Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2017 Mar 1.
Published in final edited form as: J Pediatr Health Care. 2015 Jul 30;30(2):133–142. doi: 10.1016/j.pedhc.2015.06.005

General life and diabetes-related stressors in early adolescents with type 1 diabetes

Ariana Chao 1, Karl E Minges 1, Chorong Park 1, Susan Dumser 2, Kathryn M Murphy 2, Margaret Grey 1, Robin Whittemore 1
PMCID: PMC4733440  NIHMSID: NIHMS712546  PMID: 26234658

Type 1 diabetes (T1D) is one of the most common chronic pediatric illnesses. This autoimmune disorder is diagnosed in more than 15,000 children per year in the United States and requires extensive self-management with active involvement of both the adolescent and their family in diabetes self-management (CDC, 2014). Diabetes self-management is complex and demanding, requiring frequent blood glucose monitoring, carbohydrate counting, administration of insulin, and treatment of events of hypo- and hyperglycemia. Self-management is necessary to prevent short and long-term complications such as seizures, nephropathy, diabetic ketoacidosis, neuropathy, and retinopathy (Guo et al., 2011, Campbell et al., 2014). Self-management often requires frequent blood glucose monitoring and insulin injections or the use of pump therapy (both of which require frequent adjustment depending on food intake and physical activity). Diabetes self-management is intensive, constant, complex, and visible, contributing to feelings of stress and social awkwardness in adolescents.

Adolescence is a developmental and transitional time when youth experience physical, cognitive, and psychosocial changes. Physically, adolescents are going through puberty. Cognitively, they are developing advanced reasoning skills. Psychosocially, adolescents are establishing autonomy, developing self-conceptions, and becoming more involved with their peer groups (Stang & Story, 2005; Steinberg & Morris, 2001). Having a chronic health condition during adolescence can add additional stressors related to self-management with the potential for impact on both the chronic health condition and developmental tasks. These multiple developmental tasks may be stressful to adolescents and may be sources of general life stressors (Compas et al., 2012; Suris et al., 2004). Indeed, several research studies have examined the issues adolescents encounter while balancing chronic health condition stressors and negotiating the developmental challenges of adolescence. This is particularly evident in the asthma (Chen et al., 2003), cystic fibrosis (Christian & D’Auria, 1997), cancer (Decker, 2007), and congenital heart disease literature (Karsorp et al., 2007), yet less is known regarding the T1D-related stressors during adolescence, which is a critical developmental stage when diabetes self-management skills are learned and lifelong behavioral habits are formed (Bandura, 2004; Schilling et al., 2002).

Among adolescents with T1D, the combination of general life stressors related to adolescent growth and development and diabetes-specific stressors can contribute to physiological and psychological sequelae. Exposure to multiple general life and diabetes-specific stressors places high demands on adolescents with T1D, which may result in adverse health outcomes, such as a decline in metabolic control (Palta et al., 1996) or psychosocial challenges, such as depressive symptoms (Kovacs et al., 1997). Since there are multiple types of stressors, there has been recent discussion of the importance of classifying and identifying diabetes-specific stressors versus general stressors in order to better understand the phenomena and develop tailored interventions (Fisher et al., 2007).

There is a paucity of literature in which general life and diabetes-specific stressors are examined simultaneously, and previous studies have been primarily qualitative with small sample sizes (Davidson et al., 2004; Hema et al., 2009; Huus et al., 2007). Further research is needed to describe how general life and diabetes-specific stressors may overlap and intersect with one another in the context of adolescence. Each type of stressor may have different implications for framing clinical discussions, creating management plans, and assessing outcomes (Hermanns et al., 2006). Understanding the adolescent perspective of general life and diabetes-specific stressors from a mixed methods perspective may help inform clinical discussions and the development of interventions targeting stress in adolescents with T1D as it can help us gain a more complete and comprehensive understanding of this issue.

Therefore, the purpose of this study was to examine general life and diabetes-specific stressors from the perspective of early adolescents (ages 11-14) with T1D. We also examined differences in demographic and clinical characteristics of adolescents who perceived high diabetes-specific stress compared to adolescents who perceived high general stressors.

2. Materials and Methods

2.1 Design

We used cross-sectional secondary data analysis with descriptive and content analysis approaches to examine qualitative data from a multi-site randomized clinical trial. The randomized clinical trial compared the efficacy of two Internet psycho-educational programs for early adolescents with T1D: TEENCOPE™, an internet coping skills training program, and Managing Diabetes, a diabetes education program. Participants who were exposed to the TEENCOPE program were included in this analysis because only this arm of the study examined stressors. Details of the study and the primary study results have been published previously (Grey et al., 2012; Grey et al., 2009; Whittemore et al., 2012; Grey et al., 2013). We extracted online data of participant responses to interactive questions in a lesson on stress management.

2.2 Procedures

In brief, a convenience sample was recruited from four diabetes clinical sites: The Children’s Hospital of Philadelphia, University of Arizona, University of Miami, and Yale University. Inclusion criteria were early adolescents who were 11-14 years of age, diagnosed with T1D for at least 6 months, had no other significant health problems, in a school grade appropriate to age within one year, able to speak and write English, had access to high speed internet at home, school, or in the community, and were exposed to the TEENCOPE™ program. Institutional Review Boards at all clinical sites approved the study. Trained research personnel obtained informed consent from parents and assent from adolescents. Parents completed a demographic data collection form at the time of enrollment and adolescents were provided instructions for online collection of psychosocial data. Research assistants collected Hemoglobin A1c levels by chart review. Teens in the TEENCOPE™ program completed 5 weekly lessons that were presented in the following order: self-talk, communication skills, social problem solving, stress management, and conflict resolution (Grey et al., 2012).

The data reported in this analysis derive from the responses in the stress management lesson, which was the fourth out of five lessons. At the beginning of the stress management lesson, adolescents were asked to identify their top three stressors from a checklist, respond to open-ended questions about what was stressful about each of their top 3 stressors, and rate each stressors on a scale of 1(lowest) to 10 (highest). There were 7 available options on the checklist (school, family, social life, activities and sports, having diabetes, how I look, and other).

2.3 Participants

The sample used in this analysis included 205 adolescents. A little over half of the sample was female (58.4%) with a mean age of 12.28 (SD=1.08) years and mean diabetes duration of 6.32 (SD=3.50) years. The sample was 33.0% non-White and the mean HbA1c was 8.26 (SD=1.50) percent. A total of 59.3%, 24.7%, and 13.7% of the sample received pump therapy, basal injections, and convention injections, respectively.

2.4 Data and Analysis

We used descriptive statistics and both qualitative and quantitative content analysis methods to analyze the responses within the stress management lesson. Four researchers (AC, KEM, CP, and RW) with qualitative research experience conducted the data analyses. The content analysis approach entailed systematically coding and categorizing a set of data including both numeric and interpretive data analyses (Vaismoradi et al., 2013) to generate new insights and practical and clinical guidance (Krippendorff, 2012).

2.4.1 Quantitative content analysis

The responses of the top three stressors and the ratings of each stressor were analyzed quantitatively using descriptive statistics and counts (Morgan, 1993). We used t-tests and chi-square tests to see if there were any statistical differences in clinical and demographic characteristics between adolescents who perceived diabetes as one of their top stressors compared to adolescents who perceived general stressors as their top stressors. We also calculated the percentage of adolescents who chose diabetes as a top three stressor or identified diabetes in their open-ended response of a non-diabetes related stressor (i.e., glucose monitoring, administering insulin). We used SPSS version 22.0 (Armonk, NY) for statistical analysis.

2.4.2 Qualitative content analysis

For the qualitative content analysis, we used the inductive content analysis approach proposed by Elo and Kyngäs (2008), which entailed an iterative and collaborative process of data preparation, organization, and reporting. First, researchers read through the open-ended responses to immerse themselves in the data. Next, researchers independently used open coding with as many codes as necessary to describe the aspects of the content. Another team member independently verified these codes and consensus was reached among the four researchers if discrepancies emerged. After comparison and discussion, the codes were grouped under higher order categories and reviewed by all of the authors. Categories were then collapsed into themes based on identifiable, repeated descriptions of key issues and were discussed with all authors for feedback and editing (Elo & Kyngäs, 2008; Graneheim & Lundman, 2004).

2.4.3 Quality and trustworthiness

Multiple measures were used to enhance the quality and trustworthiness of analysis. Responses were independently analyzed by at least two members of the team. We incorporated coding checks and audit trails into data analysis procedures. In addition, clinicians and researchers with expertise in T1D in early adolescence verified that themes were understandable and consistent with patient experiences (Graneheim & Lundman, 2004; Marshall & Rossman, 2010).

3. Results

Eighty-two percent of adolescents reported that school was one of their top three stressors and only 6.7% mentioned diabetes in their response as contributing to school stress. Social life was the next highest with 49.0% of adolescents reporting this as one of their top three stressors and only 4.3% mentioned diabetes as contributing to social stress. Lastly, 48.1% of adolescents reported diabetes as one of their top three stressors (Figure 1). The stressors with the highest magnitude, defined as the perceived level of stress on a scale from one (lowest) to 10 (highest), were diabetes (M=5.87, SD=2.48), family (M=5.67; SD=2.34), and school (M=5.50; SD=2.09; Figure 2). There were no statistically significant differences in A1C, age, duration of diabetes, therapy type, gender, and race (White versus non-White) between adolescents who perceived diabetes as a top stressor compared to adolescents who perceived general stressors as top stressors (p>.05).

Figure 1. Top Stressors among Early Adolescents with T1D.

Figure 1

Open in a new tab

Note. The “Other” category was available for adolescents to select if they wanted to indicate an alternative stressor not listed.

Figure 2. Sample Mean of Perceived Magnitude of Stressors.

Figure 2

Open in a new tab

Note. Stressors were rated on a scale of 1 (lowest) to 10 (highest). Error bars represent 95% confidence interval. Mean magnitudes calculated including diabetes-related stressors in each category. There were no significant differences (p>.05) with and without including diabetes-related stressors in each category. The “Other” category was available for adolescents to select if they wanted to indicate an alternative stressor not listed.

The qualitative content analysis was undertaken to identify factors that adolescents perceived as contributing to general and diabetes-specific stressors. We identified five themes that encompassed general life stressors: fitting in, having friends, balancing competing demands, living with family, and feeling pressure to do well. Themes, codes and representative quotes are displayed in Table 1. We also identified three overall themes of diabetes-specific stressors: just having diabetes, dealing with emotions, and managing diabetes. Themes, codes and representative quotes for diabetes-specific stressors are displayed in Table 2.

Table 1.

Themes, Codes, and Representative Quotes about General Stressors in Adolescents with T1D

Theme Code Representative Quotes
Fitting In Popularity Every one says they want to be popular, and if your not popular than you will probably get
teased
Appearance Lately I feel that everyone worries about their appearance in middle school, probably mostly
because a lot of kids judge a book by its cover so we want to make a good impression
Bullying I am stressed because in middle school, everybody is judgmental. So if I don’t look good, I
might get picked on
Feeling different
due to diabetes		 Nobody understands what its (diabetes) like and no one tries to understand
Having
Friends		 Friends and dating There is so much drama between my friends this year…One day we’re the best of friends, the
next day we’re fighting

I can’t get a girlfriend
Disclosure of
diabetes		 I don’t want to tell any of my boyfriends that I have diabetes because then it makes me feel
weird and plus they probably feel weird about the situation themselves
Interacting with
friends about
diabetes		 A lot of my friends don’t understand the severity of my diabetes
Balancing
Competing
Demands		 Busy schedule I get up late for school and rush to get ready. I don’t get any time to eat breakfast. I also don’t
get enough sleep.
School work and
sports		 All the homework we get and all the tests we have to take

The pressure of winning (in sports), practice and fundraisers
Diabetes impact on
school and sports		 No one understanding how hard it is sometimes to have to balance schoolwork and diabetes.

Well I try to do as many activities as I can, but even gym class I go low so I have to stay out and
I missed volleyball it’s my favorite thing we do in gym.
Inconvenience of
diabetes		 Something that is stressful with having diabetes is that I have to come in the house in a certain
time because I have to eat and take my insulin.
Living with
family		 Desiring
independence		 I’m not allowed to go far from my house without my brother and sometimes I just want to be by
myself with them (friends) and they make fun of me like he’s my babysitter or something.
Nagging by
parents/Family
conflict		 My mom is always nagging me…I know she loves me, but she can be very annoying sometimes.
Family response to
diabetes		 That I sometimes get yelled at for having high blood sugars and it gets stressful.
Feeling
Pressure to
Do Well		 High expectations
of parents		 My parents have such a high standard of excellence that I just can’t meet all the time.
Sometimes I really think they forget that I’m human just like them and that I have problems and
limitations.
Pressure to have
good control of
blood sugar level		 Having to test every 3 hours and having the stress that something can go wrong if your sugars
aren’t good.
Open in a new tab

Table 2.

Themes, Codes, and Representative Quotes about Diabetes-Specific Stressors in Adolescents with T1D

Theme Code Representative Quotes
Just having
diabetes		 Everything Everything about diabetes is stressful. I have heart palpitations from the incredible stress of
diabetes.
Blood glucose
levels		 My blood sugar is way far from my target all the time.
Dealing with
emotions		 Uncertainty of
future		 Not being able to pursue my career desire.
Lifelong
responsibility		 It never goes away and everyone makes such a big deal about it.
Managing
diabetes		 Pain My pump site – some spots really really hurt.
Diabetes equipment Remembering to take my kit with me when I babysit and when I’m with my friends.
Remembering and
getting reminded		 Remembering to check my blood sugar and give the right amount of carbs. Which sometimes
my family has to remind me, which makes them upset and gets me stressed.
Regulating diet I’m tired of everyone saying ‘are you allowed to eat that?’ That makes me so mad.
Daily decision-
making		 Injecting myself at school is a total disaster – sometimes I get the shot late.
Open in a new tab

3.1. General Life Stressors

Fitting In

Adolescents with T1D discussed the importance of “fitting in.” This theme is comprised of the codes: popularity, appearance, bullying, and feeling different due to diabetes. Adolescents expressed a desire for popularity and dressing and looking like they fit in with their peers. They also expressed self-consciousness about their appearance, particularly, “pimples and soon to be braces” and “my hair…and my clothes”. Teens also commented how they were bullied at times which contributed to them feeling like they did not fit in. Some adolescents also mentioned that having diabetes contributed to not feeling like they “fit in” and were not normal in relation to their peers or family members.

Having Friends

Adolescents perceived the experience of making and keeping friends as a source of stress. This theme was derived from the codes: friends and dating, disclosure of diabetes, and interacting with friends about diabetes. Some adolescents stated that making friends was stressful; others perceived conflict and turmoil with friends and peers, including issues with rumors and gossip as stressful. As one teen stated, “Things can get complicated between me and my friends”. Another stated, “Sometimes we get into fights and I don’t know what to do.”

Most adolescents described general friendship stressors; however, for some teens having diabetes was a source a stress within the context of their friendships. Adolescents responded that telling friends and boy/girlfriends that they had diabetes was difficult. As one teen said, “I really don’t like to tell everyone that I have diabetes.” Lastly, interacting with friends about diabetes could also be frustrating and stressful as peers had misinformation or lacked understanding.

Balancing Competing Demands

Adolescents described stress due to competing demands and living a busy life, including a schedule comprising schoolwork, sports, extracurricular activities, and diabetes self-management. The theme was abstracted from the codes: busy schedule, school and sports, diabetes impact on school and sports, and the inconvenience of diabetes. Adolescents described the challenges of a busy life and balancing multiple demands. Some adolescents noted that other health behaviors were compromised in order to keep up with school and extracurricular activities, citing lack of physical activity, proper nutrition, sleep duration, and skipping breakfast. School and sports were also perceived as stressful, with a lot of homework, difficult teachers, and challenging sports practices.

Having diabetes made some adolescents feel like they were missing out on different facets of life due to the competing demand of having to deal with diabetes. For instance, some adolescents felt that diabetes prevented or limited them from fully participating in activities and events with friends as well as during sports and school. Others expressed that diabetes affected their ability to focus in classes, “If my sugars are high or low, it’s hard to concentrate.” Others reported that missing classes due to diabetes was stressful. Adolescents also responded that completing tasks related to diabetes was a nuisance and disruptive of daily life, especially managing diabetes in school, sports and when with friends. As one teen stated, “When my friends are over, we are busy doing stuff and then I have to go test. My friends also find it kind of annoying when I have to test in the middle of EVERYTHING!!”

Living with Family

Adolescents described feeling stress due to family life and a desire for independence. The codes within this theme were: desiring independence, nagging parents/family conflict, and the family response to diabetes. Adolescents commented about the desire for behavioral autonomy to make independent decisions about what they do (e.g., curfew, dating, clothing). They felt that parents were “overprotective” and “never let me do anything I really want to do”. Parental “nagging” to complete chores or make good decisions was perceived as a source of stress. Adolescents also reported that family conflict – “yelling”, “arguing”, and “screaming” – was stressful.

Congruent with adolescents’ desire for independence in other dimensions of their life, adolescents’ also expressed moving toward independence and transitioning to take responsibility for diabetes care and management. Yet, the transitional nature of care was also expressed and described as a source of family conflict. As one teen stated, “My dad freaks out if I don’t test”. Another teen stated, “Not being allowed to sleep over a friends because of my health, I hate it.”

Feeling Pressure to do Well

Some adolescents felt a pressure to do well, especially related to schoolwork, extracurricular activities, and diabetes self-management, which was abstracted from the codes: high expectations of parents and pressure to have good control of blood glucose levels. Many participants reported stress to excel academically in their schoolwork and in their extracurricular activities and sports. One teen stated that what was most stressful to her was “being PERFECT for my mom and dad…most of the time my dad acts like I’m not good enough for him.”

The sentiment of feeling pressure to do well was also expressed related to diabetes care. Adolescents conveyed a sense of feeling pressure to be perfect, often with the threat of long-term consequences related to T1D. One teen reported stress because, “something can go wrong if your sugars aren’t good”. Similarly, blood glucose levels and HbA1c were perceived to be similar to being graded in school.

3.2 Diabetes-Specific Stressors

Just Having Diabetes

For some adolescents, everything about diabetes and paying attention to blood glucose levels was stressful. As one adolescent stated, “Do I really have to say it? It’s diabetes – a disease no one wants.” Other adolescents expressed that being able to keep their blood glucose under control at all times was stressful. Having to pay close attention to their blood glucose levels, something that everyone else in their life did not have to do, contributed to worry and stress. As one adolescent reported: “When my sugar is really high, it gets to me.”

Dealing with emotions

Dealing with emotions was another diabetes-specific stressor, which included the codes uncertainty about the future and the lifelong responsibility of diabetes. One adolescent identified, “What’s going to happen to me in the future?” as her source of stress. Others stated that being responsible for diabetes was “hard, it takes a great deal out of you” and “I hate having to deal with diabetes management all the time.” Others expressed stress because the illness and self-management “never goes away” or “I wish I could have a day off.”

Managing Diabetes

The complex and at times painful self-management of T1D was reported as stressful to adolescents. The codes within this theme were: pain, diabetes equipment, remembering and being reminded, regulating diet, and daily decision-making. Frequent blood glucose monitoring and injections were painful and a source of stress. Wearing a pump to deliver insulin and needing blood glucose monitoring and other equipment with them at all times was also stressful. Both remembering and getting reminded to check their blood glucose levels was difficult for adolescents. As one teen reported: “Sometimes my family has to remind me which makes them upset and gets me stressed.” Adolescents also reported that it was hard to regulate their diet as well as have others monitor what and when they last ate. Finally, adolescents reported that the complexity of daily decisions was stressful. As one teen stated, “I can have high blood sugars and then I don’t know if I should put in insulin for it because I don’t know if it will make my blood sugar go low.”

4. Discussion

This content analysis was undertaken to gain a richer understanding of how early adolescents’ with T1D perceived stressors by examining both general life and diabetes-specific stressors. Though adolescents with T1D experience stressors specific to T1D, many reported stressors related to normal adolescent growth and development. Yet, many diabetes-specific stressors were inextricably linked to developmental tasks and general life stressors of adolescents.

Our results both support and extend previous qualitative studies that have examined general life and diabetes-specific stressors in youth with T1D. In a sample of six adolescents between the ages of 13 to 18 years who were undergoing initiation of intensive therapy management, T1D management as well as personal, relational, and situational factors were identified as stressors impacting self-care decisions and coping response (Davidson et al., 2004). In another study with eight adolescents with T1D between the ages of 14 to 18, adolescents perceived living with diabetes as a “pendulum swinging between being normal and being different” (Huus et al., 2007). T1D contributed to adolescents’ perception of being different and being treated differently at a time when they wanted ‘a regular life’.

Our results support these findings with a more explicit connection between how general and diabetes-specific stressors fit together. While adolescents in our study were more likely to report general life stressors compared to diabetes-specific stressors, diabetes-specific stressors were the highest in magnitude. In addition, diabetes-specific stressors frequently contributed to general life stressors. For example, ‘fitting in’ was a commonly endorsed general life stressor of adolescents with T1D, similar to the aforementioned studies (Davidson et al., 2004; Huus et al., 2007), as well as to the stressors reported by adolescents without a chronic health condition (McElhaney et al., 2008). In our study, adolescents with T1D reported stress about popularity, bullying, and their appearance, with a consistent message that they wanted their peers to like them. However, they also expressed how ‘fitting in’ was stressful due to the diabetes management equipment, tasks, and resultant different experiences from peers. Although diabetes can add additional stress, it is important that clinicians focus on general adolescent stressors, diabetes-specific stressors, and the interaction between general and diabetes-specific stressors.

Research supports that general and diabetes-specific stressors are related to poorer HbA1c, but only general stress has been shown to affect adherence behavior (Farrell et al., 2004). There is also indication that diabetes-specific stressors are related to both adjustment to living with diabetes and overall adjustment to the developmental tasks of adolescence; however, general stressors primarily impact overall adjustment (Malik et al., 2009). Whether or not stressors are of a general nature or are diabetes-specific has significant implications for how clinicians frame clinical discussions with early adolescents with T1D, and in the development of interventions to help early adolescents cope with stressors (Hermanns et al., 2006). Nonetheless, little of these issues have been examined in youth with T1D.

Recent attention has been brought to the importance of understanding the similarities and differences in stressors across chronic illnesses (Sawyer et al., 2007). Indeed, within the literature on chronic health conditions in adolescence, there is increasing acknowledgment that chronic health conditions affect an adolescent’s global developmental processes (Suris et al., 2004), and as also illustrated by our study, that the management of any chronic health condition during adolescence constitutes a major challenge to youth and families. Other common stressors experienced across chronic health conditions include identity, self-image, egocentrism, disclosure of health condition, dependence on caregivers, family functioning, peer support, risky behaviors, and adherence to treatment regimen (Suris et al., 2004). Although further work is needed to characterize the general- and chronic condition-specific stressors among adolescents, our results can be used to begin to develop a framework, and to assist clinicians in assessing general and disease-specific stressors experienced by adolescents, as well as providing anticipatory guidance about how to handle some of the common stressors.

We did not find differences in demographic or clinical characteristics between adolescents who did or did not choose diabetes as a top stressor. Previous research has demonstrated that diabetes-specific stress is associated with higher A1c, longer duration of diabetes, being female, being a minority, and psychological distress (Berlin et al., 2012; Delamater et al., 2013; Hains et al., 2006). Though we did not find similar relationships, this result should be interpreted cautiously. For instance, participants were enrolled in a behavioral intervention that could theoretically have impacted their perceptions of stressors, specifically those related to diabetes.

It is important to highlight several sample characteristics that influence the generalizability of this study. The mean age of participants in this study was 12.3 years, reflective of a young or pre-teen perspective. General and diabetes-specific stressors of older adolescents are likely to be different, including stress related to developing relationships, driving, risk-taking behaviors, and independent living (Jaser et al., 2011). In the SEARCH for Diabetes in Youth, a US population-based study of youth diagnosed with T1D, approximately 22.0% of youth were on insulin pump therapy (Paris et al., 2009). In our sample 59.3% of adolescents were on pump therapy. Insulin pump therapy is associated with better metabolic control (Paris et al., 2009). Correspondingly, our sample had relatively good metabolic control (mean HbA1c of 8.26%), which may have impacted results.

Additionally, our findings must be interpreted in light of several limitations. First, data were drawn from a lesson on stress and there were no opportunities to explore participants’ interpretations of the questions or of the terms recorded in the responses. Participants were also forced to pick three stressors from the list. Nevertheless, the open-ended question and unobtrusive data collection allowed participants to record their views. Future study is necessary to explore the spectrum of stressors as we are unable to determine and differentiate between daily stressors, hassles, distress, and diagnosable problems (Serido et al., 2004). Next, there was also possible social desirability bias as other teens were able to see other participants’ responses.

In conclusion, adolescents with T1D may need psychosocial support that holistically addresses general developmental and diabetes-specific stressors and their influences on one another. In the future, it may be fruitful to create a comprehensive questionnaire with both general adolescent stressors and chronic-condition specific stressors. This may be useful to assess whether some adolescents have problems across certain dimensions and thus help improve outcomes for adolescents with T1D and other chronic conditions.

Highlights.

  • We examined general and diabetes-related stressors in teens with T1D

  • Top reported stressors were school (82%), social (49%), diabetes (48%)

  • General life stressor themes were fitting in, having friends, balancing competing demands, living with family, feeling pressure to do well

  • Diabetes-specific stressor themes were just having diabetes, dealing with emotions, and managing diabetes

Acknowledgements

We gratefully acknowledge all adolescents who participated in this study and research personnel. We also thank our funding sources: the National Institutes of Nursing Research (NINR)/National Institutes of Heath grant #2R01NR004009 to Margaret Grey and Robin Whittemore, PIs. Development of the Internet programs was supported by intramural funds provided to Margaret Grey. AC was funded by pre-doctoral fellowships from the Jonas Center for Nursing Excellence and the NINR/NIH (T32NR00834610; F31NR014375). KM was funded by a pre-doctoral fellowship from the NIDDK/NIH (T32DK07718). The funding sources had no involvement in study design, data collection, analysis, or interpretation of data and no involvement in writing the manuscript or deciding to submit it for publication. All authors were involved in drafting the manuscript and non honorarium, grant, or other form of payment was given to anyone to produce the manuscript.

Footnotes

Parts of this paper were presented at the Society of Behavioral Medicine’s Annual Meeting on April 26, 2014 in Philadelphia, PA.

Conflict of Interest: The authors have declared no financial interests or potential conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  1. Berlin KS, Rabideau EM, Hains AA. Empirically derived patterns of perceived stress among youth with type 1 diaebtes and relationships to metabolic control. Journal of Pediatric Psychology. 2012:990–998. doi: 10.1093/jpepsy/jss080. [DOI] [PubMed] [Google Scholar]
  2. Bandura A. Health promotion by social cognitive means. Health Education & Behavior. 2004;31(2):143–164. doi: 10.1177/1090198104263660. [DOI] [PubMed] [Google Scholar]
  3. Campbell MS, Schatz DA, Chen V, Wong JC, Steck A, Tamborlane W, V…T1D Exchange Clinic Network A contrast between children and adolescents with excellent and poor control: The T1D Exchange Clinic Registry experience. Pediatric Diabetes. 2014;15(2):110–117. doi: 10.1111/pedi.12067. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Centers for Disease Control and Prevention . National diabetes statistics report: estimates of diabetes and its burden in the United States, 2014. US Department of Health and Human Services; Atlanta, GA: 2014. [Google Scholar]
  5. Chen E, Fisher EB, Bacharier LB, Strunk RC. Socioeconomic status, stress, and immune markers in adolescents with asthma. Psychosomatic Medicine. 2003;65(6):984–992. doi: 10.1097/01.psy.0000097340.54195.3c. [DOI] [PubMed] [Google Scholar]
  6. Christian BJ, D’Auria JP. The child’s eye: Memories of growing up with cystic fibrosis. Journal of Pediatric Nursing. 1997;12(1):3–12. doi: 10.1016/S0882-5963(97)80016-4. [DOI] [PubMed] [Google Scholar]
  7. Compas BE, Jaser SS, Dunn MJ, Rodriguez EM. Coping with chronic illness in childhood and adoelscence. Annual Review of Clinical Psychology. 2012;8:455–480. doi: 10.1146/annurev-clinpsy-032511-143108. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Davidson M, Penney ED, Muler B, Grey M. Stressors and self-care challenges faced by adolescents living with type 1 diabetes. Applied Nursing Research. 2004;17(2):72–80. doi: 10.1016/j.apnr.2004.02.006. [DOI] [PubMed] [Google Scholar]
  9. Decker CL. Social support and adolescent cancer survivors: A review of the literature. Psycho-Oncology. 2007;16(1):1–11. doi: 10.1002/pon.1073. [DOI] [PubMed] [Google Scholar]
  10. Delamater AM, Patiño-Fernández AM, Smither KE, Bubb J. Measurement of diabetes stress in older children and adolescents with type 1 diabetes mellitus. Pediatric Diabetes. 2013;14(1):50–56. doi: 10.1111/j.1399-5448.2012.00894.x. [DOI] [PubMed] [Google Scholar]
  11. Elo S, Kyngäs H. The qualitative content analysis process. Journal of Advanced Nursing. 2008;62(1):107–115. doi: 10.1111/j.1365-2648.2007.04569.x. [DOI] [PubMed] [Google Scholar]
  12. Farrell SP, Hains AA, Davies W, Smith P, Parton E. The impact of cognitive distortions, stress, and adherence on metabolic control in youths with type 1 diabetes. Journal of Adolescent Health. 2004;34(6):461–467. doi: 10.1016/S1054-139X(03)00215-5. [DOI] [PubMed] [Google Scholar]
  13. Fisher L, Skaff MM, Mullan JT, et al. Clinical dperession versus distress among patients with type 2 diaebtes not just a question of semantics. Diabetes Care. 2007;30(3):542–548. doi: 10.2337/dc06-1614. [DOI] [PubMed] [Google Scholar]
  14. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24(2):105–112. doi: 10.1016/j.nedt.2003.10.001. [DOI] [PubMed] [Google Scholar]
  15. Grey M, Whittemore R, Jaser S, Ambrosino J, Lindemann E, Liberti L, Northrup V, Dziura J. Effects of coping skills training in school-age children with type 1 diabetes. Research in Nursing & Health. 2009;32(4):405–418. doi: 10.1002/nur.20336. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Grey M, Whittemore R, Jeon S, Murphy K, Faulkner MS, Delamater A. Internet psycho-education programs improve outcomes in youth with type 1 diabetes. Diabetes Care. 2013:2475–2482. doi: 10.2337/dc12-2199. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Grey M, Whittemore R, Liberti L, Delamater A, Murphy K, Faulkner MS. A comparison of two internet programs for adolescents with type 1 diabetes: Design and methods. Contemporary Clinical Trials. 2012;33(4):769–776. doi: 10.1016/j.cct.2012.03.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Guo J, Whittemore R, He GP. The relationship between diabetes self-management and metabolic control in youth with type 1 diabetes: An integrative review. Journal of Advanced Nursing. 2011;67(11):2294–2310. doi: 10.1111/j.1365-2648.2011.05697.x. [DOI] [PubMed] [Google Scholar]
  19. Hains AA, Berlin KS, Davies WH, Parton EA, Alemzadeh R. Attributions of adolescents with type 1 diabetes in social situations relationship with expected adherence, diabetes stress, and metabolic control. Diabetes Care. 2006;29(4):818–822. doi: 10.2337/diacare.29.04.06.dc05-1828. [DOI] [PubMed] [Google Scholar]
  20. Hema D, Roper S, Nehring J, Call A, Mandleco B, Dyches T. Daily stressors and coping responses of children and adolescents with type 1 diabetes. Child: Care, Health and Development. 2009;35(3):330–339. doi: 10.1111/j.1365-2214.2009.00937.x. [DOI] [PubMed] [Google Scholar]
  21. Hermanns N, Kulzer B, Krichbaum M, Kubiak T, Haak T. How to screen for depression and emotional problems in patietns with diabetes: Comparison of screening characteristics of depression questionnaires, measurement of diabetes-specific emotional problems and standard clinical assessment. Diabetologia. 2006;49(93):469–477. doi: 10.1007/s00125-005-0094-2. [DOI] [PubMed] [Google Scholar]
  22. Huus K, Enskär K. Adolescents’ experience of living with diabetes. Paediatric Nursing. 2007;19(3):29–31. doi: 10.7748/paed.19.3.29.s24. [DOI] [PubMed] [Google Scholar]
  23. Jaser SS, Yates H, Dumser S, Whittemore R. Risky business: Risk behaviors in adolescents with T1D. The Diabetes Educator. 2011;37(6):756–764. doi: 10.1177/0145721711422610. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Karsdorp PA, Everaerd W, Kindt M, Mulder BJ. Psychological and cognitive functioning in children and adolescents with congenital heart disease: a meta-analysis. Journal of Pediatric Psychology. 2007;32(5):527–541. doi: 10.1093/jpepsy/jsl047. [DOI] [PubMed] [Google Scholar]
  25. Kovacs M, Obrosky DS, Goldston D, Drash A. Major depressive disorder in youths with IDDM: A controlled prospective study of course and outcome. Diabetes Care. 1997;20(1):45–51. doi: 10.2337/diacare.20.1.45. [DOI] [PubMed] [Google Scholar]
  26. Krippendorff K. Content analysis: An introduction to its methodology. Sage; Thousand Oaks, CA: 2012. [Google Scholar]
  27. Malik JA, Koot HM. Explaining the Adjustment of Adolescents With Type 1 Diabetes Role of diabetes-specific and psychosocial factors. Diabetes Care. 2009;32(5):774–779. doi: 10.2337/dc08-1306. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Marshall C, Rossman GB. Designing qualitative research. Sage; Thousand Oaks, CA: 2010. [Google Scholar]
  29. McElhaney KB, Antonishak J, Allen JP. “They like me, they like me not”: Popularity and adolescents’ perceptions of acceptance predicting social functioning over time. Child Development. 2008;79(3):720–731. doi: 10.1111/j.1467-8624.2008.01153.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Morgan DL. Qualitative content analysis: A guide to paths not take. Qualitative Health Research. 1993;3(1):112–121. doi: 10.1177/104973239300300107. [DOI] [PubMed] [Google Scholar]
  31. Palta M, Shen G, Allen C, Klein R, D’lession D. Longitudinal patterns of glycemic control and diabetes care from diagnosis in a population-based cohort with type 1 diabetes. American Journal of Epidemiology. 1996;144(10):954–961. doi: 10.1093/oxfordjournals.aje.a008865. [DOI] [PubMed] [Google Scholar]
  32. Paris CA, Imperatore G, Klingensith G, Petitti D, Rodriguez B, Anderson AM, Pihoker C. Predictors of insulin regimens and impact on outcomes in youth with type 1 diabetes: The SEARCH for diabetes in youth study. The Journal of Pediatrics. 2009;155(2):183–189. doi: 10.1016/j.jpeds.2009.01.063. [DOI] [PubMed] [Google Scholar]
  33. Sawyer SM, Drew S, Yeo MS, Britto MT. Adolescents with a chronic condition: Challenges living, challenges treating. The Lancet. 2007;369(9571):1481–1489. doi: 10.1016/S0140-6736(07)60370-5. [DOI] [PubMed] [Google Scholar]
  34. Schilling LS, Grey M, Knafl KA. The concept of self-management of type 1 diabetes in children and adolescents: An evolutionary concept analysis. Journal of Advanced Nursing. 2002;37(1):87–99. doi: 10.1046/j.1365-2648.2002.02061.x. [DOI] [PubMed] [Google Scholar]
  35. Serido J, Almeida DM, Wethington E. Chronic stressors and daily hassles: Unique and interactive relationships with psychological distress. Journal of Health and Social Behavior. 2004;45(1):17–33. doi: 10.1177/002214650404500102. [DOI] [PubMed] [Google Scholar]
  36. Stang J, Story M. Adolescent growth and development. Guidelines for Adolescent Nutrition Services. Center for Leadership, Education and Training in Maternal and Child Nutrition, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota; Minneapolis, MN: 2005. [Google Scholar]
  37. Steinberg L, Morris AS. Adolescent development. Journal of Cognitive Education and Psychology. 2001;2(1):55–87. [Google Scholar]
  38. Suris JC, Michaud PA, Viner R. The adolescent with a chronic condition: Part I: Developmental issues. Archives of Disease in Childhod. 2004;89(10):938–942. doi: 10.1136/adc.2003.045369. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing & Health Sciences. 2013;15(3):398–405. doi: 10.1111/nhs.12048. [DOI] [PubMed] [Google Scholar]
  40. Whittemore R, Jaser SS, Jeon S, Liberti L, Delamater A, Murphy K, Faulkner MS, Grey M. An internet coping skills training program for youth with type 1 diabetes: Six-month outcomes. Nursing Research. 2012;61(6):395–404. doi: 10.1097/NNR.0b013e3182690a29. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES