems operating that are included in the conceptual model. Also, adaptation may change over time. Examples of risk variables, resistance variables, and outcome variables are included in Table 1. More extensive discussion of risk and resistance variables and outcome measures follows. Table 1. Risk and resistance variables in type 1 diabetes Concepts

Examples

Measures

Risk variables family

Stressors related to child

Age (adolescence), SES, poor cohesion

Resistance variables

Positive coping strategies Family support and communication

Ventilation of frustration Family cohesion instrument

Outcome variables

Psychological well-being Physical well-being Social well-being

Positive self-perception Glycosylated hemoglobin Child behavior checklist (Achenbach & Edelbrock, 1983)

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DEFINITIONS OF CONCEPTS


The following definitions were developed in conjunction with the theoretical framework. The concepts were developed and defined to clarify the relationships between concepts and the primary focus of the framework, child adaptation. Stress Processing The definition of stress for the conceptual model is adapted from Lazarus and Folkman (1984), who define it as a perception of threat that is appraised by the child as taxing or exceeding his or her resources and endangering well-being. The stress of Type 1 diabetes provides a stimulus that requires the child to respond through the process of coping. The coping appraisal of the stress and the individual’s response is the first step toward the outcome of adaptation to the illness. To maintain health, the child with Type 1 diabetes must adhere to medical regimens and also achieve adequate psychological adaptation that Wallander, Varni, Babani, Banis, and Wilcox (1989) termed “stable person variables.”

Coping Coping is the cognitive and behavioral effort to manage specific external or internal demands that are appraised as taxing or exceeding the resources of the person (Lazarus & Folkman, 1984). In the model (Figure 1), coping in children involves a positive response that buffers stress and decreases the threat to their well-being. Coping strategies, represented as flowing through the risk and resistance variables, are influenced by many independent variables. These include age and gender (Grey, Cameron, & Thurber, 1991); developmental stage, duration and type of illness, stress, family cohesion, and age (Hanson et al., 1989); and the child’s responsibilities related to the illness and past coping strategies or resources (Kager & Holden, 1992). The sociocultural environment, primarily the family environment, also influences coping ability (Kovacs, Brent, Steinberg, Paulauskas, & Reid, 1986). Other environmental variables that influence coping include family composition, cohesion, and adaptability (Grey & Thurber, 1991; Hanson et al., 1990; Pollack, 1986; Wallander et al., 1989). Development of coping strategies related to Type 1 diabetes and life in general is in part a function of the cognitive level of the child (Newbrough, Simpkins, & Maurer, 1985).

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Compliance and Adherence The two terms, compliance and adherence, have been used by different researchers, but with similar meanings. In psychology and nursing literature, the term adherence has been used more frequently. Most researchers measure child adaptation through assessments of the child’s compliance or adherence. Compliance has been defined as the ability to conform consistently to the prescribed medical regimen dictated by the physician (Sackett, 1976). In contrast, adherence has been defined as the patient’s ability to remain faithful to the required self care activities to maintain health (physiological and psychological) within the constraints of the chronic illness (Schafer, Glasgow, McCaul, & Dreher, 1983). The main difference between adherence and compliance is who makes decisions about the treatment and management of care that affects the health of the person. When decisions regarding treatment regimen are made by the health care provider alone, compliance should be used. In contrast, when the patient and family participate in health decisions adherence is a more appropriate term (Random House Dictionary, 1987; J. Brewer, personal communication, August, 1993). Collaborative management is a more recent term recognizing the collaborative spirit of care management (Trostle, 1998). Despite the limitations of self reports of adherence, investigators have evaluated adherence to the self-care regimen by using a variety of selfreport measures (Drotar, 1997). Aikens et al. (1992) suggested there may be higher construct validity in measuring adherence by self-report than previously reported. Overall physical health measures and functional ability in the child with Type 1 diabetes have been overlooked due to a singular focus on blood glucose control. Glycemic control primarily has been studied as a dependent variable, whereas adherence behavior self-reports have been treated as either a dependent or independent variable. Thus, adherence can be demonstrated by the outcome of glycemic control, a dependent variable, or self-reports of adherence behavior can be examined as independent variables to predict glycemic control as an outcome measure (Newbrough, Simpkins, & Maurer, 1985). In addition, the psychological and social well being of the child should be included. Hence, child adaptation should be measured with multiple measures of adherence, well-being, child’s health, and self-perception. Adjustment Adjustment and adaptation are frequently used interchangeably in the literature. The term adjustment conveys a more temporary state of response to the stress of childhood Type 1 diabetes than the term

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adaptation (Jacobson et al., 1990). Adjustment, as defined by Jacobson et al. (1990) refers to the alterations the child makes to respond to a set of immediate external demands. The adjustment measures used by Jacobson et al. (1990) included self-perceptions of emotional state (esteem), psychological symptoms or behavioral problems, competency in school, and social behavior. These measures were similar to those used by other investigators to indicate adaptation. Adaptation Adaptation is the primary concept in this framework (Figure 1). In light of the plurality of terms and definitions that appear in the literature, adaptation needs to be put into context. Individual adaptation to Type 1 diabetes incorporates both the temporary adjustment and coping strategies used to manage the demands of the illness and, more important, the psychological coming to terms with the reality of the long-term implications of having Type 1 diabetes. Thus, it can be conceptualized that adaptation = adjustment + coming to terms with the implications of diabetes. Thus, investigators who measure adjustment were measuring only part of adaptation. The definition of adaptation to diabetes in children used in the framework is “the ability to produce an outcome, such as adherence, that relates to successful identification of strategies that assist with managing and coping with the illness and mastery of the social and physical environment.” This mastery of the environment is evidenced by the ability to adhere to the medical demands of the illness and the ability to achieve optimal health psychologically, physically, and socially. Additional outcomes may include positive self-perception, and no signs of anxiety, depression, or behavioral problems. Conversely, children who are adjusting to warm weather and increased activity, managing the flu, or preparing to participate in soccer season make the necessary responses on a temporary basis. Hence, adaptation represents a longer term outcome than adjustment. Poorly adapted children are those who do not demonstrate the mastery of their physical, social, and psychological environments. Such children may miss many school days, have frequent admissions to the hospital, possess limited coping abilities, or have poor self-perception. Adaptation to Type 1 diabetes in children was primarily studied from the perspective of the child’s parent or caregiver’s perceptions of how the child has adapted (Aikens et al., 1992; Kager & Holden, 1992). No studies were located that provided a comprehensive child’s view of his or her adaptation to Type 1 diabetes. A clearer picture of the child with Type 1 diabetes needs to be elicited. Without information about the

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child’s perception of Type 1 diabetes, knowledge about the child’s adaptation will not be complete. This picture should include the child’s self perception related to school, home, friends, health, and how he or she perceives and manages the Type 1 diabetes.


Relationship among Concepts The concepts of stress, coping, risk and resistance, adjustment, and adaptation are related as follows. The stress of Type 1 diabetes is a risk variable that evokes coping behaviors within the child. The coping behaviors the child enlists are part of the process of coping and adjusting to Type 1 diabetes. The way in which the child copes and adjusts is influenced by a variety of risk and resistance variables and leads to the ultimate outcome of adaptation to Type 1 diabetes. The environment in which the child exists is constantly changing, both internally (within the child) and externally (outside the child). The environmental components influencing adaptation include cultural, family, growth, and development variables (Roy, 1984). In addition, Roy (1984) describes the person’s opportunity to continue to grow and develop in response to the changing environment and enhance the meaning of life for self and others with the goal being adaptation and health. A primary risk variable that children with Type 1 diabetes encounter (Wallander et al. 1989) is psychosocial stress related to the daily management of Type 1 diabetes. Children’s perception of stress related to Type 1 diabetes and the effect of stress on adaptation to Type 1 diabetes have not been explored in the research. The risk variables in the model were chosen based on the strength of the relationship with child adaptation to Type 1 diabetes in literature reviewed. Certain variables consistently surfaced as significant predictors of child adaptation to Type 1 diabetes in studies reviewed. The identified risk variables that predicted child adaptation to Type 1 diabetes were multiple and complex, ranging from sociodemographic and developmental variables to disease characteristics. The culmination of identified risk and resistance variables is the measure of child adaptation. MEASURES OF CHILD ADAPTATION TO TYPE 1 DIABETES Measuring adaptation to childhood Type 1 diabetes is a complicated task. Children adapting to Type 1 diabetes exist in a multilayered environment of family, school, and neighborhood. The multilayered environment paired with the chronic illness presents complex psychological, social, and physiological demands on the child. The child’s ability to respond to the demands of the chronic illness is influenced by the child’s own attributes,


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the family, and the social and cultural systems in which the child exists. Measuring the many interwoven variables and the relationship between the variables that directly or indirectly influence the child’s adaptation present researchers with a significant challenge. As the scope of measures of adaptation is quite wide, the conceptual framework was designed to propose relationships between the risk and resistance variables and the child’s adaptation. The child’s adaptation should be viewed in the context of physiological, psychological and social adaptation to the illness. Even though certain variables, such as the family environment, appear to directly affect the child’s adaptation to Type 1 diabetes, the studies reviewed in a recent meta-analysis included few self-reports of the child’s perception of adaptation, few comparisons of raters (child vs. parents vs. teachers), and contradictory and unclear information (Lavigne & FaierRoutman, 1992). Measures of adaptation to Type 1 diabetes included estimates of the child’s overall psychological adjustment, broad internalizing symptoms such as anxiety and depression, externalizing symptoms such as hyperactivity or aggressive behavior and, last, estimates of child self-concept or self-esteem (Lavigne & Faier-Routman, 1992). Even though these studies have contributed to the research on child adaptation, the full profile is not complete. A variety of physiological, psychological, and social measures of child adaptation was explored in the studies reviewed. The primary physical health, or physiological measures were glycosylated hemoglobin and adherence in children with Type 1 diabetes. The main psychological concepts explored in a variety of chronic illnesses included pathological behavior, mental and social well-being, perceived competency, depression, and anxiety. The social concepts measured included behavior and social competency (CBCL), coping skills, coping efficacy, and learned resourcefulness. Construct validity of these concepts and the reliability and validity of the instruments used to measure the concepts were discussed in most cases. The majority of studies used descriptive correlational data analysis and were exploratory in nature (Charron-Prochownik, Becker, Brown, Liang, & Bennett, 1993; Grey et al., 1991; Hanson et al., 1989). Age groups ranged from 7 to 20 years in studies of children with Type 1 diabetes (Hanson, Henggeler, & Burghen, 1987b; Saucier & Clark, 1993; Swift, Seidman, & Stein, 1967; Waller et al., 1986) and ages ranged from infancy through 16 years in surveys exploring several chronic illnesses (Athreya & McCormick, 1987; Cadman, Boyle, Szatmari, & Offord, 1987). Comparing adaptation in children with diabetes of different ages is difficult since puberty and rebellious behavior in adolescence are difficult to control as intervening variables. Most investigators classify age in


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children according to pre-school, school age, and adolescent years. The ideal would be to have a standard for investigators to use for categorizing ages of children. Children have not played an active role in describing their perceptions of adaptation to chronic illness. Lavigne and Faier-Routman (1992), in a meta-analysis on 87 studies of adjustment of children ages 3–19 years to physical disorders, noted discrepancies in reporting of adjustment between teachers, mental health professionals, and parents. The self-reports of self-concept of children with physical disorders across all studies in the meta-analysis (n = 87) were significantly lower than healthy children. Clearly, more information needs to be elicited from children directly regarding their adaptation to chronic illness. This area of research should be a priority for pediatric nurses. SUMMARY This conceptual model provides a framework for future study of child adaptation to Type 1 diabetes. Concepts of adaptation, adjustment, stress, and coping have been clarified and the relationships between concepts is articulated in this article and represented through the model. As Fawcett (1993) states, “Conceptual models act as guides for theory development. By focusing attention on certain concepts and their relationships, they place the concepts and their relationships in a distinctive context” (p. 20). Future research should focus on testing this model. Studies should include the child’s perspective of the perceived stress of illness, coping, and the relationship between the child and the social ecological environment in which the child exists. Last, the adaptation of the child should be measured in a comprehensive manner including psychological, social, and physiological adaptation. REFERENCES Achenbach, T., & Edelbrock, C. (1983). Manual for the child behavior checklist and revised child behavior profile, Burlington: University of Vermont. Aikens, J., Wallander, J., Bell, D., & Cole, J. A. (1992). Daily stress variability, learned resourcefulness, regimen adherence and metabolic control in type I diabetes mellitus: Evaluation of a path model. Journal of Consulting and Clinical Psychology, 60, 113– 118. Athreya, B. H., & McCormick, M. C. (1987). Impact of chronic illness on families. Rheumatic Disease Clinics of North America, 13, 123–131. Austin, J. K. (1988). Childhood epilepsy: Child adaptation and family resources. Journal of Pediatric Nursing, 1, 19–22.


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Austin, J. K. (1989). Comparison of child adaptation to epilepsy and asthma. Journal of Comprehensive Pediatric Nursing, 2(4), 139–144. Austin, J. K. (1990). Assessment of coping mechanisms used by parents and children with chronic illness. Maternal Child Nursing Journal, 15, 98–102. Betschart, J. (1993). Children and adolescents with diabetes. Nursing Clinics of North America, 28, 35–44. Blank, M. H., Barnett, D. M., Gleason, R. E., Dunn, P. J., & Soeldner, J. S. (1981). Hemoglobin A1C compared with three conventional measures of diabetes control. Diabetes Care, 4, 349–353. Bond, L. D. (1986). Families with chronically ill and handicapped children and nonaffected children: Self-esteem, stressful life events, family role expectations and family relationships. Dissertation Abstracts International, A: The Humanities and Social Sciences, 47, 668-A. Burns, K. L., Green, P., & Chase, H. P. (1986). Psychosocial correlates of glycemic control as a function of age in youth with insulin dependent diabetes. Journal of Adolescent Health Care, 7, 311–319. Cadman, D., Boyle, M., Szatmari, P., & Offord, D. R. (1987). Chronic illness and disability and mental and social well-being: Findings of the Ontario Child Health Study. Pediatrics, 79, 805–812. Chaney, J. M., Mullins, L., Frank, R. G., Peterson, L., Mace, L. D., Kashani, J. H., & Goldstein, D. L. (1997). Transactional patterns of child, mother, and father adjustment in insulin-dependent diabetes mellitus: A prospective study. Journal of Pediatric Psychology, 22(2), 229–244. Charron-Prochownik, D., Becker, M. H., Brown, M. B., Liang, W., & Bennett, S. (1993). Understanding young children’s health beliefs and diabetes regimen adherence. The Diabetes Educator, 19, 409–418. Drotar, D. (1997). Relating parent and family functioning to the psychological adjustment of children with chronic health conditions: What have we learned? What do we need to know? Journal of Pediatric Psychology, 22(2), 149–165. Ellsworth, R., & Ellsworth, S. (1981). CAAP Scale: The measurement of child and adolescent adjustment. Palo Alto, CA: Consulting Psychologists Press. Fawcett, J. (1993). Analysis and evaluation of nursing theories. Philadelphia: F.A. Davis Company. Grey, M., Cameron, M. E., & Thurber, F. W. (1991). Coping and adaptation in children with diabetes. Nursing Research, 40, 144–149. Grey, M. J., Genel, M., & Tamborlane, W. V. (1980). Psychosocial adjustment of latency-aged diabetics: Determinants and relationship to control. Pediatrics, 65, 69– 73. Grey, M., & Thurber, F. W. (1991). Adaptation to chronic illness in childhood: Diabetes mellitus. Journal of Pediatric Nursing, 6, 302–309. Hanson, C. L., Harris, M. A., Relyea, G., Cigrang, J. A., Carle, D. L., & Burghen, G. A. (1989). Coping styles in youths with insulin dependent diabetes mellitus. Journal of Consulting and Clinical Psychology, 57, 644–651. Hanson, C. L., Henggeler, S. W., & Burghen, G. A. (1987a). Model of associations between psychosocial variables and health-outcome measures of adolescents with Type 1 diabetes. Diabetes Care, 10, 752–758. Hanson, C. L., Henggeler, S. W., & Burghen, G. A. (1987b). Social competence and


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parental support as mediators of the link between stress and metabolic control in adolescents with insulin-dependent diabetes mellitus. Journal of Consult Clinical Psychology, 55, 529–533. Hanson, C. L., Rodrigue, J. R., Henggeler, S. W., Harris, M. A., Klesges, R. C., & Carle, D. L. (1990). The perceived self-competence of adolescents with insulindependent diabetes mellitus: Deficit or strength? Journal of Pediatric Psychology, 15, 605–618. Harter, S. (1985). Manual for the self-perception profile for children. Denver: University of Denver. Harter, S. (1990). Issues in the assessment of the self-concept of children and adolescents. In A. M. LaGreca (Ed.), Through the eyes of the child: Obtaining self-reports from children and adolescents. Boston: Allyn and Bacon. Holmes, C. S., Respess, D., Greer, T., & Frentz, J. (1998). Behavior problems in children with diabetes: Disentangling possible scoring confounds on the child behavior checklist. Journal of Pediatric Psychology, 23(3), 1179–1185. Jacobson, A. M., Hauser, S. T., Lavori, P., Wolfsdorf, J. I., Herskowitz, R. D., Milley, J. E., Bliss, R., Gelfand, E., Wertlieb, D., & Stein, J. (1990) Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four year longitudinal follow-up: The influence of patient coping and adjustment. Journal of Pediatric Psychology, 15, 511–526. Kager, V. A., & Holden, E. W. (1992). Preliminary investigation of the direct and moderating effects of family and individual variables on the adjustment of children and adolescents with diabetes. Journal of Pediatric Psychology, 17, 491–502. Knafl, K., & Deatrick, J. (1986). How families manage chronic conditions: An analysis of the concept of normalization. Research in Nursing and Health, 9, 215–222. Kovacs, M., Brent, D., Steinberg, T. F., Paulauskas, S., & Reid, J. (1986). Children’s self-report of psychological adjustment and coping strategies during first year of insulin-dependent diabetes mellitus. Diabetes Care, 9, 472–479. Lavigne, J. V., & Faier-Routman, J. (1992). Psychological adjustment to pediatric physical disorders: A meta-analytical review. Journal of Pediatric Psychology, 17, 133– 157. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer Publishing Company. Newbrough, J. R., Simpkins, C. G., & Maurer, H. (1985). A family development approach to studying factors in the management and control of childhood diabetes. Diabetes Care, 8, 83–92. Pollack, S. E. (1986). Human responses to chronic illness: Physiologic and psychological adaptation. Nursing Research, 35, 90–95. Roy, S. C. (1984). Introduction to nursing: An adaptation model. Englewood Cliffs, NJ: Prentice-Hall. Sackett, D. L. (1976). Introduction. In D. L. Sarkett & Haynes, R. B. (Eds.), Compliance with therapeutic regimes. Baltimore: The Johns Hopkins University Press. Saucier, C. P. (1984). Self-concept and self-care management in school age children with diabetes. Pediatric Nursing, 34, 135–138. Schafer, L. C., Glasgow, R. E., McCaul, K. D., & Dreher, M. (1983). Adherence to IDDM regimens: Relationship to psychosocial variables and metabolic control. Diabetes Care, 6, 493–498.


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Swift, C. R., Seidman, F. L., & Stein, H. (1967). Adjustment problems in juvenile diabetes. Psychosomatic Medicine, 29, 555–571. Thomas, A. M., Peterson, L., & Goldstein, D. (1997). Problem solving and diabetes regimen adherence by children and adolescents with IDDM in social pressure situations: A reflection of normal development. Journal of Pediatric Psychology, 22(4), 541–561. Trostle, J. (1998). Adherence to treatment in childhood chronic illness. The ideology of adherence: Implications for treatment and practice. Consensus Conference sponsored by University Hospital System and Rainbow Babies Children’s Hospital, Cleveland, Ohio. Wallander, J. L., & Varni, J. W. (1989). Social support and adjustment in chronically ill and handicapped children. American Journal of Community Psychology, 17, 185– 201. Wallander, J. L., Varni, J. W., Babani, L., Banis, H. T., & Wilcox, K. T. (1989). Family resources as resistance factors for psychological maladjustment in chronically ill and handicapped children. Journal of Pediatric Psychology, 14, 157–173. Waller, D. A., Chipman, J. J., Hardy, B. W., Hightower, M. S., North, A. J., Williams, S. B., & Babick, A. J. (1986). Measuring diabetes-specific family support and its relation to metabolic control: A preliminary report. Journal of the American Academy of Child Psychiatry, 25, 415–418.