Abstract
Background
Identity crisis during adolescence is an important issue; on the other hand, adolescents suffering from chronic diseases such as cancer and diabetes increase the challenges of this period and the importance of successfully overcoming it. The present study was conducted with the aim of comparing identity crisis in adolescents with cancer and diabetes.
Methods
This cross-sectional study was conducted from August 2022 to November 2024 on 300 adolescents within the age range of 15–17 years with cancer and diabetes (150 in each group) who were selected with convenience sampling. Data were collected using demographic characteristics and identity crisis questionnaires. Data analysis was performed using SPSS-22 software. The significance level in all tests was less than 0.05.
Results
The mean of identity crisis in adolescents with cancer and diabetes was 130.82 ± 2.38 and 123.49 ± 2.45, respectively. The mean total score of identity crisis and scores of areas of dissatisfaction with life, hopelessness, sadness (p < 0.001), aimlessness, worthlessness, and anxiety (p < 0.01) were higher in adolescents with cancer than in those with diabetes. The variables of the age of adolescents, cancer duration, family income, and education of the mother predicted 56.63% of the variance changes in the identity crisis of adolescents with cancer and 55.76% of the variance changes in the identity crisis of adolescents with diabetes.
Conclusion
Identity crisis is one of the important challenges in the lives of adolescents with cancer and diabetes. These adolescents experience moderate to severe identity crises, and this condition is more common in adolescents with cancer.
Clinical trial number
Not applicable.
Keywords: Identity crisis, Cancer, Diabetes, Adolescence
Introduction
Adolescence is one of the most important and challenging stages of life, as it is a period of transition from childhood to adulthood, and physical, social, and cognitive changes, as well as major changes in self-concept, independence, and self-esteem, occur during this period [1, 2].
According to the World Health Organization, adolescence includes the age range of 10–19 years [3].
Early years of adolescence coincide with the onset of puberty and the display of gender-related behaviors by both genders [3]. Going through this turbulent period can lead to many psychological and emotional crises for adolescents [2]. Therefore, it is essential to help them adapt to physical, mental, and emotional changes, as well as feelings of ambition and independence so that they can acquire an appropriate identity [4].
Identity is a mental concept based on one’s coherent, integrated, and unique awareness of oneself, which includes their values, goals, and preferences, and contributes to their alignment with social conditions and the surrounding environment, as well as their position in society [5]. One of the most important psychological harms of the growth and development process during adolescence and young adulthood is the lack of achievement of identity, which can seriously affect the physical and mental health of adolescents [6–8].
Identity crisis is a challenge that adolescents face when trying to create a secure and trusting sense of self, and if they fail in this, their personal relationships with others will deteriorate [9]. Individuals with identity crisis experience symptoms, such as aimlessness, emptiness, hopelessness, lack of self-confidence, worthlessness, dissatisfaction, anxiety, sadness, aggression, and anger [10].
Furthermore, lack of familial cohesion, inappropriate communication in the family, parental addiction, poor financial and cultural status, inappropriate interactions with peers, and chronic diseases are the most important factors in the emergence of identity crises in adolescents [11]. Emergence of chronic diseases during adolescence creates psychological challenges and may lead to an identity crisis [12].
The incidence of chronic conditions is rising, and 20–30% of teenagers have a chronic illness, defined as one that lasts longer than six months. However, 10–13% of teenagers report having a chronic condition that substantially limits their daily life or requires extended periods of care and supervision [13]. Among them, diabetes [14] and cancer [15] are the most important and common chronic diseases of adolescence. Cancer is on the rise in the world [16] and Iran [17], and every year about 5,000 adolescents aged 15–19 years in the United States are diagnosed with cancer [18]. Accurate statistics on adolescents with cancer in Iran are not available, but it is estimated that about 2,000–3,000 adolescents are diagnosed with cancer annually [19]. Cancer is also one of the causes of death from disease in adolescents worldwide [7]. Accordingly, 9% of adolescent deaths in Iran are related to cancer [20].
According to research, younger patients with cancer have more symptoms, such as anxiety, hopelessness, depression, fear of death, inadequate management of symptoms, wish for a quick death, and loss of meaning and purpose in life, which are associated with lower adherence to treatment, higher rates of healthcare utilization, and poor quality of life [21]. Therefore, changes caused by cancer and its treatment lead to major changes in appearance, level of adolescent interactions, motivation, life expectancy, self-esteem, and independence, and their ability to play a role in the family and community, and subsequently affect the formation of identity in these adolescents [22].
Type 1 diabetes is a metabolic disorder in adolescence that is on the rise in different parts of the world [23]. On average, 10% of the world population has diabetes, and the prevalence of this disease in Iran is estimated at 3.9% [24]. In Iran, 5,000 out of 5–7 million patients with diabetes are children and adolescents [25]. Diabetes can cause behavioral disorders, depression, anxiety, and hopelessness that severely affect the mental health and identity formation of inflicted adolescents [26], therefore, these adolescents may experience an identity crisis.
The difficulties and conflicts of adolescence, on the one hand, and the pressures of family, culture, and society to acquire professional and social skills, on the other hand, impose great psychological stress on adolescents [27, 28]. Besides, the contraction of a disease, especially chronic diseases, further affects the natural process of growth and development, gaining independence, and identity formation in these adolescents, which may lead to an identity crisis [28].
The treatment team, especially pediatric nurses, can minimize the identity crisis in these patients by identifying and intervening immediately [29]. One of the most important tasks of pediatric nurses is to provide educational and counseling services to adolescents with chronic illnesses and their families, which improves the treatment process, increases the quality of life, and enhances their care [28, 29].
Limited studies are available regarding the identity crisis in adolescents with poor health status, especially those suffering from cancer and diabetes. Moreover, no research on this subject has been performed in Iran. Therefore, the present study aimed to compare adolescents with cancer and diabetes in terms of identity crisis.
Methods
Study design
This cross-sectional study was conducted in the west of Iran from August 2022 to November 2024 based on the strengthening of the reporting of observational studies in epidemiology (STROBE) guidelines for observational research. The study focused on two main objectives: evaluating the identity crisis in adolescents with cancer and diabetes and Comparison of identity crisis in adolescents with cancer and diabetes”.
Participants and sampling
According to the study performed by Prikken et al. (2020) and(µ1 = 2.45, µ2 = 2.65, sd1=0.62, sd2 = 0.62), power of 80%, α = 0.05, and taking into consideration a10% dropout rate, the sample size in each group was estimated at 166 subjects [6]. The samples of two groups of patients were selected using the convenience sampling method. The inclusion criteria were an age range of 15–19 years, a definitive diagnosis of stage 1 or 2 of leukemia based on the medical record and the opinion of the treating physician, a definitive diagnosis of type 1 diabetes based on tmedical record and the opinion of the treating physician, passage of at least 6 months since the definitive diagnosis of cancer or diabetes, a positive response to treatment based on the contents of the medical record and the opinion of the treating physician, no other diseases and physical disorders, no mental disabilities or cognitive developmental problems, literacy and willingness of adolescents and their parents to participate in the study.The exclusion criteria consisted of failure to complete the relevant questionnaires and lack of response to more than 20% of the items of the questionnaires. After receiving the code of ethics, the first author visited three medical centers affiliated with the University of Medical Sciences in western Iran and invited adolescents and their parents to participate in the study. If they were willing to participate in the study, questionnaires were given to the adolescents and after completing the questionnaires, the researcher collected .Out of the 166 subjects, 150 in each group completed the questionnaires and participated in this study. The response rate was 90.36% in each group. The participants’ reasons for not completing this study were lost in the questionnaires and not motivated.
Instrument
Demographic information questionnaire
The questionnaire included age, gender, education level, illness duration, occupation and education of the parents, and income.
The identity crisis questionnaire
The identity crisis questionnaire is a paper-and-pencil scale designed in Iran by Rajaee et al. [30]. This questionnaire consists of 50 items in 10 dimensions (namely, purposelessness, emptiness, hopelessness, lack of self-confidence, worthlessness, dissatisfaction with life, anxiety, sadness, aggression, and anger) that are scored on a five-point Likert scale ranging from one (completely disagree) to five (completely agree). The maximum and minimum scores of this questionnaire were 250 and 50, respectively. The more the score tends towards 250, the more crises the subjects experience in acquiring an identity. Banad Kuki et al. (2014) reported that the content validity of this questionnaire is appropriate and also reported a reliability of 0.93 using Cronbach’s alpha method [31]. In the present study, the content validity of this scale was confirmed by 10 experts (nurses, faculty members, and physicians) for adolescents with diabetes and cancer. Also, the questionnaire’s reliability was calculated to be 86%, indicating a very acceptable level of reliability.
Data analyses
In this study, the collected data will be analyzed with SPSS software version 22. For this purpose, descriptive statistics (frequency, percentage, mean, and standard deviation) were used. ANOVA, independent t-test, chi-square, and Fisher’s exact test were also used to investigate the relationship between identity crisis and demographic information. The significance level was considered to be P < 0.05. Then, the demographic variables were included in a multiple linear regression model using a backward strategy (p < 0.25). Before conducting the regression analysis, the researcher assessed the assumptions of normality of data, homogeneity of variance, and independence of residuals.
Ethics approval and consent to participate
The institutional review board of the medical universities located in the west of Iran provided ethics approval (IR.UMSHA.REC.1401.530). All methods were performed in accordance with the relevant guidelines and regulations, and all the research methods met the ethical guidelines described in the Declaration of Helsinki. At the start of the study, the researcher introduced herself and outlined the study’s objectives. Parents were then provided with written explanations and asked to consent. They were assured that all information would be kept confidential. The researcher also made it clear that parents could withdraw from the study at any point without facing any consequences.
Results
The results showed that the majority of adolescents participating in this study were male: 80 (53.34%) in the cancer group and 82 (54.66%) in the diabetic group, within the age range of 15–19 years, and studying at the secondary level of high school. There was no significant difference between the two groups of adolescents with cancer and diabetes in terms of the examined personal characteristics (P > 0.05). Mean scores of identity crisis in adolescents with cancer and diabetes differed significantly only in terms of age, illness duration, maternal education level, and family income (P < 0.05) (Table 1).
Table 1.
Comparison of the mean scores of identity crisis according to personal characteristics in each group of adolescents with cancer and diabetes and inter-group comparison of personal characteristics
| Variable | Adolescents with cancer | Adolescents with diabetes | P-value* | ||||
|---|---|---|---|---|---|---|---|
| Number (percentage) | Mean ± SD | P-value | Number (percentage) | Mean ± SD | P-value | ||
| Gender | |||||||
|
Male Female |
80 (53.34) 70 (46.66) |
125.32 ± 2.41 127.29 ± 2.47 |
0.611a |
82 (54.66) 68 (45.34) |
122.12 ± 2.21 125.54 ± 2.65 |
0.623a | 0.870c |
| Age (years) | |||||||
|
15 16 17 18 19 |
39 (26.00) 42 (28.00) 25 (16.66) 30 (20.00) 14 (9.34) |
138.82 ± 2.23 125.15 ± 2.43 120.17 ± 2.31 115.12 ± 2.51 114.82 ± 2.15 |
0.010b |
45 (30.00) 16 (10.66) 50 (33.34) 25 (16.66) 14 (9.34) |
129.43 ± 2.13 125.76 ± 2.54 119.32 ± 2.41 114.54 ± 2.41 112.02 ± 2.55 |
0.014b | 0.492c |
| Education level | |||||||
|
Primary high school Secondary high school University |
34 (22.67) 114 (76.00) 2 (1.34) |
126.82 ± 2.23 120.14 ± 2.42 120.82 ± 2.15 |
0.402b |
41 (27.34) 100 (66.66) 9 (6.00) |
123.43 ± 2.62 120.74 ± 2.32 119.12 ± 2.35 |
0.483b | 0.664c |
| Illness duration | |||||||
|
1–2 2–4 4–6 6–8 8–10 |
34 (22.67) 43 (28.67) 39 (26.00) 27 (18.00) 7 (4.66) |
126.27 ± 2.08 117.07 ± 2.28 114.48 ± 2.14 110.65 ± 2.31 106/03 ± 2.22 |
0.013b |
27 (18.00) 43 (28.67) 55 (36.66) 20 (13.34) 6 (4.00) |
121.92 ± 2.34 117.37 ± 2.11 110.21 ± 2.24 107.65 ± 2.31 106.55 ± 2.48 |
0.016b | 0.423c |
| Age of the mother | |||||||
|
25–35 35–40 40–45 45–50 |
39 (26.00) 55 (36.67) 43 (28.66) 13 (8.67) |
124.37 ± 2.38 124.89 ± 2.55 122.32 ± 2.13 119.26 ± 2.57 |
0.461b |
41 (27.34) 50 (33.34) 43 (28.66) 16 (10.66) |
123.53 ± 2.42 122.79 ± 2.36 120.07 ± 2.21 119.02 ± 2.32 |
0.492b | 0.680c |
| Education of the mother | |||||||
|
Elementary school High school Bachelor’s degree Master’s degree and higher |
12 (8.00) 84 (56.00) 30 (20.00) 24 (16.00) |
116.04 ± 2.17 119.39 ± 2.49 121.75 ± 2.28 128.58 ± 2.21 |
0.019b |
14 (9.34) 82 (54.66) 33 (22.00) 21 (14.00) |
11.04 ± 2.63 118.46 ± 2.54 122.31 ± 2.49 127.32 ± 2.32 |
0.019b | 0.843c |
| Occupation of the mother | |||||||
|
Housewife Self-employed Employee |
36 (24.00) 71 (7.34) 43 (28.66) |
124.32 ± 2.03 120.09 ± 2.61 119.27 ± 2.42 |
0.450b |
38 (25.33) 80 (53.34) 32 (21.33) |
122.41 ± 2.45 121.21 ± 2.33 118.27 ± 2.11 |
0.470b | 0.765c |
| Age of the father | |||||||
|
25–35 35–40 40–45 45–50 |
29 (19.34) 60 (19.34) 35 (24.00) 25 (16.66) |
12.04 ± 2.02 120.12 ± 2.33 118.57 ± 2.23 17.34 ± 2.12 |
0.498b |
33 (22.00) 55 (33.66) 41 (27.34) 21 (14.00) |
121.54 ± 2.32 119.01 ± 2.54 118.34 ± 2.23 116.76 ± 2.62 |
0.432b | 0.691c |
| Education of the father | |||||||
|
Elementary school High school Bachelor’s degree Master’s degree and higher |
4 (2.66) 71 (47.34) 55 (36.67) 20 (13.33) |
11,794 ± 2.47 117.16 ± 2.18 116.19 ± 2.32 115.14 ± 2.24 |
0.541b |
6 (4.00) 70 (45.66) 59 (39.34) 15 (10.00) |
115.54 ± 2.32 114.16 ± 2.43 13.11 ± 2.12 111.86 ± 2.52 |
0.472b | 0.782d |
| Occupation of the father | |||||||
|
Farmer Self-employed Employee |
43 (28.66) 92 (61.34) 15 (10.00) |
115.62 ± 2.39 114.41 ± 2.12 113.32 ± 2.28 |
0.550b |
50 (33.34) 79 (52.66) 21 (14.00) |
115.53 ± 2.22 113.56 ± 2.65 111.67 ± 2.34 |
0.485b | 0.674c |
| Number of children in family | |||||||
|
One 2–3 Four and above |
43 (28.66) 84 (56.00) 23 (15.34) |
117.17 ± 2.68 116.09 ± 2.57 116.02 ± 2.23 |
0.750b |
45 (30.00) 82 (54.66) 23 (15.34) |
115.65 ± 2.34 114.72 ± 2.32 113.76 ± 2.41 |
0.621b | 0.891c |
| Breadwinner of the family | |||||||
|
Mother Father Both parents |
26 (17.34) 24 (16.00) 100 (66.67) |
128.37 ± 2.28 122.27 ± 2.11 121.42 ± 2.62 |
0.350b |
27 (18.00) 23 (15.34) 100 (66.67) |
125.56 ± 2.32 123.67 ± 2.37 121.54 ± 2.21 |
0.485b | 0.840c |
| Family income | |||||||
|
Less than 5 million Tomans 5–10 million Tomans Above 10 million Tomans |
6 (4.00) 108 (72.00) 36 (24.00) |
37.37 ± 2.18 121.89 ± 2.23 120.02 ± 2.43 |
0.016b |
5 (3.33) 107 (71.00) 38 (25.33) |
130.98 ± 2.54 123.43 ± 2.22 116.54 ± 2.27 |
0.017b | 0.864d |
a: Independent t-test, b: One-way ANOVA test, c: Chi-square test, d: Fisher’s exact test
*: Significance level of the inter-group comparison of personal characteristics
Factors predicting identity crisis in adolescents with cancer
Results of the multiple linear regression test with a backward strategy indicated that for each year of increase in the age of the adolescent, the identity crisis of adolescents with cancer increases by 2.98 units. Moreover, for each year of cancer duration, the identity crisis of adolescents with cancer increases by 2.76 units. Besides, the identity crisis of adolescents with cancer increases with an increase in maternal education and a decrease in household income.
According to the standardized beta coefficients (β), in the regression model, the contribution of the variable of cancer duration (β = 0.65) was greater than those of other variables, followed by the variables of age, family income, and education of the mother, in that order. In general, the variables of the age of adolescents, cancer duration, family income, and education of the mother predicted 56.63% of the variance changes in the identity crisis of adolescents with cancer in this study (Table 2).
Table 2.
Factors predicting identity crisis in adolescents with cancer participating in the study
| Factors | Unstandardized coefficient | Standard coefficient | Confidence intervals | T | P-Value | ||
|---|---|---|---|---|---|---|---|
| B | SE | β | |||||
| Age of adolescents (years) | 2.98 | 1.18 | 0.62 | 0.32–1.55 | 2.52 | 0.011 | |
| Cancer duration (years) | 2.76 | 1.07 | 0.65 | 0.34–1.46 | 2.57 | 0.013 | |
| Family income | Less than 500$ | Reference | --- | --- | --- | --- | --- |
| 500–1000$ | -2.65 | 1.38 | 0.60 | 0.30–1.31 | 1.92 | 0.018 | |
| Above 1000$ | -2.75 | 1.35 | 0.61 | 0.34–1.28 | 1.90 | 0.017 | |
| Education of the mother | Elementary school | Reference | --- | --- | --- | --- | --- |
| High school | 1.96 | 1.23 | 0.60 | 0.28–1.05 | 1.59 | 0.018 | |
| Bachelor’s degree | 2.18 | 1.13 | 0.58 | 0.29–1.10 | 1.9 | 0.019 | |
| Master’s degree and higher | 2.23 | 1.18 | 0.54 | 0.28–1.08 | 1.88 | 0.021 | |
Adjusted R2: 56.63%
Factors predicting identity crisis in adolescents with diabetic
The results of the multiple linear regression test with the backward strategy showed that for each year of the age of the adolescents with diabetes, their identity crisis increased by 2.59 units, and for each year of diabetes duration, the identity crisis of adolescents with diabetes increased by 2.34 units. Furthermore, the identity crisis of adolescents with diabetes increased with the increase in the education level of the mother and the decrease in family income.
According to the standardized beta coefficients (β), in the regression model, the contribution of diabetes duration in adolescents (β = 0.62) was greater than those of the other variables in Table 3, and was followed by the variables of age, family income, and education level of the mother. In general, the variables of adolescent age, duration of cancer, education level of the mother, and income predicted 55.76% of the variance changes in the identity crisis of adolescents with diabetes in this study (Table 3).
Table 3.
Predictive factors of identity crisis in adolescents with diabetes participating in the study
| Factors | Unstandardized coefficient | Standard coefficient | T | Confidence intervals | P-Value | ||
|---|---|---|---|---|---|---|---|
| B | SE | β | |||||
| Age of adolescents (years) | 2.59 | 1.10 | 0.60 | 2.35 | 0.46–1.67 | 0.012 | |
| Diabetes duration (years) | 2.34 | 1.05 | 0.62 | 2.22 | 0.42–1.54 | 0.014 | |
| Family income | Less than 500$ | Reference | --- | --- | --- | --- | |
| 500–1000$ | -2.20 | 1.15 | 0.57 | 1.91 | 0.34–1.32 | 0.017 | |
| Above 1000$ | -2.17 | 1.12 | 0.58 | 1.93 | 0.33–1.35 | 0.017 | |
| Education of the mother | Elementary school | Reference | --- | --- | --- | --- | --- |
| High school | 1.98 | 1.25 | 0.58 | 1.58 | 0.41–1.08 | 0.019 | |
| Bachelor’s degree | 2.13 | 1.12 | 0.57 | 1.90 | 0.40–1.12 | 0.018 | |
| Master’s degree and higher | 2.18 | 1.15 | 0.56 | 1.89 | 0.40–1.10 | 0.021 | |
Adjusted R2: 55.76%
Comparison of the mean and standard deviation of identity crisis in adolescents with cancer and diabetes
In the present study, adolescents with cancer reported a mean identity crisis score of 130.82 ± 2.38, and adolescents with diabetes reported a mean identity crisis score of 123.49 ± 2.45. Based on an independent t-test, the total score of identity crisis and the domains of life dissatisfaction, hopelessness, sadness, worthlessness, and anxiety were higher in adolescents with cancer, compared to adolescents with diabetes (P < 0.05) (Table 4).
Table 4.
Comparison of the mean and standard deviation of identity crisis in adolescents with cancer and diabetes
| Variable | Domains | Adolescents with Cancer | Adolescents with Diabetes | P-Value |
|---|---|---|---|---|
| (Mean ± SD) | (Mean ± SD) | |||
| Identity Crisis | Sadness | 139.84 ± 2.83 | 124.54 ± 2.27 | 0.001 |
| Hopelessness | 142.62 ± 2.27 | 127.22 ± 2.43 | 0.001 | |
| Dissatisfaction with Life | 139.32 ± 2.73 | 123.21 ± 2.64 | 0.001 | |
| Worthlessness | 126.72 ± 2.21 | 118.11 ± 2.22 | 0.01 | |
| Anxiety | 131.62 ± 2.43 | 125.43 ± 2.29 | 0.01 | |
| Aimlessness | 130.37 ± 2.31 | 121.43 ± 2.65 | 0.01 | |
| Aggression | 126.02 ± 2.11 | 125.87 ± 2.42 | 0.79 | |
| Anger | 123.02 ± 2.32 | 125.42 ± 2.37 | 0.76 | |
| Self-Confidence | 119.12 ± 2.13 | 117.12 ± 2.87 | 0.75 | |
| Emptiness | 129.58 ± 2.47 | 126.58 ± 2.32 | 0.71 | |
| Total | 130.82 ± 2.38 | 123.49 ± 2.45 | 0.01 |
Discussion
Results of the study showed that the average identity crisis scores of adolescents with cancer and diabetes were at an intermediate to high level. Moreover, it was found that the illness duration, the age of the adolescent, family income, and education level of the mother were among the variables predicting identity crisis in these adolescents.
These results are in line with those of a study performed by Mohammadi Bahram et al. (2019), who reported that the frequency of anxiety (one of the dimensions of identity crisis) in children and adolescents with cancer was high [32]. In this regard, a review study by Al-Saadi et al. (2024) showed that the prevalence rates of three major psychological disorders, including anxiety, depression, and post-traumatic stress disorder, are significant among children and adolescents with cancer [33].Oers et al. (2021) have also shown that cancer patients experience higher levels of hopelessness and suicidal thoughts compared to patients with other types of diseases and express their stress in different ways [34]. Walsh et al. (2020) have also reported relatively low self-esteem in young adult cancer survivors [35]. Results of the above-mentioned studies, which show the impact of cancer on different dimensions of identity crisis, are similar to those of the present study, and this indicates that individuals should be referred to psychiatric clinics immediately after diagnosis and measures should be taken to prevent identity crisis and its dimensions in this group of patients. Findings of the present study are consistent with those of a study performed by Klerk et al. (2024), who reported that the identity of young people with type 1 diabetes is different from that of people without this disease and that multiple external factors significantly influence the development of identity in these young people [36]. A review study carried out by Eines et al. (2022) also showed that adolescents with type 1 diabetes experience negative emotions, such as fear, anxiety, anger, and sadness, and feel different from their peers, which disrupts their lives [37]. Lugasi et al. (2013) also reported that adolescents with diabetes experience delayed identity formation [38], as managing type 1 diabetes requires special effort, and daily restrictions and awareness of long-term complications may negatively impact identity development [39]. This highlights the importance of healthcare professionals and researchers prioritizing addressing diabetes-related challenges related to feelings of deviance, as they can help the youth maintain a sense of being normal and prevent adverse emotional outcomes.
Results of the present research also showed that the identity crisis of adolescents with cancer and diabetes decreases with the increase of age and illness duration. These results are consistent with those of a study performed by Verschueren et al. (2020) [40] and Bogaerts et al. (2019) [41], who showed that young people who were diagnosed with cancer at a younger age may have delays in certain developmental areas, such as living independently. Delays may indicate differentiation from their peers and difficulties in adjusting to living independently. Young people diagnosed with cancer at an earlier age are likely to face challenges and conflicts related to the disease that can affect their identity. However, in contrast to the findings of the present study, those of a study conducted by Walsh et al. (2020) indicated that the identity of adolescents with cancer had no significant relationship with age and illness duration [35]. Differences in cultural structures, values, and attitudes between countries may lead to differences in the experiences of adolescents regarding identity crises. Nevertheless, the longer duration of cancer has greater social and familial impacts. Individuals may experience challenges and changes in their relationships and families over time, which can be associated with identity crises [42]. Cancer experiences and treatments may also be associated with long-term physical changes in the bodies of patients. These changes may affect the self-image and identity of the individual, leading to identity crises. Studies have identified a variety of psychosocial challenges that adolescents and young adults experience in the face of cancer, including distress, fear of cancer recurrence, anxiety, and depression [43, 44].
Overall, these results show that the conditions that children and adolescents experience during treatment, including the disease severity, treatment method, and complications, can change the impact of the age of onset and illness duration on the identity crisis of adolescents, and more studies are needed in this field to reach a more reliable answer. The results of the present study showed that as family income increased, mean scores on identity crisis decreased. High-income households may provide better conditions for youth due to greater financial resources, access to health and recreational services, and more educational opportunities [45]. These conditions may contribute to the development of identities of adolescents. In lower-income households, psychological distress is more likely to occur due to deficiencies in support services, high medical costs, and lack of economic resources. These may act as exacerbating factors for identity crisis in adolescents affected by cancer [46]. These results are consistent with those of a study performed by Ritter et al. (2023), who showed that the interaction of gender and poverty can influence the severity of symptoms among adolescents with cancer [47]. Other studies have also reported that children with poor socioeconomic status have a lower quality of life [48, 49]. In adolescents with diabetes, the need for ongoing care and treatment also comes with significant costs. For families with limited incomes, meeting these costs is a major financial challenge that may impact the economic identity of the adolescent [45]. Results of a study conducted by Verschueren et al. (2017) also suggested that unemployment and lack of income may be considered a threat to the identity of the individual during the transition to adulthood [50]. Perhaps a possible explanation for this finding is that cancer or diabetes in adolescents negatively affects the employment status of parents as a result of long-term care of their child, as well as changes in parental roles and family functioning. They may lose their jobs or work fewer hours, resulting in a decrease in the family income, which further harms the adolescent.
However, inconsistent with these results, a study found that adolescents from low-income families may be more resilient in the face of cancer [51]. The aforementioned study suggested that lower health-related barriers in low-income adolescents may be due to the use of more adaptive coping styles to handle uncontrollable stress and increased persistence in pursuing valued goals despite adversity. This difference in results may be due to differences in the study population, used variables, or employed statistical methods. Results of the present study showed that an increase in the education levels of mothers leads to an increase in the identity crisis of adolescents with cancer and diabetes. However, it was expected that the increase in education levels of mothers would be associated a decrease in the identity crisis of these adolescents, as a higher educational level can increase the self-confidence of mothers and improve their ability to manage and solve the psychological problems of their children. In other words, maternal education can act as an effective factor in the formation of the identity and preferences of the child [45, 52] since mothers with a higher level of education may have more up-to-date information about the disease and its management methods due to access to educational resources and would be more capable of providing psychological and social support to adolescents. This support can assist adolescents in confronting the identity challenges related to the disease and empower them to gain greater control over this issue [53]. Nevertheless, the contrast between the results of the present study and other studies may be due to the influence of other variables, such as the attitude, sensitivity of mothers, cultural factors, and social and family context. Mothers with higher levels of education might be more sensitive toward their adolescent children, leading to more restrictions and an increase in adolescent identity crisis [54].
The present study is in contrast to the study conducted by Bagheri et al. (2019), which reported a direct relationship between the variable of parental education level and the formation of social identity; accordingly, the higher the parental education, the higher the social identity of their children [55]. The aforementioned study was conducted only on healthy female adolescents, and this could be one of the reasons for the difference in its results. However, given that maternal education in the present study had a negative effect on identity crisis in adolescents with cancer and diabetes, it is recommended to further examine this issue in future studies. Mohammadi et al. (2023) also reported that the economic status and age of adolescents and the type and severity of burns are predictors of identity crisis in adolescents with burns. Although this study is consistent with the present study, the difference in scores and predictors of identity crisis could be due to the study of adolescents with burns [56].Findings of the present study revealed that the mean total score of identity crisis and scores of life dissatisfaction, hopelessness, sadness, aimlessness, worthlessness, and anxiety domains were higher in adolescents with cancer, compared to those in adolescents with diabetes. These results were consistent with those of a study carried out by Barbot et al. (2021), who compared three groups of young adults without a disease, recovered, and with cancer in terms of identity distress. They found that the group with cancer was associated with higher identity distress and that identity distress had a considerable contribution to reducing life satisfaction among the three groups [57]. In this regard, Lee et al. (2020) concluded that the resilience of adolescents with leukemia is lower than that of adolescents with congenital heart disease [58]. Results of the aforementioned study also showed that the important factors related to the dimensions of identity crisis in adolescents vary among those with different chronic diseases, and we must be mindful of these differences in preventive and therapeutic interventions.
Limitations
A significant limitation of the study was that there was not study that evaluated identity crisis in teenagers with cancer and diabetes, which could provide more definitive interpretations of the results. So the findings of this study could serve as a foundation for future research on the identity crisis in adolescents with chronic diseases. Therefore, it is recommended that future studies examine identity crises in adolescents with cancer, diabetes, and other chronic diseases. Therefore, it is recommended that future studies examine identity crises in adolescents with cancer, diabetes, and other chronic diseases. It is also suggested that the effect of counseling and behavioral therapy interventions on identity crisis in these adolescents be investigated. In addition, educational workshops on coping with crises caused by diseases should be held for adolescents with chronic diseases.
Conclusion
Results showed that adolescents with cancer and diabetes experience moderate to severe identity crisis, and identity crisis is more common in those with cancer. Age, illness duration, education level of the mother, and family income are among the factors predicting identity crisis in adolescents with cancer and diabetes. It is expected that the authorities and nurses of pediatric wards, by increasing their awareness and transferring it to patients and their families, seek solutions to reduce these crises and make it easier for these patients to navigate this stage of life.
Acknowledgements
The present article is the outcome of a research project registered at Hamadan University of Medical Sciences (project code: 140106295596). The researchers express their gratitude to the authorities at Hamadan University’s School of Nursing and Midwifery, as well as to the participants and other individuals who provided valuable cooperation.
Author contributions
FM, MJH, AKH, SKH and MEP were involved in the conception and design of the study. They are responsible for data collection. Then, FM and SKH analyzed the data. FM, MJH, AKH, SKH and MEP drafted the primary manuscript, and FM revised and approved the final manuscript.
Funding
This research was not funded by any specific grants from public, commercial, or not-for-profit sectors.
Data availability
The data supporting this study’s findings are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The institutional review board of the medical universities located in the west of Iran provided ethics approval (IR.UMSHA.REC.1401.530). All methods were performed in accordance with the relevant guidelines and regulations, and all the research methods met the ethical guidelines described in the Declaration of Helsinki. At the start of the study, the researcher introduced herself and outlined the study’s objectives. Parents were then provided with written explanations and asked to consent. They were assured that all information would be kept confidential. The researcher also made it clear that parents could withdraw from the study at any point without facing any consequences.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting this study’s findings are available from the corresponding author upon reasonable request.