‘Dancing with diabetes’: Family coping strategies to promote psychological and behavioural adaptation in older children and adolescents with type 1 diabetes—A qualitative study

Abstract

Aims

To explore how families facilitate psychological and behavioural adaptation among older children and adolescents with T1D from the perspective of parents, children and families.

Methods

A qualitative descriptive study was conducted using maximum variance sampling method. Seventeen families in China, including 16 parents and 10 older children/adolescents with T1D, participated in semi‐structured online interviews via phone or social software. Conventional content analysis was employed for data analysis.

Results

Three interrelated themes emerged: (1) emotional adjustment through support and compensation; (2) positive belief formation through transcendence and identity; and (3) enhanced self‐management through cooperation and development. Emotional exchange, verbal support, companionship and practical compensation were identified from parents or children for regulating children's emotions. Parents fostered positive self‐identity and set role models to encourage children's resilience and optimism. Shared responsibility, cognitive‐behavioural adjustments, expansion of supportive environments and avoiding unhealthy behaviors were shown to be effective strategies for improving children's diabetes management.

Conclusions

Perspectives on psychological and behavioural adaptation differed among parents, children and families, underscoring the need for family‐centred approaches that address diverse emotional needs and align behavioural goals. Interventions should strengthen emotional connections, foster positive beliefs and enhance collaborative self‐management within families to support children's adaptation to diabetes.

What's new?

• Three overarching mechanisms of adaptation emerged, including emotion regulation through support and compensation, identity reconstruction through transcendence and positive belief formation and improved diabetes self‐management through collaborative problem‐solving and behavioural development.

• Adaptation strategies differed across stakeholders, with parents focusing on emotional regulation and caregiving responsibility, children highlighting addressing emotional burden and improving autonomy, and families emphasising a supportive home environment and daily life normalcy.

• Findings highlight the need for family‐centred interventions that align emotional and behavioural goals across family members to support children's psychological and behavioural adaptation to T1D.

1. INTRODUCTION

Type 1 diabetes (T1D) is one of the most prevalent chronic diseases among the pediatric population ¹ and is characterized by elevated blood glucose levels. It is estimated that, in 2024, 1.81 million people younger than 20 years had T1D globally, with 219,000 new cases reported among this age group. ² A recent nationwide study in China estimated the prevalence of T1D among children and adolescents (aged 3–18 years) at 44/100,000. ³ China has achieved progress in children's diabetes management, such as improving the accessibility of intensive insulin therapy and implementing structured diabetes self‐management education. However, considerable challenges still exist in clinical practice, including the low uptake of insulin pumps and continuous glucose monitoring (CGM) and insufficient psychological support for families. ⁴ Suboptimal glycemic levels can result in serious short‐ and long‐term complications for older children and adolescents and impose a heavy emotional and financial burden on their families and economic burden on society. Older children and adolescents with T1D, defined as those aged 7–18 years, ⁵ exhibit a heightened prevalence of psychological comorbidities, including but not limited to depression and anxiety, compared with the general pediatric population. ⁶ , ⁷ They also face challenges in complex diabetes self‐management, with some demonstrating low engagement with diabetes care guidelines ⁸ and lower levels of physical activity. ⁹

The family plays a pivotal role in the psychological adaptation and diabetes management of older children and adolescents with T1D. Research has suggested that parents of older children and adolescents with T1D need to assist in managing multiple aspects of diabetes care, including acquiring diabetes‐related knowledge and communicating with healthcare professionals. ¹⁰ , ¹¹ Parental involvement and monitoring have been linked to improved self‐management and better metabolic levels among adolescents with T1D. ¹² , ¹³ Several systematic reviews have demonstrated that family‐based interventions significantly improve psychological well‐being ¹⁴ and self‐management ¹⁵ among children with T1D. These findings underscore the importance of identifying and strengthening family coping strategies to enhance children's psychological adaptation and behavioural coping abilities.

One review and several observational studies have examined how families cope with diabetes‐related challenges, such as the transition of care from adolescence to young adulthood, ¹¹ mothers' roles in seeking social support ¹⁰ and adolescents' behavioural coping strategies in response to diabetes distress. ¹⁶ However, few studies have used the qualitative approach to explore family coping strategies from the perspectives of both parents and children within the lens of family resilience. A qualitative approach is particularly valuable as it enables in‐depth exploration of the lived experiences and perceptions underlying family coping with diabetes, which cannot be fully captured by quantitative methods. Family resilience refers to families' ability to adapt, rebound and maintain positive functions when facing significant life challenges, including trauma, chronic diseases and other adverse conditions. ¹⁷ Walsh proposed three key interactive processes that underpin family resilience: establishing positive belief systems (making meanings, hope and transcendence or spirituality), mobilising family organisational resources (flexibility, connectedness and access to social or economic resources), and promoting supportive communication (clarity, emotional sharing and collaborative problem‐solving). ¹⁷ Previous empirical research has applied this framework to identify positive coping strategies used by families facing adverse childhood experiences, including accessing social support, maintaining family routines and preserving personal space. ¹⁸ In the present study, the family resilience lens was used to understand how families of older children and adolescents with T1D respond effectively to diabetes‐related challenges and foster positive psychological and behavioural adaptation. Considering both parental and child perspectives helps identify effective parental strategies and those accepted by children. As family routines in T1D management become stabilised over time, ¹⁹ early recognition of adaptive strategies is essential for fostering psychological well‐being and self‐management. Guided by the established family resilience framework, this study qualitatively explored coping strategies that promote the psychological and behavioural adaptation of older children and adolescents with T1D from the perspectives of both parents and children.

2. METHODS

A descriptive qualitative study was conducted using semi‐structured interviews with parents, older children and adolescents with T1D, as family coping with T1D remains under‐researched, and this approach is well‐suited to staying close to the data and providing a comprehensive understanding of how families cope with T1D‐related challenges. Grounded in the principles of naturalistic inquiry, this approach enabled an exploration of the lived experiences of families and the meanings they attribute to their coping practices. ²⁰ This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ): a 32‐item checklist for interviews and focus groups ²¹ (see Supplementary File 1).

This study was approved by the ethics committee of Peking University Health Science Center (approval no. IRB00001052‐21050) and the ethics committee of Beijing Children's Hospital (No. 2020‐Z‐166). All participants provided written informed consent prior to enrollment in the study.

2.1. Participants and recruitment

Participants were recruited from the specialist diabetes outpatient clinic at Beijing Childrens Hospital in Beijing, the capital of China, between November 2021 and January 2022. As a major pediatric referral centre, the hospital serves families from both Beijing and other regions of China. Parents who served as the primary caregivers for their childrens diabetes management, had been living with their children since the diagnosis of diabetes, and were sufficiently fluent in Chinese were invited to participate in the interviews. Older children and adolescents who had been diagnosed with T1D, aged 7–18 years, had varying durations of diabetes and were capable of independently understanding and speaking Chinese, were also invited to participate. In this study, we specifically focused on older children and adolescents (aged 7–18 years). This age threshold was selected because age 7 marks a pivotal developmental transition into the concrete operational stage, characterised by the emergence of cognitive independence and logical reasoning. ⁵ Maximum variance sampling was employed to ensure the inclusion of participants with diverse child and family characteristics (i.e., age, diabetes duration, family income, educational background). Prior to the study, the researcher approached parents face‐to‐face in the clinic to introduce the study and invite participation. Families who expressed interest in the study were invited to participate and provided written informed consent.

2.2. Data collection

Tailored interview guides were developed for parents and for older children and adolescents by our research team. Our research team had backgrounds in diabetes care and qualitative research. The team's research focuses on diabetes nursing, and the corresponding author has professional experience in diabetes nursing. Prior to data collection, the interview guides were reviewed through expert consultation and refined by the research team to improve the wording of questions and to further elaborate on behavioural and psychological aspects of coping, such as strategies used to reduce stress and enhance confidence in diabetes management. The revised interview guides for parents, older children and adolescents were determined and are presented in Table 1. Interviews were conducted by a trained qualitative researcher (ZHJ, Master of Nursing, female) who had no direct clinical relationship with the participants. The interviews were conducted via phone calls or WeChat (a Chinese social media software that allows voice communication). As the study was conducted during the COVID‐19 pandemic, interviews were undertaken remotely to reduce face‐to‐face contact and potential infection risk. WeChat was used because it was familiar, widely accessible and convenient for participating families in China. Each interview began with open‐ended questions about emotional and family experiences related to diabetes, followed by an exploration of how families managed emotions and behaviours associated with diabetes self‐management. Interviews with parents and older children and adolescents were conducted separately rather than as joint family interviews. In each family, the interview with the parent (mother or father) was conducted first, followed by the interview with the older child or adolescent. During interviews with older children and adolescents, parents were asked not to intervene, prompt or answer on behalf of the child and questions were directed to the child to reduce overlapping responses. Repeat interviews were not conducted, and each participant was interviewed once. Reflective notes were recorded after each interview to document the main topics discussed, issues encountered during the interview, and priorities for subsequent interviews, such as recruiting participants from different age groups or with different durations of diabetes. All interviews were audio‐recorded and transcribed verbatim by researchers (ZHJ and LD). The average interview duration was approximately 35 min, ranging from 30 to 56 min.

TABLE 1.

The interview outline for the family of an older child or adolescent with T1D.

Numbers	Questions for primary caregivers
1	In what ways, if any, has your child's diabetes influenced your family life and interactions?
2	How does your child usually express emotions related to diabetes in daily life?
3	What strategies have you or your family used to help your child cope with emotional challenges related to diabetes management?
4	How do you support your child in developing confidence for diabetes self‐management?
5	How do you support your child in developing skills for diabetes self‐management?
6	What family practices or routines have been helpful (or unhelpful) in supporting your child's diabetes self‐management?

Numbers	Questions for older children or adolescents
1	In what ways has living with diabetes influenced your family life?
2	How do you usually feel or express your emotions related to diabetes in daily life?
3	What do you usually do when you feel upset or stressed about managing diabetes?
4	How do your parents or family help you feel more confident about managing diabetes?
5	What kinds of things have you or your family done that made diabetes management easier (or harder) for you?

2.3. Data analysis

Conventional content analysis ²² was conducted using NVivo 12.0 software. In line with the principle of information power, ²³ recruitment ceased separately for parents and children when the latter interviews provided sufficient information to address the study aim and generated no substantially new information. After 14 participants and 9 children had been interviewed, no substantively new information, codes or categories related to psychological and behavioural adaptation strategies were identified in either group. Two additional interviews with parents and one additional interview with a child were then conducted to confirm this pattern, indicating information redundancy. Recruitment was therefore discontinued. Data collection and analysis proceeded iteratively. The coding process began immediately after the first few interviews and continued throughout the data collection period. Transcripts were first read repeatedly to gain a comprehensive understanding of the data. Initial codes were generated using keywords or participants' own expressions. As the analysis progressed, codes were expanded, refined, merged and adjusted as the analysis of subsequent transcripts progressed. A preliminary coding framework was developed from the initial transcripts. In the early stage of analysis, coping strategies were grouped into three broad domains: alleviating negative emotions, fostering positive beliefs and enhancing diabetes self‐management. Codes were then organised into categories based on similarities and differences. Two researchers (ZHJ and LD) independently coded the data from the first two participants to enhance consistency in coding. The initial inter‐coder reliability coefficient was 0.75, indicating satisfactory agreement. The remaining transcripts were then independently coded, followed by discussions to ensure consensus and rigour in the analysis process. Interview data from parents and children were analysed separately. Strategies described by parents regarding how they supported their children were coded as the parental perspective. Strategies described by children as actions or supports they perceived from their parents were coded as the child's perspective. When a strategy was reported by both parents and children, it was coded as the family perspective, reflecting shared understanding and concordant experiences within the family. All transcripts were coded and analysed in Chinese. Initial codes, categories and illustrative quotes were then translated into English by ZHJ and reviewed by the research team using back‐translation. The wording was refined through discussion to ensure that the translated codes and quotes accurately conveyed the original meanings.

2.4. Reflexivity and trustworthiness

The researchers' professional backgrounds and prior understanding of how families adapt to older children's and adolescents' T1D may have influenced data collection and interpretation. Several strategies were therefore employed throughout the study to enhance reflexivity and methodological rigour. Dependability was supported using a consistent interview guide and a clear analytic process across data collection and analysis. To enhance reflexivity and confirmability, reflective notes were recorded after each interview and coding and theme development were discussed within the research team. Discrepancies in interpretation were resolved through discussion and by returning to the original transcripts to ensure that the findings were grounded in participants' accounts. Transferability was supported by providing detailed descriptions of the study context, participant characteristics and research procedures, enabling readers to assess the relevance of the findings to other settings.

3. RESULTS

A total of 17 parents and 10 children participated in the interviews, with one parent dropping out (refused to continue interviewing). Finally, 26 participants from 16 families completed the interview, including 13 mothers, 3 fathers and 10 older children and adolescents with T1D. The mean age of the 16 participating parents was 40.13 ± 5.49 years, of whom 14 (87.5%) were married, and 9 (56.3%) were employed. The mean age of older children and adolescents with T1D was 11.81 ± 2.64 years, and 7 (43.8%) were female. The duration of diabetes ranged from 3 months to 10 years, with an average duration of 3.39 ± 3.42 years. Demographic and diabetes‐related characteristics are summarised in Table 2.

TABLE 2.

Demographic and diabetes‐related information of participants.

No.	Participants	Parent					Child					Family monthly income (yuan)
		Gender	Age	Educational level	Current employment status	Marital status	Gender	Age	Diabetes duration	Insulin regimen	HbA1c mmol/mol(%)
1	Parent and child	F	38	Bachelor or above	Employed	Married	F	10	7 months	Daily injections	85 (10)	>20,000
2	Parent	F	48	Secondary school	Not working	Married	M	11	5 years	Daily injections	37 (5.5)	10,000–20,000
3	Parent and child	F	41	Senior high school	Not working	Married	F	17	10 years	Daily injections	87 (10.1)	10,000–20,000
4	Parent and child	F	39	Junior high school	Not working	Divorced	M	14	3 months	Daily injections	50 (6.7)	<5000
5	Parent and child	F	34	Junior high school	Employed	Married	M	13	5 years	Daily injections	62 (7.8)	5000–10,000
6	Parent and child	F	40	Bachelor or above	Employed	Married	M	11	5 years	Insulin pump use	46 (6.4)	>20,000
7	Parent	M	45	Bachelor or above	Employed	Married	M	13	7 years	Insulin pump use	58 (7.5)	>20,000
8	Parent and child	F	41	Associate degree	Not working	Married	M	11	1 year	Daily injections	48 (6.5)	10,000–20,000
9	Parent and child	F	36	Secondary school	Not working	Married	F	10	1 year	Daily injections	60 (7.6)	<5000
10	Parent and child	F	34	Associate degree	Employed	Married	F	10	9 years	Daily injections	53 (7)	10,000–20,000
11	Parent	F	35	Associate degree	Not working	Married	F	7	1 years	Daily injections	60 (7.6)	5000–10,000
12	Parent	M	45	Junior high school	Not working	Separated	F	15	1 year	Daily injections	41 (5.9)	<5000
13	Parent	F	40	Junior high school	Employed	Married	M	14	1 month	Daily injections	‐	5000–10,000
14	Parent and child	F	33	Associate degree	Employed	Married	M	11	8 months	Insulin pump use	41 (5.9)	5000–10,000
15	Parent and child	F	40	Bachelor or above	Employed	Married	F	8	7 months	Daily injections	45 (6.3)	10,000–20,000
16	Parent	M	53	Bachelor or above	Employed	Married	M	14	7 years	Insulin pump use	48 (6.5)	>20,000

Note: In general cities in China, a monthly household income of 10,000 yuan is considered to be at a middle‐to‐high level.

Abbreviations: F, female; M, male; HbA_1c, hemoglobin A_1c.

As the disease progressed, families gradually developed coping strategies to promote the psychological and behavioural adaptation of older children and adolescents with T1D. Their focus shifted from alleviating negative emotions to fostering positive beliefs and supporting effective diabetes management. Three major themes were identified to describe families' coping strategies for promoting psychological and behavioural adaptation: (1) emotional adjustment through support and compensation; (2) positive belief formation through transcendence and identity; and (3) enhancing diabetes self‐management through cooperation and development. The themes and subthemes are summarised in Table 3, with illustrative quotes for each subtheme presented in Supplementary File 2, Table S1.

TABLE 3.

Families' coping strategies for psychological and behavioural adaptation of older children and adolescents with T1D.

Themes	Subthemes	Parental perspective	Family perspective	Child perspective
Emotional adjustment through support and compensation	Emotion exchange	Empathy	Love and be loved	‐
	Verbal support	Conceptual metaphor	‐	Diminish fears Fostering positive expectations
	Companionship	‐	Fighting together	Taking positive glucose management actions
	Alternative compensation	Gift compensation	Activity compensation	‐
Positive belief formation through transcendence and identity	‘Dancing with diabetes’	Transforming inferiority into strength	Fostering hope for the future	‐
		Character cultivation	Maintaining normalcy	‐
	Developing a sense of identity	Encouraging peer communication	Rejecting the patient identity	Feeling valued
			‐	Reducing criticism
	Setting positive role models	Parents as role models	‐	Ordinary people as role models
		People with diabetes as role models	‐	‐
Enhancing diabetes self‐management through cooperation and development	Reinforcing roles and responsibilities	Supervision	Reminding	‘The second doctor after myself’
		Setting boundaries	Transmission of diabetes management skills	Empowerment
		Appropriate criticism	Mutual negotiation	‐
	Cognitive‐behavioural adjustments	Role‐playing	Enhancing knowledge	Actionable plans
		Situation‐based reflection	Learning from experiences	‐
		Task‐based self‐management training	‐	‐
	Expanding the supportive environment	School support	Support from relatives	Support from friends
			Support from healthcare professionals
			Online informational support
	Avoiding unhealthy behaviours	Distracting attention	Managing snack intake

3.1. Theme 1: Emotional adjustment through support and compensation

1. Emotional exchange within families facilitated children's emotional adjustment. Parents showed empathy to help children cope with emotional distress (parental perspective). Parents expressed love, and children's sense of being loved strengthened family cohesion and positive emotions (family perspective).

I'd tell him, “Mom is anxious too, but I love you.” Then he understands and accepts it. (N14, mother)

• 2 Verbal support: Parents used conceptual metaphor to help children understand their condition and reduce anxiety (parental perspective). Children reported feeling reassured when parents diminished their fears and fostered positive expectations (child perspective).

I told him, ‘It's like some kids have food allergies. You just need well management’. (N7, father)

• 3 Companionship: Parents' constant companionship conveyed emotional security beyond words. Families described ‘fighting diabetes together,’ which reduced children's fear and worry (family perspective). Some older children and adolescents reported feeling a sense of safety and reduced worries about diabetes when parents took positive glucose management actions (child perspective).

I feel safe knowing my parents help me keep good glucose level, such as noticing early signs of high or low blood sugar and regularly checking my glucose levels. (N14, child)

• 4 Alternative compensation: Parents may provide children with a gift to compensate for their disappointment or distress when they cannot eat snacks (parental perspective). Parents and children also mentioned that engaging in activities, such as playing games at appropriate times, could compensate for children's inability to go outside during episodes of hypoglycemia (family perspective).

When he can't play with others due to low glucose levels, I make up for it later so he feels no different. (N11, mother)

3.2. Theme 2: Positive belief formation through transcendence and identity

In this study, transcendence refers to families' reconstruction of meaning in response to T1D, whereby they reframe the illness experience, strengthen family values and transform perceived vulnerability into strength.

1. ‘Dancing with the diabetes’: Although the diagnosis and management of diabetes may initially be perceived as an inferiority to personal development, parents helped reframe optimal diabetes management as a strength that promotes healthier lifestyles among older children and adolescents with T1D (parental perspective). Additionally, parents viewed character cultivation as a way to broaden children's perspectives and foster a more positive mindset towards diabetes management (parental perspective). Families also fostered hope for the future through advances in diabetes treatment and management technology, which enhanced their confidence in better diabetes management and well‐being (family perspective). Maintaining normalcy in daily routines was also viewed as a way to reduce the perceived gap between children and their peers and to promote psychological adaptation (family perspective).

I told her, ‘Diabetes needs to be taken seriously. If you manage it well, you can dance with it, it will teach you self‐discipline and won't make you inferior to anyone’. (N6, mother)

He can do what he wants and eats what he likes, it's okay. (N16, father)

• 2 Developing a sense of identity: Parents encouraged peer communication among children with T1D to strengthen their children's sense of belonging and foster a positive self‐concept (parental perspective). Families as a whole rejected the ‘patient’ identity, helping children build a stronger sense of self and reducing the sense of internal stigma (family perspective). In this study, stigma primarily manifested as internalised stigma, characterised by children's feelings of shame, inferior to others and concerns about being perceived differently due to their condition. Moreover, children reported feeling valued and facing less criticism from parents, which enhanced their sense of identity by fostering self‐worth and acceptance of their condition (child perspective).

I once fainted, and my parents rushed from work to be with me at the hospital. It made me feel cared for and showed how strong my family is. It also made me believe we can overcome diabetes. (N3, child)

• 3 Setting positive role models: Parents themselves, as well as other individuals living successfully with diabetes, served as role models by demonstrating how effective problem‐solving in diabetes management (parental perspective). Children reported that when parents highlighted ordinary people as role models, it eased their pressure and conveyed the belief that they too could live well (child perspective).

My mom told me that as long as I manage my diabetes well, I can be just like other people and live a healthy life. (N5, child)

3.3. Theme 3: Enhancing diabetes self‐management through cooperation and development

1. Reinforcing roles and responsibilities: Parents' supervision supported children in managing their diet and regularly exercising (parental perspective). Setting boundaries clarified what children should not do, such as avoiding exercise when blood sugar levels are high (parental perspective). Appropriate criticism helped children recognise the consequences of negative behaviours, such as secretly eating restricted foods, and guided them to adjust their self‐care behaviours (parental perspective).

He sometimes ate restricted foods in secret. I usually ignored it, but if it happened more than twice, I would express my anger. (N12, father)

Parents and children described several practical strategies. Parents often reminded children to monitor glucose levels and encouraged exercise after meals to develop healthy habits. Transmission of diabetes management skills from parents to children fostered a sense of responsibility and promoted self‐management. Mutual negotiation within families was also important to reduce children's dependence and help them become familiar with diabetes management.

If I argued with him, he refused to eat or check his glucose. But calmly discussing how to manage snacks and blood sugar helped him accept my suggestions. (N10, mother)

Children identified strategies that supported their self‐management. Many described parents as a ‘second doctor,’ enhancing their ability to manage diabetes independently while encouraging timely support‐seeking. Being empowered to participate in activities like glucose monitoring helped children transition from dependence on their parents to greater independence.

I usually handle diabetes problems myself. If I can't, I ask my parents, and if needed, we consult the doctor. (N5, child)

• 2 Cognitive‐behavioural adjustment: Role‐playing was an effective strategy used by parents to reinforce children's diabetes knowledge and enhance parent–child communication (parental perspective). Situation‐based reflection also supported independent diabetes management (parental perspective). Parents designed task‐based self‐management trainings, such as recording daily food intake, insulin units, glucose levels and completing daily walks, to strengthen children's skills (parental perspective).

I explained, ‘Just like sometimes we don't feel well and lack energy, I hope you can learn to take care of yourself’. (N14, mother)

From the family perspective, enhancing knowledge about diabetes, including carbohydrate counting and understanding acute and chronic complications, was fundamental for cognitive adjustment. Learning from experiences also strengthened problem‐solving skills, enabling children to manage diabetes more effectively.

At first, when my blood sugar was high, we didn't know what to do and went to the hospital. Over time, we learned to identify the cause, maybe eating too much or not enough insulin. (N3, child)

Children reported that actionable plans from parents allowed them to recognise and respond to management problems more efficiently.

My parents gave me a simple plan, when my blood sugar was high, I drink water or exercise; when low, I have juice or something sweet. (N1, child)

• 3 Expanding the supportive environment: Parents helped create a supportive school environment through ongoing communication with teachers, including initial explanations of the child's diabetes management needs and subsequent follow‐up when difficulties arose at school or when the child felt embarrassed or afraid to monitor blood glucose at school (parental perspective).

She felt too timid to scan the Abbott device at school. I personally communicated with her teacher to be understanding and supportive. I hoped they would notice when she felt embarrassed and support her in managing her blood glucose at school, especially during exams. (N10, mother)

From the family perspective, support from relatives, such as grandparents, helped monitor the child and promote positive behaviours. Families also sought guidance from healthcare professionals and online information to keep up‐to‐date on diabetes management.

We help him learn about complications through computer resources, so he understands the challenges and potential harm of diabetes. (N13, mother)

Children noted that support from friends created a non‐discriminatory environment, which facilitated dietary management and blood sugar management.

Although I eat different foods from my friends, they don't mind and even invite me to join them. (N4, child)

• 4 Avoiding unhealthy behaviours: Distracting the child's attention was an effective way to prevent negative coping behaviours when diabetes was not well managed (parental perspective).

When his blood sugar was high, we distracted him with walks, taking the dog out, or other activities. (N13, mother)

Parents and children reported that managing snack intake was crucial for diet management. Parents implemented measures to reduce unnecessary snacking, such as limiting access at home.

If I'm the only one at home doing homework, my mom locks the snacks in the kitchen. I can have a little only if my blood sugar is normal. (N15, child)

4. DISCUSSION

This study explored families' coping strategies for improving the psychological and behavioural adaptation of older children and adolescents with T1D from the perspective of parents, children and families. The main findings indicate that families primarily use emotional exchange, verbal support, companionship and alternative compensation to promote emotional adjustment. Families helped older children and adolescents with diabetes develop a sense of identity and develop positive role models, which facilitated the formation of positive beliefs. Additionally, families enhanced children's diabetes self‐management through reinforcing parental and children's roles and responsibilities, cognitive behavioural modifications, expanding the supportive environment and avoiding unhealthy behaviours. Results offer valuable insights for healthcare professionals to design family‐based interventions that optimise both diabetes management and psychological well‐being.

Several older children and adolescents in this study had been diagnosed within three months prior to the interview. At this early stage, long‐term family adaptation processes may not yet have fully developed. Nevertheless, some overarching themes of family coping strategies emerged across families with different diabetes durations. Families with a shorter duration appeared to focus more on reducing psychological distress, whereas families with a longer duration tended to emphasise establishing positive beliefs and developing family‐tailored diabetes management strategies. This pattern may suggest that family adaptation evolves over time, with resilience potentially strengthening as families gain experience in managing the condition. Previous research has shown that family resilience is positively associated with children's psychological resilience and self‐management behaviors in T1D. ²⁴ However, as this study did not conduct a formal comparison of coping strategies across different diagnostic durations, these findings should be interpreted cautiously. Future longitudinal qualitative studies are warranted to further explore how family adaptation changes over time since diagnosis.

Notably, strategies for promoting psychological and behavioural adaptation differed across the perspectives of parents, children and families, highlighting the complexity of diabetes management in pediatric populations. From the parental perspective, the focus was often on emotional regulation and strengthening parental responsibilities to maintain stability in daily diabetes management routines. In contrast, children emphasised the emotional and social challenges they faced, including stigma, fear and the struggle for autonomy in self‐management. The family perspective highlighted the importance of fostering a supportive home environment and maintaining normalcy in daily life and psychological functioning. These divergent views suggest that healthcare providers should engage all family members in the treatment process, ensuring that emotional needs are understood and behavioural goals are aligned within families. Moreover, involving children in decision‐making and empowering them with diabetes self‐management skills can promote autonomy and enhance psychological resilience. ²⁵

In a recent study, parents of children with T1D reported difficulty understanding and managing their child's psychological needs, which often led to parent–child conflict. ²⁶ Findings from our study illustrated how parents promoted emotional adjustment in older children and adolescents with T1D, identifying four supportive strategies employed by parents. Among these, emotional exchange emerged as a direct and easily implemented approach within families. Parents expressed love and sympathy towards their children, and this emotional conveyance helped reduce anxiety. This study also found that using conceptual metaphors was effective in reducing children's negative perceptions associated with T1D. In addition, companionship, though often overlooked, played a significant role in promoting children's mental health. Parents emphasised that they were confronting diabetes‐related challenges together with their children. This fostered a sense of security in children, who knew that support was always available. ²⁷ A qualitative study similarly highlighted the importance of being together as a protective factor for improving emotional well‐being among children with chronic diseases. ²⁸ Distinct from previous research, our study found that some parents provided alternative compensations (e.g., activities or gifts) to reduce disappointment and enhance children's sense of fairness compared with siblings and peers. Therefore, providing tangible behavioural support, such as fighting together positively and activity‐based compensation, can reduce negative emotions and promote psychological adjustment in older children and adolescents with T1D.

Positive attitudes toward diabetes have been found to predict the intention to engage in self‐care behaviours in individuals with type 2 diabetes. ²⁹ A qualitative study by Azimi et al. ³⁰ revealed that ‘finding the positives’ was a key experience for mothers of children with T1D. In contrast, our study found that parents guided their children to ‘dance with diabetes’, fostering a positive outlook on life with the condition. Parents encouraged children to focus on the positive aspects of disease management and conveyed moral and traditional values to help establish meaning and purpose in living with diabetes. Simultaneously, the family as a whole worked to foster hope for the future and maintain normalcy, supporting long‐term psychological adaptation. These findings suggest that healthcare providers should encourage families to cultivate positive attitudes and shared values toward diabetes, helping children develop confidence and a sense of normalcy that underpin long‐term psychological adjustment.

Leung et al. ³¹ found that adolescents with T1D established identity by using self‐confidence to deflect stigma and discrimination from the community. In our study, however, parents actively fostered a sense of identity in their children, not only reducing feelings of discrimination but also providing respect and promoting personal development. Children reported that feeling valued by their parents enhanced their self‐worth and self‐confidence, forming a foundation for positive growth. Furthermore, older children and adolescents considered parents, peers, or even ordinary people as role models, which could enhance self‐efficacy and hope for positive development. However, it is essential for parents to carefully select role models, as negative attitudes or misconceptions could undermine children's confidence in effectively managing diabetes. ³²

Parents play a crucial role in supporting older children and adolescents' transition from dependence to independence in diabetes management. Four overarching strategies emerged from this study to enhance diabetes self‐management. Strong parent–child relationships, parental monitoring, and involvement have been associated with improved diabetes management and better glucose levels. ¹² , ³³ This study also identified additional strategies reported by parents (e.g., setting boundaries), families (e.g., mutual negotiation) and children (e.g., viewing parents as ‘the second doctor after myself’). Children described that they perceived parents as a second doctor motivated them to take on self‐care responsibilities while feeling safe. Thus, parents should balance their relationship with their children by clarifying their roles in diabetes management and effectively empowering children to gradually assume responsibility for managing their condition.

Cognitive‐behavioural adjustments were important for modifying children's diabetes management behaviours. Notably, some strategies were particularly effective in certain families or for addressing complex challenges, such as situation‐based reflection and actionable plans. In this study, children received actionable plans from their mothers, which helped them regulate blood sugar when it was abnormal. Simplified strategies for balancing diet, exercise, glucose management and insulin therapy can make self‐management more accessible for children. Healthcare providers can facilitate family communication about diabetes management experiences and simplify intervention strategies to promote health consequences.

Parents further supported children by expanding the supportive environment, including school and online support. However, unlike other studies, ¹¹ children in this study perceived little or no support from their schools. Some were reluctant to disclose their health condition to teachers or classmates due to concerns about stigma, discrimination, or being treated differently. ³⁴ Otherwise, existing school health resources may be insufficient for regular glucose monitoring, dietary management, or emergency care during school hours, ¹¹ limiting children's ability to manage diabetes effectively. Given the small sample size of older children and adolescents in this study, these results should be interpreted with caution. Nonetheless, findings highlight the need to develop more supportive school environments to reduce discrimination and promote effective diabetes management.

Existing research on family adaptation to T1D has mainly been conducted in Western countries. ¹¹ , ³⁵ Our findings provided additional insights into the positive coping processes of Chinese families. Similarities were observed across contexts, including maintaining normalcy, rejecting the patient identity and actively seeking social support. ¹⁰ , ³⁶ These shared strategies suggest that families universally strive to support older children and adolescents' psychological and behavioural adaptation. However, some differences were evident. Whereas Western studies often emphasise autonomy and early independence in self‐management, families in our study described a more family‐centred pattern characterised by value‐based guidance and more family's responsibilities. For example, some parents encouraged their children to engage with traditional cultural teachings to cultivate responsibility and strengthen motivation for diabetes self‐management. In addition, families frequently reported receiving support from extended relatives, which contrasts with findings from some Western studies where support was more commonly sought from community services and organisations. ¹⁰ , ³⁵ This interpretation is consistent with prior evidence indicating that family‐based interventions may be particularly effective in Asian contexts. ³⁷ The distinct pathways of adaptation observed across regions highlight the importance of considering sociocultural context when interpreting family coping processes and designing future interventions.

The study provides valuable insights into the coping strategies employed by families to promote psychological and behavioural adaptation in older children and adolescents with T1D. The findings underscore the importance of family support and involvement in diabetes management ³⁷ and suggest potential avenues for family‐based interventions in healthcare practice. First, parents play a crucial role in providing emotional exchange, verbal support and companionship to mitigate the negative emotions experienced by their children. Healthcare providers should recognise and address the emotional needs of both patients and their families. Second, families should establish a meaningful outlook on life, foster a sense of identity and provide positive role models to enhance children's beliefs and attitudes. Integrating moral education with resilience‐enhancing strategies could strengthen family‐based interventions. ³⁸ Third, parents can enhance children's self‐management behaviours through setting boundaries, mutual negotiation and distraction strategies, thereby empowering children to manage diabetes independently while still receiving necessary support. Fourthly, families can develop personalised diabetes management plans based on previous experiences, optimising the relationship between glucose levels, diet and insulin. Finally, multidimensional interventions that incorporate resources from schools, relatives, peers and online platforms can improve the overall diabetes management environment.

Several limitations may affect the transferability of the study findings. First, conducting interviews online may have influenced participants' responses, potentially affecting openness and accuracy. Second, the inability to observe participants' expressions or behaviours could limit trustworthiness. Third, the number of parents exceeded that of children, which may have resulted in a greater proportion of strategies being reported from the parental perspective. Some findings should therefore be interpreted cautiously when generalising to broader populations. Fourth, despite reaching information power, the relatively small number of participating older children and adolescents may have limited the range of adolescent experiences captured. Recruitment challenges in this age group, including school schedules, parental gatekeeping or adolescents' preference for peer over family discussions, may have contributed to this limitation. Fifth, although parents were asked not to intervene during interviews with older children and adolescents, their presence in some cases may still have influenced how openly children expressed their views. Finally, the interview guides were developed by the research team rather than in collaboration with participants and were not formally pilot‐tested before data collection. In addition, member checking was not conducted during the analysis process. These factors may have limited the representativeness and credibility of the findings. Future research should recruit larger and more balanced samples, employ multiple data collection methods, conduct formal pilot testing, incorporate participant validation and ensure separate interviews for parents and children to capture diverse perspectives and enhance credibility.

5. CONCLUSIONS

This study provides a comprehensive summary of the perspectives of parents, older children and adolescents with T1D on family coping strategies for psychological and behavioural adaptation. Three key themes emerged: support and compensation, transcendence and identity and cooperation and development. These findings offer practical insights for designing family interventions. A multi‐perspective approach highlights the importance of developing personalised care plans that consider the unique dynamics of each family member. Family‐based interventions can integrate strategies that recognise. This family strengths, address potential conflicts or negative perceptions related to diabetes and clarify roles in diabetes management. Healthcare providers can apply specific coping strategies identified in this study, such as distracting attention and situation‐based problem‐solving, to guide parents in addressing psychological distress and behavioural challenges experienced by their children.

AUTHOR CONTRIBUTIONS

Huijing Zhang: Data collection, software, conceptualization, formal analysis, investigation, writing—original draft. Kun Li: Formal analysis, writing—review & editing. Dan Luo: Formal analysis, writing—review & editing. Yi Wu: Formal analysis, writing—original draft. Mingzi Li: Resources, supervision, project administration, writing—review & editing.

FUNDING INFORMATION

This work was supported by the National Natural Science Foundation of China (NSFC) (grant number 72074008), the National Natural Science Foundation of China (grant number 72204125) and King's College London‐Peking University Health Science Center Joint Institute for Medical Research (grant number BMU2021KCL003).

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

ETHICS STATEMENT

Our study was approved by the ethics committee of Peking University Health Science Center (approval no. IRB00001052‐21050) and the ethics committee of Beijing Children's Hospital (No. 2020‐Z‐166).

CONSENT

All participants provided written informed consent prior to enrollment in the study.

Supporting information

Data S1.

Table S1.

DATA AVAILABILITY STATEMENT

Research data are not shared.