Daily Diabetes-Specific Family Conflict, Problems, and Blood Glucose During Adolescence

Abstract

Diabetes-related family conflict is widely regarded as a risk factor for diabetes outcomes, yet it has not been examined on a daily basis. Parental acceptance may attenuate the degree to which family conflict is associated with diabetes outcomes. The present study examined 1) within- and between-person fluctuations in diabetes problems and family conflict, 2) within- and between-person links between conflict and BG mean and 3) whether parental acceptance moderated these associations. 180 adolescents (M age=12.92 years) with T1D completed a 14-day diary measuring diabetes problems, conflict with mother, conflict with father, and parental acceptance at the end of each day. Daily average blood glucose (BG) values were calculated from glucometer readings. Higher diabetes problems on average across the 14-day diary were associated with more average conflict with mothers (between-person), but daily fluctuations in the number of diabetes problems were not related to daily conflict (within-person). Adolescents with higher conflict with mothers and fathers on average across the 14 days had higher BG means (between-person); however, on days when adolescents reported higher conflict, they had greater risk for low BG (within-person). Daily parental acceptance did not moderate associations between problems and conflict nor conflict and BG mean. This study was the first to examine daily diabetes-specific conflict with mothers and fathers during adolescence. The number of diabetes problems did not predict daily conflict. Fluctuations in daily conflict were associated with greater risk for low BG, underscoring the need for future research examining in-the-moment relations among conflict and BG extremes.

Individuals with type 1 diabetes (T1D) must adhere to daily, complex self-care tasks to ensure optimal health. Tasks such as monitoring blood glucose (BG) values, calculating and administering proper insulin doses, closely monitoring nutritional intake and energy expenditure must occur several times per day, every day of the week. Performing these self-care behaviors daily is especially challenging during adolescence, with less than 17% of adolescents meeting American Diabetes Association recommendations for diabetes targets (e.g., HbA1c <7% a measure of how well glucose is controlled over the past 3–4 months; American Diabetes Association, 2020; Miller et al., 2015). When adolescents do not engage in self-care behaviors (e.g., forget to check blood glucose levels), problems such as taking the wrong amount of insulin and highs/lows in BG can occur. Adolescents vary in the number of daily diabetes problems that occur across days, with greater problems associated with more negative affect around diabetes, greater parental worry, and less parental confidence in adolescents’ ability to manage T1D (Berg et al., 2013; Lansing et al., 2016). Diabetes problems may create conflict for parents and adolescents, which is associated with poorer diabetes outcomes (Anderson, 2004). Given that T1D is a daily chronic illness, examining problems with diabetes management and its relation to family conflict at the daily level is a crucial component of understanding the family processes involved in managing T1D.

Research consistently indicates that higher diabetes-specific family conflict (typically measured in the diabetes literature as conflict with parents) is associated with higher BG levels, higher HbA1c (further away from targets), lower self-management behaviors, higher levels of depression and anxiety, and lower quality of life both cross-sectionally (Ingerski et al., 2010; Rybak et al., 2017), and longitudinally (Campbell, Berg et al., 2019; Gray et al., 2013; Herzer et al., 2011; Hilliard et al., 2011). This indicates that more frequent conflict is not simply co-occurring together with difficulties with adherence or high HbA1c, but that conflict itself may be a barrier for successful diabetes management across time.

Although arguments over diabetes-specific tasks (e.g., forgetting to check blood glucose values (BG), having a high or low BG) likely occur daily, research thus far has examined diabetes-specific conflict and its associations with diabetes outcomes as between-person differences (often assessed every 3–6 months), limiting our understanding of diabetes-specific conflict in daily life (Campbell, Wang, et al., 2019; Hood et al., 2007). The daily problems that adolescents face when managing the complex diabetes regimen may create the opportunity for arguments to ensue with both mothers and fathers as families work to address persistent daily problems and may be best examined at the daily level of analysis. Findings from developmental and marital literatures indicate that on days when individuals experience greater problems and stressors, they experience greater family or marital conflict (Bai et al., 2017; Timmons et al., 2017). Standard measures of family conflict may be incomplete in that they overlook the day-to-day nature of T1D and limit our understanding of conflict with mothers and fathers and its associations with diabetes outcomes.

Family conflict (measured more broadly among family members) has been examined on a daily basis in adolescents without T1D, with evidence suggesting that the frequency of conflict not only varies between people, but also fluctuates across days (Bai et al., 2017; Brinberg et al., 2017; Fosco & Lydon-Staley, 2019; LoBraico et al., 2020). Fosco and Lydon-Staley (2019) found that on days when adolescents reported higher family conflict than usual, they also reported more depressed, anxious, and angry mood, indicating that daily variation in conflict holds important implications for adolescent health and well-being. It is unknown whether the pattern of daily conflict about repeated, complex diabetes-specific topics (e.g., miscalculating insulin, forgetting to test BG) differs from patterns of daily family conflict in adolescents without T1D (e.g., homework, peer groups). The frequency of family conflict around daily diabetes tasks likely varies across days with potentially different effects at the daily versus the between-person level for blood glucose levels. For instance, family conflict could be beneficial at the within-person level if the relative increase in conflict resolves problems on a daily level and brings BG closer to targets. However, at the between-person level conflict, could be associated with higher BG, as repeated conflict may be problematic for glucose control. Capturing within- versus between-person effects may have intervention implications for diabetes health outcomes such as BG. Specifically, if the effects of problems and conflict are at the within-person level, interventions may be most effective when targeted in-the-moment on a daily level. However, if the effects of high average conflict and problems occur largely between-person, interventions may be best targeted with more general family functioning interventions. To our knowledge, this is the first study to examine the within- and between-person associations of daily diabetes family conflict and daily diabetes outcomes (e.g., BG).

Developmental researchers argue that parent-adolescent conflict is a normative part of development that can, in the context of a warm and accepting parent-child relationship, be beneficial for adolescent development (e.g., promote adolescent autonomy, self-regulation; Adams & Laursen, 2007; Collins et al., 1997; Laursen & Hafen, 2010). In adolescents without T1D, parental acceptance moderates the associations between family conflict and adolescent outcomes, with adolescents realizing more benefits of family conflict (e.g., identity development, autonomy) in the context of a warm and accepting parent-adolescent relationship (Adams & Laursen, 2007; Collins et al., 1997; Laursen & Hafen, 2010). Among adolescents with T1D, parental acceptance is associated with higher adherence and lower (better) HbA1c (Berg et al., 2008; Davis et al., 2001; Young et al., 2014), but has yet to be examined as a moderator of family conflict and diabetes outcomes. It is possible that higher parental acceptance may offer similar benefits for adolescents with T1D to those found in the developmental literature (e.g., promote adolescent autonomy for T1D tasks, conflict resolution skills). Further, feelings of love, warmth, and acceptance in close relationships fluctuate daily (Bai et al., 2017; Brinberg et al., 2017; Coffey et al., 2020; Fosco & Lydon-Staley, 2019). Parental acceptance may vary such that on days when adolescents report higher than usual parental acceptance, they also report lower family conflict despite diabetes problems. Given the known challenges associated with managing this complex illness on a daily basis, understanding parental acceptance as a time-varying aspect of family functioning in the context of T1D is a crucial consideration in this population. A significant contribution of the present study is the examination of within-person differences in addition to between-person differences in these family processes, as understanding this distinction may fine-tune intervention efforts.

The purpose of this study was to examine the daily associations between diabetes problems, family conflict and BG, and whether parental acceptance moderated these associations. We first examined whether fluctuations in the number of daily diabetes problems was related to same-day and next-day levels of diabetes family conflict, and whether these associations were moderated by within- and between-person differences in daily parental acceptance (Aim 1). We hypothesized that on days when adolescents reported higher numbers of diabetes problems than their own average, they would report higher same-day conflict with mothers and fathers (within-person). We did not hypothesize that these associations would be different for mothers compared to fathers. As T1D requires daily management and each day potentially poses new challenges for adolescents, we expected each day’s problems to be related to that day’s family conflict, and did not expect that fluctuations in daily diabetes problems would predict increases in next-day family conflict. As some families may manage diabetes problems more effectively in the context of an accepting relationship, we expected that on days when adolescents reported higher parental acceptance than their own average, adolescents would report less conflict with mothers and fathers (within-person) despite diabetes problems, and that among adolescents who reported higher parental acceptance across the 14 days relative to other adolescents, the link between daily diabetes problems and daily family conflict would be reduced (between-person). We then examined the daily associations between daily diabetes-specific family conflict and daily BG mean (both same day and next day) and whether within- and between-person variation in daily parental acceptance moderated the degree to which diabetes conflict was associated with daily adolescent BG (Aim 2). We expected that on days when adolescents reported greater family conflict, they would have higher same-day BG mean (within-person). Given the longitudinal findings suggesting that diabetes family conflict has lasting implications for BG, we hypothesized that greater daily family conflict would be associated with higher BG mean on the following day. Further, we hypothesized that the detrimental association between family conflict and BG would be buffered by higher daily parental acceptance.

Method

Participants

The present study is a secondary analysis of a larger longitudinal study of T1D management during adolescence; participants came from the second wave of data collected from 2005–2007. Participants included 180 adolescents (54% female, M age=12.92, SD=1.54 years) who had useable data from a daily diary protocol (the ADAPT study, see (Berg et al., 2013). Adolescents were 54% female, 95% White, and had an average age of 12.92 years (range 10–15 years). Participants had been diagnosed for 4.45 years on average, the average HbA1c value for the sample was 8.25% (SD=1.42), and 58% of the sample was using an insulin pump. In the larger study, eligible participants were recruited during regular clinic visits at two pediatric endocrinology clinics. Adolescents were eligible to participate if they were between 10 and 14 years old, had T1D for greater than 1 year, lived with their mother, and were able to read and write in English or Spanish. Of the families approached, 66% agreed to participate in the study, with reasons for declining including not interested (30%), too busy (21%), travel distance (18%), uncomfortable being studied (14%), and time commitment (5%). The majority of participants reported household incomes of greater than $50,000 annually (67%). This resulted in 252 adolescents with T1D and their parents who participated in the first wave of data collection. At the second timepoint (i.e., 6 months after enrollment), a total of 207 adolescents participated in the daily diary protocol. Twenty-seven adolescents provided unusable daily BG readings and were excluded from the present analyses. Reasons for incomplete BG data included declined to use study meter or failed to provide readings from own meter (n = 8), BG meter not returned (n = 6), experimenter failure to send a BG meter (n = 6), software malfunction (n = 5), or unknown (n = 2). Of the 180 participants, 46% returned all 14 completed diaries, and 54% missed between 1 and 8 days (M=12.81; SD=1.68 days complete). A total of 180 adolescents reported on conflict with mothers and 165 reported on conflict with fathers in the diary. While we did not have data to confirm whether fathers were living in the home for those 15 adolescents who did not report conflict with father in the Time 2 diary, 11 of the 15 reported on other aspects of father involvement at Time 2. As such, we chose to impute for these missing data and in the final analyses, which resulted in a total of 180 adolescent reports of conflict for both mothers and fathers. There were no significant differences in age, gender, or HbA1c between participants who did and did not participate at each time point.

Procedures

The present study was approved by the University of Utah’s Institutional Review Board and parents provided informed consent and adolescents provided written assent. The present analysis includes data from the second study assessment (Time 2). At enrollment, participants were scheduled for a one-hour training session where they completed a questionnaire packet and were provided training for completion of a 14-day electronic daily diary and using a study-provided glucometer. A two-week time period was selected to maximize the measurement of problematic diabetes episodes without jeopardizing participant compliance. Participants were instructed to complete each diary at the end of each day via a secure website. Trained research assistants verified completion of online entries and made reminder calls when entries were not posted by the designated time. Participants were paid $50 for completing the training and the questionnaire packet and $4 for each completed diary. This study was not preregistered. Data and materials are available upon request from the authors.

Measures

Daily Diary Measures

Daily Family Conflict.

Adolescents reported how much diabetes-related conflict they experienced with their mothers and fathers each day. One question was used to assess daily family conflict (How much conflict did you and your mother/father have related to your diabetes?), with adolescents reporting on conflict separately for mothers and fathers. Adolescents reported the amount of conflict on a scale from 1 (not at all) to 5 (a lot).

Daily Number of Problems with Diabetes.

Adolescents indicated whether they experienced any of 10 problems (e.g., forgetting or skipping a blood glucose test, taking the wrong amount of insulin, problems with eating, high BG, low BG; see Berg et al., 2013 for complete list of items) with daily diabetes management during the last 24 hours (i.e., since going to bed the previous night). These items were drawn from our prior studies in which adolescents and their mothers reported the most common problems associated with their diabetes management (Beveridge et al., 2006). A total number of problems per day was calculated.

Daily Parental Acceptance.

To assess daily parental acceptance, adolescents responded to the question “how much did you feel loved and cared for by your parents today related to your diabetes?” on a scale from 1 (not at all) to 5 (extremely).

Daily Average Blood Glucose.

All blood glucose readings were obtained from study-provided glucometers and an average blood glucose for each day was computed.

Analytic Plan

Missing data in the diary averaged 9.08%. In order to recapture missing data, one hundred data sets were generated through multiple imputation using BLIMP Studio v.2.1 (Enders et al., 2018; Keller & Enders, 2019), which allows for a specification of a multilevel imputation model with both random intercepts and random slopes. Study hypotheses were tested using multilevel models (MLMs) due to the nested design (i.e., diary days nested within adolescents) using IBM SPSS Mixed (Version 27; IBM Corp. 2020). An intraclass correlation (ICC) was calculated from a baseline model to examine whether there was meaningful variation in adolescent reports of daily diabetes-related family conflict and daily adolescent mean BG (DVs). ICCs indicated that just over half of the variation in adolescent reports of daily diabetes-related family conflict with mothers (ICC = .52) and with fathers (ICC = .63) was between-person and less than half was between-person for daily BG mean (ICC = .40). We used procedures recommended by Enders and Tofighi (2007) and Hofmann and Gavin (1998) to examine both within-person (e.g., daily variation in number of problems) and between-person effects (e.g., individual differences). Daily Level 1 predictor variables were person-mean centered to examine within-person effects and Level 2 predictor variables were grand-mean centered to represent deviations from the sample mean.

To address the links between daily problems and family conflict, family conflict was regressed onto person-centered daily diabetes problems, grand-mean centered diabetes problems, and covariates of adolescent sex and age (with all covariates centered around their mean), the interaction of person-centered diabetes problems and person-centered parental acceptance, the interaction of grand-centered diabetes problems and grand-centered parental acceptance, and random effects of diabetes problems and parental acceptance. Diary day was centered at the midpoint of the diary period (day 7.5) to estimate an average day across the two weeks. The following equation illustrates the model used:

$$\begin{gathered} \text{Level 1: }{\text{Conflict}}_{\text{ij}}={\beta }_{0\text{j}}+{\beta }_{1\text{j}}{\text{day}}_{ij}+{\beta }_{2\text{j}}\left({\text{problems}}_{-}{\text{pc}}_{\text{ij}}\right)+{\beta }_{3\text{j}}\left({\text{acceptance}}_{-}{\text{pc}}_{\text{ij}}\right)+{\beta }_{4\text{j}}\left({\text{prob}}_{\text{ij}}*{\text{accept}}_{\text{ij}}\right) \\ +{\text{e}}_{\text{ij}} \end{gathered}$$

$$\begin{gathered} \text{Level 2: }{\beta }_{0\text{j}}={\gamma }_{00}+{\gamma }_{01}\left({\text{sex}}_{\text{j}}\right)+{\gamma }_{02}\left({\text{age}}_{\text{j}}\right)+{\gamma }_{03}\left({\text{problems\_gc}}_{\text{j}}\right)+{\gamma }_{04}\left({\text{acceptance\_gc}}_{\text{j}}\right)+ \\ {\gamma }_{05}\left({\text{prob}}_{\text{i}}*{\text{accept}}_{\text{j}}\right)+{\text{u}}_{0\text{j}} \end{gathered}$$

$${\beta }_{1\text{j}}={\gamma }_{10}$$

$${\beta }_{2\text{j}}={\gamma }_{20}$$

$${\beta }_{3\text{j}}={\gamma }_{30}$$

$${\beta }_{4\text{j}}={\gamma }_{40}$$

where i represents a given day and j represents the individual. Given that the level of daily involvement differs between mothers and fathers (Berg et al., 2013; Lansing et al., 2017), we examined mother and father models separately, as it is possible that adolescent perspectives of conflict with mothers and fathers operate differently. In addition to examining same-day effects, separate models were conducted to examine whether fluctuations in daily diabetes problems were associated with next-day conflict, controlling for the prior day’s conflict. Two similar multi-level analyses were conducted to address the links between daily family conflict and BG, including adolescent sex, age, and pump status as covariates of between-person links. A single level 1 error variance was included and a random intercept term was specified. Random slopes were not included in this model due to overparameterization. In addition to examining same-day effects, separate lagged models were conducted to examine whether fluctuations in daily diabetes-specific family conflict were associated with next-day BG mean, controlling for prior day BG mean. Preliminary analyses were conducted to determine which covariates to include in the models.

Results

Table 1 provides a summary of correlations, means, and standard deviations for key study variables. Daily diary variables are reported as the average of the variables across the 14 days of the diary period. Adolescents reported higher average daily conflict with mothers (M=1.62, SD=1.04) compared to fathers (M=1.39, SD=0.87; t(428)=9.65, p<.001). Adolescent age was negatively associated with the average daily conflict with mothers (r=−.104, p<.001) and fathers (r=−.103, p < .001), and was included as a covariate of daily links in multilevel models with conflict as the dependent variable. Adolescent females reported more daily conflict with mothers (M=1.71, SD=1.11) compared to adolescent males (M=1.54, SD=0.95; t(2517)=−3.83, p<.001). Adolescent reports of conflict with fathers did not differ depending on adolescent sex. Adolescents using an insulin pump had lower BG mean (M=196.00, SD=76.91) compared to those not using a pump (M=216.54, SD=92.53; t(1928)=−5.71, p<.001), thus pump status was included as a covariate in these models. Adolescent females had higher BG mean (M=208.55, SD=89.76) compared to males (M=200.23, SD=77.55; t(2338)=−2.41, p<.05), with sex included as a covariate in these models. Further, adolescent age was negatively associated with BG Mean (B=−.05, p < .05) and was included as a covariate of daily links. Length of diagnosis was not associated with BG mean and thus was excluded from multilevel models.

Table 1.

Pearson correlations and descriptive statistics of key study variables at the between-person level (N = 180).

	M (SD)	Range	1	2	3	4	5	6	7	8	9	10	11	12
1. Adolescent age	12.92 (1.54)	10.55 – 15.65	1
2. Adolescent sex (female)	53.6%	--	−.04	1
3. Pump status (yes)	57.5%	--	−.06**	.02	1
4. Conflict with mothers	1.63 (1.06)	1 – 5	−.10**	.08**	.06**	1
5. Conflict with fathers	1.42 (0.91)	1 – 5	−.10**	−.01	−.00	.85**	1
6. Daily diabetes problems	1.36 (1.53)	0 – 9	.09**	.16**	.04	.12	.02	1
7. Daily parental acceptance	3.57 (1.48)	1 – 5	−.08**	−.02	−.02	.13	.18*	−.11	1
8. Survey maternal acceptance	4.41 (0.62)	1 – 5	.20**	−.01	−.12**	−.02	.03	.02	.26**	1
9. Survey paternal acceptance	4.26 (0.77)	1 – 5	.05*	−.03	−.16**	−.08	.01	−.06	.23**	.59**	1
10. Daily BG Mean	204.80 (84.56)	47 – 601	−.05*	.05*	.12**	.33**	.23**	.15	−.05	−.05	−.06	1
11. Risk High BG	17.99 (10.72)	0.14 – 64.63	−.05*	.06**	.12**	.32**	.22**	.15*	−.05	−.04	−.04	.99**	1
12. Risk Low BG	1.87 (1.52)	0 – 7.99	−.00	−.01	−.01	−.24**	−.14	−.05	.04	.09	.14	−.59**	−.51**	1

Note.

^*indicates significance p < .05

^**p < .01.

All daily diary variables are the average of the daily variables across the 14 days of the diary. Pump status was dichotomized as currently using insulin pump (yes) or not using insulin pump (no).

Daily Diabetes Problems and Daily Conflict

Multi-level models predicting daily diabetes family conflict from daily diabetes problems revealed significant between-person associations of diabetes problems with diabetes family conflict with mothers only (See Table 2) indicating that adolescents who reported more diabetes problems on average across the 14 days relative to others also reported greater daily family conflict with mothers. There were no significant within-person associations of daily diabetes problems with daily conflict for reports of either mothers’ or fathers’ conflict. In addition, a significant random effect of daily diabetes problems on conflict with mothers (but not fathers) indicated that individuals varied in the association of problems and conflict with mothers, which was not accounted for by independent variables in our model. Models also indicated a significant effect of the variable day for models of mother conflict, such that adolescents tended to report less conflict with mothers (but not fathers) across the diary period. Lagged analyses did not indicate any significant next-day effects, such that the number of diabetes problems on a given day did not predict conflict with mothers or fathers on the subsequent day, controlling for prior day conflict (see bottom of Table 2).

Table 2.

Multilevel models examining daily associations of diabetes problems and diabetes-related conflict with mothers and fathers.

	Daily Conflict with Mothers	Daily Conflict with Fathers
Same-day	Estimate (SE)	Estimate (SE)
Intercept	1.59(.09)**	1.44(.08)**
Day	−0.02(.00)**	−0.00(.00)
Adolescent age	−0.07(.04)	−0.06(.04)
Adolescent sex (female)	0.11(.12)	−0.03(.11)
WP daily problems	−0.03(.06)	0.01(.06)
BP daily problems	0.11(.06)*	0.04(.06)
WP daily acceptance	−0.096(.05)	−0.08(.05)
BP daily acceptance	0.08(.05)	0.10(.04)*
BP problems x BP acceptance	−0.00(.01)	0.01(.01)
WP problems x WP acceptance	−0.04(.02)	−0.00(.02)
	Outcome: Next-day Conflict with Mothers	Outcome: Next-day Conflict with Fathers
Next-day	Estimate (SE)	Estimate (SE)
Intercept	1.70(.03)**	1.47(.04)**
Day	0.01(.01)**	0.00(.00)
Adolescent age	−0.01(.01)	0.01(.02)
Adolescent sex (female)	−0.04(.04)	−0.03(.06)
WP conflict (previous day)	−0.75(.02)**	−0.82(.06)**
BP conflict (previous day)	1.04(.02)**	0.99(.05)**
WP daily problems	0.02(.02)	0.00(.03)
BP daily problems	0.03(.02)	0.02(.03)
WP daily acceptance	0.00(.02)	−0.01(.03)
BP daily acceptance	−0.00(.01)	−0.00(.02)
BP problems x BP acceptance	0.01(.01)	0.00(.01)
WP problems x WP acceptance	0.01(.02)	−0.01(.02)

Note.

^*indicates significance p < .05

^**p < .01.

WP represents within-person and BP represents between-person associations.

Contrary to hypotheses, adolescent perceptions of daily parental acceptance did not significantly moderate the relationship between daily diabetes problems and daily conflict with mothers or with fathers. Further, no between-person interaction effects were found. No main effect of daily acceptance was found for analyses of conflict with mothers, but higher average acceptance across the 14 days was associated with more conflict with father. Analysis of random effects indicated significant variability in the association of daily acceptance and conflict with mothers and fathers that was not accounted for by the variables in our model.

Daily Blood Glucose Mean and Daily Diabetes Conflict

Multi-level models predicting daily BG mean from daily diabetes conflict revealed significant between-person associations of diabetes family conflict with mothers and fathers with daily BG mean (see Table 3). The between-person effect indicated that adolescents who reported more diabetes-related family conflict on average across the 14 days relative to others also had higher daily BG means. In addition, multilevel models revealed significant within-person associations of daily diabetes conflict with mothers and fathers with daily BG mean. The within-person association was negative, however, suggesting that on days when adolescents reported more diabetes conflict with mothers and fathers than their own average, they had lower BG mean that day. Further, adolescents using an insulin pump had lower daily BG mean. Lagged analyses did not indicate any significant next-day effects, such that the amount of daily conflict with mothers or fathers did not significantly predict next-day BG means. Further, adolescent reports of daily parental acceptance did not significantly moderate the relationship of daily conflict with mothers and fathers with BG mean at either the within-or between-person level.

Table 3.

Multilevel models predicting BG Mean from daily diabetes-related conflict and moderation by daily parental acceptance.

	Daily BG Mean		Next day BG Mean
	Estimate (SE)		Estimate (SE)
MOTHERS
Intercept	213.22(7.41)**	Intercept	205.67(2.90)**
Day	0.39(.35)	Day	−0.12(.38)
Pump (yes)	−16.62(7.92)*	Pump (yes)	−0.04(3.23)
Adolescent sex (female)	3.60(7.89)	Adolescent sex (female)	−1.09(2.93)
Adolescent age	−0.85(2.59)	Adolescent age	−0.16(.96)
		WP previous day BG mean	−1.04(.04)**
		BP previous day BG mean	1.00(.03)**
WP daily conflict mom	−21.04(5.62)**	WP conflict mom	−3.81(3.46)
BP daily conflict mom	23.33(5.25)**	BP conflict mom	−1.27(2.28)
WP daily acceptance	5.22(3.69)	WP daily acceptance	−2.19(2.38)
BP daily acceptance	−4.14(3.23)	BP daily acceptance	−0.09(1.27)
BP conflict mom x BP acceptance	−0.32(1.44)	BP conflict mom x BP acceptance	1.77(1.35)
WP conflict mom x WP acceptance	−0.99(2.34)	WP conflict mom x WP acceptance	−3.45(3.28)
FATHERS
Intercept	212.88(7.57)**	Intercept	205.81(2.88)**
Day	0.35(.35)	Day	−0.08(.38)
Pump (yes)	−19.46(8.07)*	Pump (yes)	0.18(3.26)
Adolescent sex (female)	7.73(8.01)	Adolescent sex (female)	−1.26(2.94)
Adolescent age	−1.35(2.63)	Adolescent age	−0.17(.96)
		WP previous day BG mean	−1.05(.04)**
		BP previous day BG mean	1.00(.03)**
WP daily conflict dad	−18.26(6.49)**	WP daily conflict dad	−3.05(3.79)
BP daily conflict dad	19.68(5.79)**	BP daily conflict dad	−1.39(2.38)
WP daily acceptance	5.46(3.76)	WP daily acceptance	−1.75(2.37)
BP daily acceptance	−4.53(3.32)	BP daily acceptance	−0.15(1.26)
BP conflict dad x BP conflict dad	−1.88(1.89)	BP conflict dad x BP conflict dad	2.20(1.55)
WP conflict dad x WP acceptance	0.07(3.48)	WP conflict dad x WP acceptance	−2.80(3.79)

Note.

^*indicates significance p < .05

^**p < .01.

WP represents within-person and BP represents between-person associations.

To further explore the negative associations of within-person daily conflict and BG mean, we conducted exploratory analyses to understand whether this negative association was due to very low BG values being associated with conflict. Specifically, we aimed to understand whether daily conflict occurred more frequently on days when adolescents experienced low BGs rather than high BGs, as families may try to avoid low BG for fear of hypoglycemia (Driscoll et al., 2016). Following procedures to quantify glycemic extremes described by McCall and Kovatchev (2009), we created two index variables calculated from BG meter readings to indicate an adolescent’s daily risk of hyperglycemia (High BG Index; >180 mg/dl) and daily risk of hypoglycemia (Low BG Index; <70 mg/dl). Higher numbers represent a higher daily risk for respective BG extremes. Given the nonsignificant effect of conflict on next-day BG, we restricted these exploratory analyses to same-day risk for high and low values only. Models indicated that on days when adolescents reported more daily conflict with mothers and fathers than their own average, they had a higher risk for low BG and lower risk for high BG (Table 4). In contrast, adolescents with higher average daily conflict relative to the sample had lower risk for low BG and greater risk for high BG (Table 4).

Table 4.

Multilevel models predicting risk for high and low BG from daily diabetes-related conflict with mothers (top) and fathers (bottom) and moderation by daily parental acceptance.

	Risk for Low BG	Risk for High BG
	Estimate (SE)	Estimate (SE)
MOTHERS
Intercept	1.85(.21)**	19.23(1.39)**
Day	−0.00(.01)	0.07(.07)
Pump (yes)	−0.00(.22)	−3.26(1.49)*
Adolescent sex (female)	0.04(.22)	0.93(1.48)
WP daily conflict mom	0.57(.17)**	−3.73(1.05)**
BP daily conflict mom	−0.51(.15)**	4.30(.98)**
WP daily acceptance	−0.12(.12)	0.95(.69)
BP daily acceptance	0.10(.09)	−0.76(.60)
BP conflict mom x BP acceptance	0.06(.06)	−0.05(.27)
WP conflict mom x WP acceptance	−0.05(.10)	−0.24(.45)
FATHERS
Intercept	1.87(.21)**	19.18(1.42)**
Day	−0.00(.01)	0.06(.07)
Pump (yes)	0.06(.23)	−3.80(1.51)*
Adolescent sex (female)	−0.05(.23)	1.71(1.50)
WP daily conflict dad	0.41(.20)*	−3.37(1.22)*
BP daily conflict dad	−0.34(.16)*	3.73(1.08)**
WP daily acceptance	−0.11(.12)	1.00(.71)
BP daily Acceptance	0.09(.09)	−0.84(.62)
BP conflict dad x BP acceptance	0.02(.07)	−0.40(.36)
WP conflict dad x WP acceptance	−0.09(.14)	0.02(.66)

Note.

^*indicates significance p < .05

^**p <.01

WP=within person, BP=between person. BG represents blood glucose.

Discussion

The goal of the present study was to extend the current literature base on diabetes-specific family conflict during adolescence by examining how conflict on a daily timescale is associated with diabetes problems and BG. To our knowledge, this is the first study to examine diabetes-specific family conflict on a daily basis. The lack of within-person effects of problems and conflict together with the significant between-person effects are consistent with a more general style of individual or family interactions around family conflict That is, adolescents who reported a higher number of diabetes problems across the 14 days compared to the average of the sample also reported greater conflict with mothers, but not fathers. The lack of between-person associations of diabetes problems and conflict with fathers was surprising given the high correlation between conflict with mothers and fathers. Nonetheless, the association of higher problems on average with higher conflict with mothers is consistent with research linking higher numbers of diabetes problems with greater adolescent negative affect, greater parental worry, and less parental confidence in adolescents’ ability to manage T1D (Berg et al., 2013; Lansing et al., 2016).

Our results support an individual difference interpretation of conflict in families, such that in families where teens experience consistently high numbers of diabetes problems, they also engage in more frequent conflict with mothers around these issues. The fact that these associations existed only for mothers, and not fathers, may reflect mothers’ higher level of involvement in and knowledge of daily diabetes problems. Further, it might not be the specific problems that occur on a given day that coincide with an argument, but a pattern of difficulties managing T1D over a period of time (i.e., 14 days) that contributes to overall tension in the family environment and undermines parents’ confidence in teens self-management abilities. However, this study was not designed to examine whether individuals were having the same problem repeatedly and thus it is difficult to interpret this finding as such. Further, it is important to note that there was no evidence for next-day effects, which tempers our interpretation that it is an accumulation of problems that leads to conflict in the following days. The lack of next-day effects suggests that each day may present a new opportunity for new challenges, and so today’s problem may not reliably relate to tomorrow’s conflict.

Contrary to hypotheses, however, the number of diabetes problems reported on a given day did not significantly predict the amount of conflict reported that day. It is possible that parents and adolescents respond to diabetes problems in an effective way and thus avoid arguments. This may also indicate that families were able to problem-solve and handle the issue without getting into an argument, although the present study did not examine parents’ specific responses to diabetes problems in real-time. Future research that specifically examines how families respond to diabetes problems in real-time (i.e., ecological momentary assessment (EMA) methodology) would be fruitful. Importantly, the adolescents in the present sample had been diagnosed with T1D for an average of 4.45 years and may be quite accustomed to daily problems in a way that a newly diagnosed sample may not. It is also possible that the number of problems per se are not sufficient to spark conflict, but instead, a consistent pattern of high problem days or a specific, recurrent problem triggers an argument. Future research designed to specifically examine the effect of repeated or recurrent diabetes problems would be useful. Further, while we theorized that heightened problems would predict more conflict (Bai et al., 2017; Timmons et al., 2017), it is possible that this association is bidirectional, which warrants future research.

Findings further support existing evidence of an individual difference pattern of diabetes-specific family conflict such that adolescents who tend to have more conflict with parents also tend to have higher BG means. However, the negative within-person effect warranted a more nuanced interpretation and supplemental analyses suggest that perhaps there is something unique about low BGs that create conflict for families that may not exist for high BGs. It is likely that adolescents have high BGs more frequently than low BGs and thus families may not be as reactive to this problem on a daily basis, or parents may not be informed of a high BG if this is considered a common experience. As a result, low BGs may be perceived as more dangerous and fear-inducing, which could heighten emotional intensity and likelihood of conflicts occurring among adolescents and their parents (Driscoll et al., 2016). Future research is needed to better understand the direction of these effects, including whether conflict occurs in response to highs and lows or whether conflict itself disrupts self-care routines and increases adolescent daily risk for high or low BG, which was beyond the scope of the present analyses.

An additional aim of the present study was to understand whether adolescents’ report of daily parental acceptance buffered the degree to which daily diabetes problems predicted daily diabetes conflict, which was not supported by our data. It is possible that our measure of daily parental acceptance (a single-item proxy for acceptance) did not fully capture the process of family management that occurs each day. In particular, the measure of acceptance used in this study taps into constructs such as parental warmth, which may not fully capture other aspects of parental acceptance that may promote effective stress and conflict management among families (e.g., active listening, validation). Furthermore, the significant random effects of diabetes problems and acceptance indicate that the associations between daily diabetes problems and daily conflict with mothers and fathers does vary between individuals, which suggests that there is some remaining variance in these association that may not be buffered by parental acceptance, but perhaps another variable altogether (e.g., intensity of conflict, autonomy support, parenting style). Given the existing evidence that parental acceptance is an important protective factor for adolescent self-management of T1D, it is possible that related constructs such as autonomy support may better capture the specific components of a supportive and accepting parental relationship in the context of managing T1D (Goethals et al., 2020).

There are several clinical implications of these findings. First, the lack of association between the number of daily diabetes problems and daily diabetes-specific conflict suggests that most families are able to effectively handle problems without argument. However, given that on average diabetes problems were related to more family conflict across the 14 days, interventions that promote effective communication strategies (e.g., how to resolve disagreements, problem-solving) for both parents and adolescents to discuss problems may help reduce family conflict. Moreover, interventions that deliver in-the-moment feedback through text-message reminders to remind parents and adolescents to use effective communication skills may be fruitful, perhaps to help work through low BG days. Second, results provide support for existing interventions to decrease family conflict in order to prevent deteriorations in glycemic targets, and our results underscore the need for such interventions targeted toward families who tend to have high levels of diabetes conflict on average. Lastly, as families appear to respond to extreme BG values, providers working with this population may encourage families to regard extreme low BG values with less judgment in order to reduce conflict.

The present findings must be interpreted in the context of study limitations. First, we did not assess whether adolescents disclosed diabetes problems to parents, which limits our ability to interpret the lack of significant within-person effects. For instance, if parents were unaware of a problem that occurred at school, they likely would not have an argument about this. As such, it is possible that our method of measuring diabetes problems and conflict precluded our ability to fully understand the nuances of family interactions around daily management. Second, characteristics of the sample including primarily White, relatively high global acceptance and fairly low levels of daily conflict among largely intact families may have affected results (Main et al., 2014). The low levels of conflict may also have limited our ability to detect variation in the associations of problems and conflict as well as conflict and daily BG, although the level of daily conflict in our sample is comparable to reports of daily parent-adolescent conflict among adolescents without diabetes (Fosco et al., 2019). Nonetheless, future research in a more demographically diverse sample and with a greater range of parental acceptance and frequency of conflict may provide additional insights into understanding the daily links among conflict, problems, and BG. Lastly, it is possible that our measurement of diabetes problems and conflict at the end of the day did not fully capture the nature of their association. Specifically, problems and/or conflict may have been resolved at the time of diary completion (end of day) and thus limited our ability to find within-person associations on a daily basis. A more nuanced examination of problems and conflict using EMA and Continuous Glucose Monitoring (CGM) technologies may reveal such links. Tracking conflict throughout the day in combination with CGM may also reveal whether problems such as low BG are uniquely related to family conflict beyond the diabetes problems measured in the present study.

This study presented novel findings suggesting significant variation in the number of diabetes-related problems adolescents report on a daily basis as well as the amount of daily conflict they experience with parents, which has implications for intervention. Importantly, daily diabetes problems did not predict daily diabetes-specific family conflict, suggesting that at least for some adolescents, these problems are adequately managed throughout the day. Greater daily conflict on average was associated with higher BG mean, although within-person associations suggested that low BGs may be more problematic for families. Future research is needed to better understand how families manage high and low BGs and conflict in daily life. Findings suggest that parental acceptance may not be a key buffer of daily diabetes conflict, which raises interesting questions for future research around other biological, individual, and family characteristics that promote high functioning despite daily diabetes management challenges (Campbell & Berg, 2022). Given the challenges adolescents and their parents face in managing this complex illness on a daily basis, understanding these developmentally salient aspects of T1D as they occur in daily life is a significant contribution to the pediatric diabetes literature.