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. 2012 Sep 26;38(2):141–150. doi: 10.1093/jpepsy/jss102

What Mom and Dad Don’t Know CAN Hurt You: Adolescent Disclosure to and Secrecy From Parents About Type 1 Diabetes

Peter Osborn 1,✉, Cynthia A Berg 1, Amy E Hughes 1, Phung Pham 1, Deborah J Wiebe 2
PMCID: PMC3579162  PMID: 23009958

Abstract

Objective To examine how adolescent disclosure to and secrecy from parents were related to parental knowledge of diabetes management behaviors, and to adolescent adherence, metabolic control, and depressive symptoms. Methods A total of 183 adolescents with type 1 diabetes reported on disclosure to and secrecy from parents regarding diabetes management, adherence behaviors, depressive symptoms, and perceptions of parental knowledge. Mothers and fathers reported on their own knowledge. Results Adolescent disclosure was associated with all reporters’ perceptions of knowledge. Secrecy from both parents moderated the relationship between disclosure and adherence, and secrecy from fathers moderated the relationship between disclosure to fathers and glycosylated hemoglobin level. In all cases, disclosure was associated with better diabetes management only when secrecy was low. Finally, higher secrecy related to greater adolescent depressive symptoms. Conclusions Disclosure to parents appears to be an important component of how parents get their knowledge about adolescents’ diabetes management, but may be most beneficial for diabetes management when it occurs together with low secrecy.

Keywords: adherence, disclosure, parental knowledge, parental monitoring, secrecy, type 1 diabetes

The management of type 1 diabetes during adolescence is challenging, as adolescents expect and are granted more autonomy (Tilton-Weaver & Marshall, 2008) and illness-related responsibilities (Helgeson, Reynolds, Siminerio, Escobar, & Becker, 2008). Diabetes management is better when parents remain involved in diabetes care through parental monitoring, a construct frequently measured as parents’ overall knowledge of their adolescents’ illness management (Ellis et al., 2007b, Berg et al., 2008). Parents gain knowledge about management behaviors through their own attempts (direct observation, questioning their adolescents, structuring their activities, and relying on others for information, see Crouter, Bumpus, Davis, & McHale, 2005; Ellis et al., 2012), as well as through information adolescents actively disclose to them (Stattin & Kerr, 2000). Adolescent disclosure appears crucial for understanding the benefits of parental knowledge on a range of adolescent outcomes, as teens spend increasing time away from their parents’ presence (e.g., Darling, Cumsille, Caldwell, & Dowdy, 2006; Kerr, Stattin, & Burk, 2010; Smetana, 2008; Tilton-Weaver et al., 2010).

Although adolescent disclosure is key to understanding links between high parental knowledge and positive adolescent adjustment, Frijns, Keijsers, Branje, & Meeus (2010) noted that commonly used measures of adolescent disclosure (e.g., Stattin & Kerr, 2000) confound adolescents’ voluntary disclosure to parents with keeping secrets from parents. These two constructs are not simply opposites along a single continuum, as youth can disclose while also keeping secrets about their lives. Furthermore, secrecy is associated with adolescent problems such as depression beyond the effects of disclosure (Finkenauer, Engels, & Meeus, 2002; Frijns, Finkenauer, Vermulst, & Engels, 2005; Frijns et al., 2010), presumably because of the different benefits of disclosures versus the costs of secrecy (e.g., Lane & Wegner, 1995; Wismeijer, 2011). For youth with diabetes, disclosing to parents may be beneficial by increasing parental knowledge and eliciting their involvement when adolescents need help. However, adolescents most often keep information secret from parents to avoid punishment or disapproval for negative behaviors (e.g., Smetana, 2008). Keeping secrets about instances of poor diabetes management may skew parents’ knowledge of problems with their adolescent’s illness management behaviors. Secrecy about problems with diabetes management could also be psychologically taxing on adolescents, as it involves self-monitoring to avoid the truth from being known (Pennebaker, 1997). The primary aim of the present study was to examine whether disclosure and secrecy among adolescents with type 1 diabetes were uniquely associated with parental knowledge of diabetes, and whether these constructs were related to adolescents’ health (adherence, metabolic control) as well as psychological (depression) outcomes. Depression is an important outcome because youth with diabetes experience heightened risk for depression, and depressive symptoms may undermine diabetes management (e.g., Korbel, Wiebe, Berg, & Palmer, 2007).

Although secrecy is uniquely associated with negative outcomes in the general developmental literature (Finkenauer, Frijns, Engels, & Kerkhof, 2005; Frijns et al., 2010; Laird & Marrero, 2010), it remains unclear whether secrecy and disclosure operate independently or whether they interact to predict outcomes such as adherence, glycemic control, or depression. Disclosure and secrecy may be uniquely (i.e., independently) associated with how well adolescents manage their illness. Alternatively, secrecy and disclosure may interact such that disclosure to parents is most beneficial when adolescents simultaneously keep few secrets from their parents. For example, if adolescents tell parents a great deal about their diabetes care, but also keep important information regarding diabetes problems from them, parents may be unable to offer adequate support. Given the complex demands of type 1 diabetes, the combination of disclosure and secrecy will likely be important for understanding diabetes care behaviors.

Adolescent disclosure and secrecy may be differentially associated with measures of parental knowledge depending on whether adolescents or parents are the reporters, as parents are not privy to information adolescents keep secret from them. Adolescent reports of parental knowledge may be informed by what they keep secret from parents—information that they alone have access to—whereas parent reports may rely more heavily on disclosed information. An important aspect of the present study was to explore whether adolescents’ reports of disclosure and secrecy may relate to both adolescents’ and parents’ reports of parental knowledge.

Disclosure and secrecy may also be differentially related to adolescent outcomes when they occur with mothers versus fathers (Bumpus, Crouter, & McHale, 2001; Smetana, Metzger, Gettman, & Campione-Barr, 2006), given that mothers are often more responsible for and involved in their adolescent’s diabetes (Seiffge-Krenke, 2002). Adolescents tend to confide more in mothers than fathers about schoolwork and personal issues (Smetana et al., 2006). Given mothers’ more prominent role in managing and monitoring diabetes care, it is possible that keeping secrets from mother may be associated with poorer health outcomes than keeping secrets from father.

The present study examined how disclosure and secrecy related to both adolescent and parent reports of knowledge, and to measures of adolescent adherence, metabolic control, and depressive symptoms. Adolescents reported separately on their perceptions of maternal and paternal diabetes knowledge; mothers and fathers reported on their own knowledge. Furthermore, adolescents assessed the amount they disclosed to each parent, as well as the amount they kept secret, regarding their diabetes. Consistent with the broader developmental literature (Smetana et al., 2006; Stattin & Kerr, 2000), we expected that adolescent disclosure and secrecy would be uniquely associated with adolescents’ own reports of parental diabetes knowledge, and that disclosure, but not secrecy, would be uniquely associated with parents’ reports of knowledge. In line with research on adolescent depression, delinquency, and other negative behavioral outcomes, we predicted that secrecy regarding diabetes management would be uniquely associated with negative health outcomes above the effects of disclosure, and that disclosure would be more beneficial when secrecy was low. Finally, we explored whether disclosure to and secrecy from mother showed a different pattern of associations with adolescent outcomes than did disclosure to and secrecy from father.

Methods

Participants

The Institutional Review Board approved the study. Parents gave written informed consent, and adolescents gave written assent. The present cross-sectional data were drawn from the fourth wave of data collected as part of a larger longitudinal study that examined 252 families every 6 months for 3 years. Participants in the larger study were recruited during routine outpatient visits to a university diabetes clinic (76%) or a community-based private practice (24%) that followed similar treatment regimens. Eligibility criteria at enrollment included 10 - to 14-year-olds with type 1 diabetes for at least 1 year, living with mother (because the larger study targeted the mother–adolescent dyad), and able to read and write English or Spanish. Of the qualifying patients approached, 66% agreed to participate; refusals primarily involved distance and time constraints and lack of interest in being studied. Eligible adolescents who did versus did not participate were older (12.5 vs. 11.6 years, t(367) = 6.20, p < .01), but did not differ on gender, pump status, glycosylated hemoglobin (HbA1c), or illness duration (ps > .20). Participants were primarily Caucasian (94%) and middle class, with 73% of families earning >$50,000 a year. Measures of disclosure and secrecy were added to the longitudinal protocol at time 4 (i.e., 2 years after enrollment). Although 194 adolescents completed measures at this time point, 10 were missing data on fathers’ knowledge because no biological or stepfather was in the home, and one was missing data on mothers’ knowledge. Thus, 183 adolescents were included in the present analyses (M age = 14.1 years, standard deviation [SD] = 1.51, 53.8% females). More than half (64.4%) of adolescents were on an insulin pump, with the remainder prescribed multiple daily injections. These 183 participants did not differ from those in the longitudinal cohort who did not complete time 4 measures on age or illness duration, but they did have better metabolic control at enrollment as indexed by lower HbA1c (M [SD] = 8.24 [1.53] vs. 8.68 [1.67], t(249) = −2.05, p = .04). In all, 178 mothers and 134 fathers also reported on their own knowledge of their adolescent’s diabetes management and on their perception of their adolescent’s adherence to diabetes care regimens.

Procedure

Participants individually completed measures either at home (i.e., adherence) or during a scheduled laboratory visit (i.e., parental knowledge, disclosure and secrecy, depression). For all questionnaires, participants received oral and written instructions to complete them individually and to direct questions to the investigators rather than family members.

Measures

Parental Knowledge

Adolescents completed a scale consisting of six items to capture parents’ knowledge of adolescents’ daily activities concerning diabetes management (Berg et al., 2008), modeled after Barber’s (1996) parental monitoring scale. Adolescents reported how much mothers and fathers really know about their diabetes management (e.g., blood sugar readings, insulin taken) using a 1 (doesn’t know) to 5 (knows everything) scale; mothers and fathers reported on their own knowledge (α ≥ .87 for all reporters).

Diabetes Disclosure and Secrecy

Adolescents completed five items from Stattin and Kerr’s (2000) disclosure measure (α = .81; 2-month test–retest reliabilities = .87), modified to capture how much information adolescents disclose to or keep secret from their mother and father about diabetes care. Adolescents rated on a 1 (strongly disagree) to 5 (strongly agree) scale their agreement with statements separately about their mother and father. The disclosure subscale contained three items (“I spontaneously tell my [mother/father] about what is going on with my diabetes management,” “I often want to tell my [mother/father] what is going on with my diabetes management,” “I like to tell my [mother/father] about my diabetes management”), and the secrecy subscale contained two items (“I keep a lot of secrets from my [mother/father] about my diabetes management,” “I hide a lot from my [mother/father] about my diabetes management during nights and weekends when I am away from [her/him]”). This measure has no previous use in a population of adolescents with type 1 diabetes, but the original scale has been validated in an adolescent population (Stattin & Kerr, 2000). The disclosure (mother α = .83, father α = .90) and secrecy (mother α = .86, father α = .93) subscales had excellent reliability in the present study.

Adolescent Depressive Symptoms

Adolescents completed the Children’s Depression Inventory (CDI; Kovacs, 1985), a 27-item self-report scale that indicates depressive symptoms (e.g., disturbances in mood, self-evaluation). This scale has high internal consistency (α = .85 in our sample) and is associated with difficulties in managing diabetes (e.g., Grey, Davidson, Boland, & Tamborlane, 2001; Kovacs, Goldston, Obrosky, & Bonar, 1997).

Adherence

Adolescents and parents completed a Self Care Inventory (adapted from La Greca, Follansbee, & Skyler, 1990) to assess adherence to 16 different aspects of the diabetes regimen over the preceding month (1 = never did this to 5 = always did this as recommended without fail). La Greca’s scale was adapted by updating items and adding two items with the assistance of a certified diabetes educator to reflect the current focus on carbohydrate counting and adjusting insulin. Average scores across all 16 items were computed. This scale has excellent reliability (α ≥ .85 across reporters) and correlates well with more time-intensive measures of adherence (Lewin et al., 2009).

Metabolic Control

Adolescents’ metabolic control was indexed by HbA1c recorded in medical records. HbA1c was obtained using the Bayer DCA2000 by clinic staff. Participant authorization provided access to medical records to obtain other illness information (e.g., pump status, illness duration).

Analysis Plan

A mean substitution strategy was used to replace missing data for individual items on scales when <20% of the items were missing. We first conducted two mixed-design analyses of variance to determine whether female and male individuals significantly differed in their ratings of mothers’ and fathers’ knowledge, disclosure, and secrecy. Multiple regression analyses were then performed to examine the unique associations of secrecy and disclosure and their interaction with adolescent and parent reports of parental diabetes knowledge. Similar analyses were then conducted to understand the unique and interactive associations of disclosure and secrecy with adolescent and parent reports of adherence, HbA1c, and adolescent report of depressive symptoms. Significant interactions were further explored through simple slopes analyses.

Results

Preliminary Analyses

Means and correlations among variables are reported in Table I. Disclosure to parents was associated with higher parental knowledge and lower secrecy, as well as with better adherence and lower depressive symptoms. Secrecy from parents was associated with lower parental knowledge, with lower adherence, and with higher depressive symptoms. Secrecy from mothers was correlated with poorer (higher) HbA1c. Not surprisingly, older adolescents reported lower parental knowledge and disclosure, and higher secrecy from mothers. Three 2 × 2 mixed-design (adolescent sex as between-subjects variable, report of mother/father as within-subjects variable) analyses of variance were conducted to assess whether female and male individuals differed in their ratings of mothers’ and fathers’ diabetes knowledge, disclosure, and secrecy. The interaction between sex and mother versus father revealed that boys rated their fathers as knowing more about their diabetes (M = 3.07, SD = .12) than did girls (M = 2.61, SD = .13) (F (1, 171) = 5.35, p = .02). No differences were found between girls’ and boys’ ratings of mothers’ knowledge. Similarly, the interaction between sex and disclosure to mother versus father revealed that boys disclosed more about their diabetes to fathers (M = 3.02, SD = .14) than did girls (M = 2.55, SD = .12) (F (1, 166) = 9.8, p = .00). No differences were found between boys’ and girls’ disclosure to mother. No sex differences were found between teen reports of secrecy from mother and father.

Table I.

Correlations and Descriptive Statistics for Study Variables

1 2 3 4 5 6 7 8 9 10 11 12
1. A report of M knowledge 1.0
2. A report of D knowledge .63** 1.0
3. M report of M knowledge .42** .19* 1.0
4. D report of D knowledge .28** .46** .25** 1.0
5. A report of disclosure to M .50** .40** .35** .09 1.0
6. A report of secrecy from M −.23** −.21** −.16* −.15 −.41** 1.0
7. A report of disclosure to D .44** .71** .22** .29** .69** −.28** 1.0
8. A report of secrecy from D −.18* −.27** −.13 −.26** −.24** .68** −.3** 1.0
9. Age −.35** −.21** −.29** −.27** −.35** .20** −.24* .20* 1.0
10. HbA1c −.05 −.02 −.19* −.04 −.14 .23** −.11 .09 .04 1.0
11. A report of adherence .33** .35** .28** .19* .44** −.38** .43** −.33** −.21** −.36** 1.0
12. A report of depression −.20** −.25** −.10 −.21* −.21** .38** −.24** .35** .10 .18* −.29** 1.0
Mean (SD) 3.59 (0.87) 2.82 (1.12) 3.41 (0.72) 2.97 (0.76) 3.32 (1.01) 1.79 (0.92) 2.76 (1.20) 1.78 (1.01) 14.05 (1.51) 8.71 (1.72) 3.88 (0.58) 5.10 (5.47)
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Note. A = adolescent; M = mother; D = father.

*p < .05; **p < .01.

Preliminary analyses were also conducted to determine whether the age and sex of teens significantly moderated the associations of teen disclosure and secrecy with reports of knowledge, adherence, HbA1c, or depressive symptoms. Because no interactions were found (ps > .05), we did not include age or sex as additional moderating variables in the primary analyses reported later in the text. That is, neither sex nor age moderated the associations of disclosure and secrecy with parental knowledge or any outcome variable.

Associations of Disclosure and Secrecy With Parental Knowledge of Diabetes

We ran four multiple regressions with adolescent, mother, and father reports of parental diabetes knowledge serving as outcome variables. In each model, we included as predictors adolescent reports of disclosure and secrecy and their interaction (calculated after centering each independent variable, Aiken & West, 1991). Age, pump status, and illness duration were included as covariates, given their relationship to diabetes management outcomes (Wiebe et al., 2010). Because the primary aims were to examine associations of disclosure and secrecy with parental knowledge and outcomes, we do not report the significant effects of covariates in these analyses. Across all reporters, greater adolescent disclosure was associated with more parental knowledge: adolescents’ report of mother (B = .37, t(166) = 5.70, p = .00, 95% confidence interval [CI] .24, 49), adolescents’ report of father (B = .65, t(155) = 10.96, p = .00, 95% CI .53, 76), mother’s report (B = .21, t(155) = 3.40, p = .00, 95% CI .09, 33), and father’s report (B = .16, t(121) = 2.62, p = .01, 95% CI .04, 28). Across all reporters, neither secrecy (ps > .09) nor the secrecy by disclosure interaction (ps > .07) was associated with parental knowledge. These models predicted significant proportions of the variance in parental diabetes knowledge: for adolescents’ reports of mothers’ knowledge (R2 = .26, F(5, 166) = 10.70, p < .01), adolescents’ reports of fathers’ knowledge (R2 = .23, F(5, 155) = 32.01, p < .01), mothers’ reports (R2 = .13, F(5, 163) = 4.61, p < .01), and fathers’ reports (R2 = .17, F(5, 121) = 4.52, p < .01). Thus, across all reporters, disclosure to parents, but not secrecy, was a significant unique predictor of parental knowledge.

Associations of Disclosure and Secrecy With Adolescent Outcome Variables

Two multiple regression models were conducted predicting teens’ reports of adherence from their reports of disclosure and secrecy with mother and father (see Table II). Disclosure, secrecy, and their interaction were significantly associated with adherence in both models. Greater disclosure was associated with better adherence, whereas greater secrecy was associated with poorer adherence. The interaction between secrecy and disclosure with mothers is graphed in Figure 1, plotting adherence at 1 SD above and below the mean of teen secrecy; the shape of this interaction was identical for disclosure to and secrecy from fathers. Simple slopes testing (Preacher, Curran, & Bauer, 2006) indicated that the slope was significantly different from zero for adolescents with low secrecy from mothers and from fathers, respectively, (slope = .29, t(166) = 5.61, p < .001; slope = .24, t(155) = 5.63, p < .001, respectively), but not for adolescents with high secrecy from mothers and from fathers (slope = .04, t(166) = .61, p = .54; slope = .02, t(155) = .30, p = .77, respectively). Thus, at lower levels of secrecy, adolescents with higher disclosure reported better adherence; however, higher levels of secrecy diminished the positive relationship between disclosure and adherence. Similar regressions were conducted using parents’ reports of adolescent adherence. In the analysis using mothers’ reports of adherence as the outcome, more adolescent disclosure was associated with higher mother reports of adherence (B = .10, t(161) = 2.16, p = .03, 95% CI .01, 19). No associations were found between disclosure, secrecy, and fathers’ reports of adherence.

Table II.

Regression Analyses for Adolescent Disclosure and Secrecy Associations With Self-Reported Adherence

Disclosure to/Secrecy from mother
 Disclosure to/Secrecy from father
B(SE B) 95% CI t p B(SE B) 95% CI t p
Pump status .14 (.09) −.03, 31 1.65 .10 .15 (.09) −.02,.31 1.70 .09
Age −.01 (.03) −.07, 04 −.47 .64 −.03 (.03) −.08,.02 −1.10 .27
Illness duration .00 (.00) −.00, 00 −.21 .84 .00 (.00) −.00,.00 −.11 .91
Disclosure .15 (.05) .06, 25 3.26 .00 .18 (.04) .04,.19 3.08 .00
Secrecy −.22 (.05) −.33, −.11 −4.03 .00 −.23 (.05) −.34, −.13 −4.39 .00
Disclosure × secrecy −.15 (.05) −.25, −.05 −2.83 .01 −.12 (.04) −.20, −.05 −3.25 .00
R2 = .29, F(6, 154) = 12.51** R2 = .29, F(6, 145) = 11.70**
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Note. **p < .01.

Figure 1.

Figure 1.

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Interaction of teen disclosure to mother and secrecy from mother associated with teen report of adherence.

Similar multiple regression models were conducted for HbA1c. Adolescents’ reports of secrecy from mother (but not disclosure) were uniquely associated with HbA1c, such that higher secrecy was associated with higher (worse) HbA1c levels (B = .32, t(156) = 1.98, p = .05, 95% CI .65, 00). The interaction between secrecy and disclosure to mother was not significant. The main effect for adolescents’ reports of secrecy from father was qualified by an interaction with disclosure to father (B = .34, t(147) = 2.94, p = .00, 95% CI .11, 57). The plot of this interaction (see Figure 2) indicated that disclosure to fathers was associated with better HbA1c only when adolescents reported keeping fewer secrets from fathers. Simple slopes testing revealed that each slope was significantly different from zero, but in opposite directions, for adolescents with low and high secrecy from fathers, respectively (slope = −.308, t(147) = −2.22, p = .03; slope = .380, t(147) = 2.01, p = .05, respectively). Disclosure to fathers was associated with better HbA1c only when adolescents reported low secrecy. These models predicted significant proportions of the variance in HbA1c levels: for adolescents’ reports of disclosure to and secrecy from mothers (R2 = .12, F(6, 154) = 3.55, p < .01), and adolescents’ reports of disclosure to and secrecy from fathers (R2 = .16, F(6, 145) = 4.52, p < .01).

Figure 2.

Figure 2.

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Interaction of teen disclosure to father and secrecy from father associated with HbA1c.

Multiple regression models for adolescent reports of depressive symptoms revealed secrecy from parents was the only significant predictor of adolescent reports of symptoms of depression. Adolescents’ reports of secrecy from mothers (B = 2.63, t(166) = 4.95, p = .00, 95% CI 1.58, 3.68, R2 = .18, F(5, 166) = 7.12, p < .01) and from fathers (B = 2.08, t = 4.18, df = 155, p = .00, 95% CI 1.10, 3.07, R2 = .18, F(5, 155) = 6.26, p < .01) were uniquely associated with higher depressive symptoms. All other effects were not significant (ps > .05).

Discussion

Our results add to the literature on the importance of parental monitoring and knowledge for adolescent diabetes management by suggesting that parents gain knowledge about their adolescent’s illness management through the information adolescents are willing to disclose. Our findings also suggest that keeping secrets about diabetes from parents is associated with poorer health and psychological outcomes in youth with diabetes. Secrecy from parents was related to diabetes health outcomes by moderating the relationship between disclosure to parents and teen reports of adherence, but only disclosure was associated with mother’s (not father’s) report of adherence. Furthermore, secrecy especially from mother was related to poorer HbA1c above and beyond the effect of disclosure. Similar to recent findings in the general developmental and clinical literature, keeping diabetes-related secrets from either parent was associated with higher depressive symptoms (e.g., Finkenauer et al., 2005; Frijns et al., 2010).

These results support a growing literature (e.g., Stattin & Kerr, 2000) indicating that parental monitoring questionnaires that contain items of parental knowledge (Ellis et al., 2007b; Berg et al., 2008) may be especially influenced by adolescent disclosure. When adolescents report about parental knowledge, they appear to consider how much they are disclosing to their parents, rather than what they keep secret. That is, disclosure was associated with adolescent reports of parent knowledge above and beyond their reports of secrecy from parents. These findings were predicted for parent reports of knowledge, as parents likely do not have access to information adolescents keep secret from them. However, these results were contrary to our expectations for adolescent reports, as we had predicted both disclosure and secrecy would be associated with adolescents’ reports of parental knowledge. One explanation for this result could be that the phrasing of questions commonly used to assess parental knowledge (“How much does your parent really know”) may prime youth to call to mind what they tell parents. Distinguishing between disclosures and secrecy about illness management is important for future research linking parental knowledge with health outcomes, given that disclosure and secrecy are associated differently with health outcomes.

As hypothesized, our results demonstrate that the secrets that adolescents keep may be important in understanding when adolescent disclosure about illness management is beneficial to their physical as well as psychological health. When teens reported high levels of secrecy about diabetes management, disclosure was not associated with better diabetes management. In addition, keeping secrets from parents was associated with higher depressive symptoms and appeared to undermine the benefits of disclosure. These results provide additional support for recent conceptualizations of the importance of secrecy for understanding maladjustment in the larger developmental literature (e.g., Frijns et al., 2010). The fact that disclosure alone was associated with mother (not father) reports of adherence suggests that mothers in particular rely on youth disclosure in making judgments about their child’s illness management. Such disclosure provides mothers with information about how well adherence is going and may facilitate their ability to provide necessary support and assistance. One explanation for the moderating effects of secrecy on the benefits of disclosure for diabetes management may lie in the reasons why youth choose to withhold information from parents. Smetana, Villalobos, Tasopoulos-Chan, Gettman, and Campione-Barr (2009) found youth disclose less to parents about issues pertaining to health and safety primarily because they are afraid of parental disapproval or punishment. Youth who are not adhering well to the diabetes regimen (e.g., forgetting to check blood glucose, miscounting carbohydrates, not adjusting insulin) may attempt to avoid getting in trouble for mismanagement by keeping these “slips” secret from parents. If adolescents keep their parents in the dark about their poor management decisions, they may not avail themselves of the possible guidance and assistance that their parents would otherwise be in a position to provide. In addition, maintaining secrecy is an effortful and psychologically taxing behavior (Frijns & Finkenauer, 2009), potentially making coping with their illness even more stressful.

Adolescent disclosure to and secrecy from mothers about diabetes were found to be associated with adolescent mental/physical health in different ways than disclosure/secrecy from fathers. For fathers, secrecy again moderated the relationship between disclosure and metabolic control, such that disclosure was associated with better HbA1c only when adolescents kept fewer secrets from their fathers. For mothers, secrecy was associated with worse HbA1c; neither disclosure to mothers nor the interaction between secrecy and disclosure was significantly associated with HbA1c. Because mothers are most often the parent involved in helping to manage and solve diabetes problems, keeping secrets about certain aspects of management (e.g., choosing not to bolus at mealtime) from mothers may be especially detrimental to metabolic control irrespective of information disclosure. The significant moderating effect of secrecy from both parents on the relationship between disclosure and adherence highlights that although disclosure alone uniquely related to adherence, having clear and open communication (i.e., high disclosure and low secrecy) with parents may boost adolescent adherence.

The study should be interpreted in the context of several limitations. The cross-sectional data limit our ability to make temporally based conclusions or to rule-out third-variable explanations of associations between disclosure and diabetes management. Longitudinal research is needed to understand how high disclosure to and low secrecy from parents may develop out of high-quality parent–child relationships and facilitate diabetes adherence. Further research is also needed to understand how secrecy from parents may reflect other long-standing risk factors such as externalizing behaviors that have been linked to poor diabetes outcomes (Horton, Berg, Butner, & Wiebe, 2009). It is likely that adolescents who keep secrets from their parents about diabetes management similarly keep secrets about other risky behaviors. Research is also needed to understand what aspects of diabetes management adolescents keep secret and whether particular types of secrets (e.g., high or low blood glucose) are more problematic than others (e.g., forgetting supplies). In addition, studies have indicated that telling lies, as opposed to not disclosing or purposefully keeping secrets, is a strong indicator of problematic behaviors in children and adolescents (e.g., Gervais, Tremblay, Desmarais-Gervais, & Vitaro, 2000). Future research should examine whether lying to parents about diabetes management is uniquely associated with mental and physical outcomes when compared with disclosure and secrecy. Finally, our results are restricted in generalizability, as our sample included participants who had been motivated to remain in a longitudinal study for 2 years, and who were in predominantly intact, white, English-speaking, middle-class families. Although similar patterns of disclosure and secrecy about adolescents’ general lives have been found across ethnicities and cultures (e.g., Bakken & Brown, 2010; Hunter, Barber, Olsen, McNeely, & Bose, 2011), replicating the present findings in a more ethnically diverse sample would be beneficial.

The finding that diabetes health outcomes are associated with adolescent disclosure only when secret-keeping is low may hold implications for promoting better illness management. Psychosocial interventions for adolescents with diabetes have often included family-based behavioral programs such as setting short- and long-term goals, developing and implementing reinforcement contingencies, creating behavioral contracts, and appropriately sharing responsibility for illness management (Anderson & Collier, 1999; Satin, La Greca, Zigo, & Skyler, 1989). By reducing negativity and increasing problem-solving knowledge and skills, interventions that promote family communication and parental support and involvement (Ellis, Naar-King, Templin, Frey, & Cunningham, 2007a) may work partially by increasing the likelihood that youth disclose to parents. Such interventions may be enhanced if they are able to not only increase disclosure but also reduce keeping secrets from parents. If family conditions fostering secret-keeping are too strongly entrenched and/or are unchanged by treatment interventions, health-related gains may be reduced. Family-based interventions that explore adolescents’ understanding of potential parental reactions to disclosures (e.g., anger) may assist in reducing adolescent secrecy to instances of poor management decisions. Future interventions, however, must be informed by developmental trends that suggest that keeping more things “private” from parents is a normal and even adaptive part of adolescent autonomy development (e.g., Finkenauer et al., 2002).

Funding

This research was supported by grant number R01 DK-063044 from the National Institute of Diabetes and Digestive and Kidney Diseases, awarded to Dr. Deborah J. Wiebe (PI) and Dr. Cynthia A. Berg (co-PI).

Conflicts of interest: None declared.

Acknowledgments

The authors thank members of the ADAPT research group for their valuable input and assistance during the development and execution of this project. They also thank the physicians and staff at the Utah Diabetes Center and Mountain Vista Medicine, as well as the adolescents and their families who participated in this study.

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