Read Time: 2 mins

Behavioral Factors Influencing Health Outcomes in Youth with Type 1 Diabetes

Copy Link
Published Online: Sep 14th 2012 US Endocrinology, 2012;8(2):77-83 DOI:
Authors: Jessica C Kichler, Ashley Moss, Astrida S Kaugars
Quick Links:
Article Information

The Pediatric Self-Management Model provides an overview of how behavioral factors influence children’s chronic medical illnesses. This general framework is used to organize the present review of how self-management behaviors, contextual factors, and processes impact health outcomes for adolescent youth with type 1 diabetes. Adherence has been widely studied in the diabetes literature, and there are consistent findings demonstrating associations between aspects of self-management, adherence, and metabolic control, yet there are still equivocal approaches to adherence assessment methodology (e.g. global versus specific measures). Metabolic control is a hallmark health outcome for youth with type 1 diabetes, but additional outcomes need to be further explored. Future research should utilize the Pediatric Self-Management Model’s operational definitions to guide empirically-supported interventions for youth with type 1 diabetes.


Behavioral factors, type 1 diabetes, youth


Adherence to medical regimen is often identified as a hallmark modifiable factor that impacts health outcomes for those with chronic medical illnesses.

Adherence to medical regimen is often identified as a hallmark modifiable factor that impacts health outcomes for those with chronic medical illnesses. Rapoff suggests that adherence to medical regimens is estimated to be between 50–55 % for all chronically ill patients.1 He describes a number of patient and family (e.g., demographic, adjustment/coping, family involvement), disease- and regimen-related correlates to adherence; however, correlates do not imply causation and should be interpreted cautiously.1 Researchers have rated non-adherence rates to be between 20 to 93 %1–3 for youth with type 1 diabetes and have found that adherence is widely accepted as related to diabetes control.4

In a recent review article, Modi et al. make a distinction between two constructs: self-management (i.e., the interactions of health behaviors and related processes that patients and families engage in to care for chronic medical conditions) and adherence (i.e., the extent to which a person’s behavior coincides with medical or health advice).5 In their Pediatric Self-Management Model, self-management influences adherence, which then affects outcomes, including health outcomes. The authors also suggest that there may be certain self-management factors that impact outcomes without the mediating role of adherence in pediatric conditions.5

This present review article will focus on the first two of three stages in the Pediatric Self-Management Model, self-management and adherence, to discuss the behavioral factors that may influence health outcomes for youth with type 1 diabetes during adolescence (see Figure 1). Findings from individual, family, peer, and group therapy interventions that have targeted these behavioral factors in order to improve health outcomes will then be outlined.

Modi et al. describe the construct of self-management as having three components.5 The first component is self-management behaviors, which are the actual behaviors performed by the youth and/or family in order to care for a chronic medical illness. Secondly, there are contextual variables, which are four systems that impact how the self-management behaviors occur. These include individual, family, community, and healthcare domains. Finally, there are processes that link the self-management behaviors with the contextual systems. These processes include individuals’ cognitive, emotional, and social perceptions. Three components of self-management, self-management behaviors, contextual variables, and processes as they relate to youth with type 1 diabetes, will be reviewed below (see Table 1).

To view the full article in PDF or eBook formats, please click on the icons above.

Article Information:

The authors have no conflicts of interest to declare.


Jessica C Kichler, PhD, CDE, Cincinnati Children’s Hospital Medical Center, Behavioral Medicine and Clinical Psychology, 3333 Burnet Ave, MLC 3015, Cincinnati, OH 45229, US. E:




  1. Rapoff MA, Adherence to Pediatric Medical Regimens, 2nd edition, New York, NY: Springer, 2010.
  2. Kovacs M, Goldsteon D, Obrosky SD, Iyengar S, Prevalence of predictors of pervasive noncompliance with medical treatment among youths with insulin dependent diabetes mellitus, J Am Acad Child Psy, 1992;31:1112–9.
  3. Wysocki T, Buckloh LM, Lochrie AS, Antal H, The psychologic context of pediatric diabetes, Pediatr Clin N Am, 2005;52:1755–78.
  4. Wysocki T, Buckloh LM, Greco P, The psychological context of diabetes mellitus in youths, In: Roberts MC, Steele RG (eds), Handbook of Pediatric Psychology, 4th edition, New York: The Guilford Press.
  5. Modi AC, Pai A, Hommel K, et al., Pediatric self-management: a framework for research, practice, and policy, Pediatrics, 2012;129:e473–85.
  6. Lewin AB, Heidgerken AD, Geffken GR, et al., The relation between family factors and metabolic control: the role of diabetes adherence, J Pediatr Psychol, 2006;31:174–83.
  7. Anderson BJ, Vangness L, Connell A, et al., Family conflict, adherence, and glycaemic control in youth with short duration type 1 diabetes, Diabetic Med, 2002;19:635–42.
  8. Berg CA, Schindler I, Maharajh S, Adolescents' and mothers' perceptions of the cognitive and relational functions of collaboration and adjustment in dealing with type 1 diabetes, J Fam Psychol, 2008;22:865–74.
  9. Gillibrand R, Stevenson J, The extended health belief model applied to the experience of diabetes in young people, Brit J Health Psych, 2006;11:155–69.
  10. Wysocki T, Nansel TR, Holmbeck GN, et al., Collaborative involvement of primary and secondary caregivers: associations with youths' diabetes outcomes, J Pediatr Psychol, 2009;34:869–81.
  11. Kaugars A, Kichler J, Alemzadeh R, Assessing readiness to change the balance of responsibility for managing type 1 diabetes mellitus: adolescent, mother, and father perspectives, Pediatr Diabetes, 2011;12:547–55.
  12. Miller VA, Drotar DD, Discrepancies between mother and adolescent perceptions of diabetes-related decision-making autonomy and their relationship to diabetes-related conflict and adherence to treatment, J Pediatr Psychol, 2003;28:265–74.
  13. Hsin O, La Greca AM, Valenzuela J, et al., Adherence and glycemic control among Hispanic youth with type 1 diabetes: role of family involvement and acculturation, J Pediatr Psychol, 2010;35:156–66.
  14. Wolpert HA, Anderson BJ, Weissberg-Benchell, Transitions in care: meeting the challenges of type 1 diabetes in young adults, Alexandria, VA: American Diabetes Association, 2009.
  15. Wysocki T, Lochrie A, Antal H, Buckloh LM, Youth and parent knowledge and communication about major complications of type 1 diabetes, Diabetes Care, 2011;34:1701–5.
  16. Dashiff C, Vance D, Abdullatif H, Wallander J, Parenting, autonomy and self-care of adolescents with type 1 diabetes, Child Care Hlth Dev, 2009;35:79–88.
  17. Greening L, Stoppelbein L, Konishi C, et al., Child routines and youths' adherence to treatment for type 1 diabetes, J Pediatr Psychol, 2007;32:437–47.
  18. Bagner DM, Williams LB, Geffken GR, et al., Type 1 diabetes in youth: the relationship between adherence and executive functioning, Child Health Care, 2007;36:169-79.
  19. Cavanaugh K, Huizinga MM, Wallston KA, et al., Association of numeracy and diabetes control, Ann Intern Med, 2008;148:737–46.
  20. Di Battista AM, Hart TA, Greco L, Gloizer J, Type 1 diabetes among adolescents: reduced diabetes self-care caused by social fear and fear of hypoglycemia, Diabetes Educator, 2009;35:465–75.
  21. Korbel CD, Wiebe DJ, Berg CA, Palmer D, Gender differences in adherence to type 1 diabetes management across adolescence: the mediating role of depression, Child Health Care, 2007;36:83–98.
  22. Naar-King S, Idalski A, Ellis D, et al., Gender differences in adherence and metabolic control in urban youth with poorly controlled type 1 diabetes: the mediating role of mental health symptoms, J Pediatr Psychol, 2006;31:793–802.
  23. Herzer M, Hood KK, Anxiety symptoms in adolescents with type 1 diabetes: association with blood glucose monitoring and glycemic control, J Pediatr Psychol, 2010;35:415–25.
  24. Hilliard ME, Herzer M, Dolan LM, Hood KK, Psychological screening in adolescents with type 1 diabetes predicts outcomes one year later, Diabetes Res Clin Pr, 2011;94:39–44.
  25. McGrady ME, Hood KK, Depressive symptoms in adolescents with type 1 diabetes: associations with longitudinal outcomes, Diabetes Res Clin Pr, 2010;88:e35–7.
  26. Kichler JC, Foster C, Opipari-Arrigan L, The relationship between negative communication and body image dissatisfaction in adolescent females with type 1 diabetes mellitus, J Health Psychol, 2008;13:336–47.
  27. Farrell SP, Hains AA, Davies WH, et al., The impact of cognitive distortions, stress, and adherence on metabolic control in youths with type 1 diabetes, J Adolescent Health, 2004;34:461–7.
  28. Wheeler K, Wagaman A, McCord D, Personality traits as predictors of adherence in adolescents with type 1 diabetes, J Child Adolesc Psychiatr Nurs, 2012;25:66–74.
  29. Patino AM, Sanchez J, Eidson M, Delamater AM, Health beliefs and regimen adherence in minority adolescents with type 1 diabetes, J Pediatr Psychol, 2005;30:503–12.
  30. Kyngas HA, Predictors of good adherence of adolescents with diabetes (insulin-dependent diabetes mellitus), Chronic Illness, 2007;3:20–8.
  31. Polonsky WH, Diabetes Burnout: What To Do When You Can’t Take It Anymore, Alexandria, VA: American Diabetes Association, 1999.
  32. Drew LM, Berg C, King P, et al., Depleted parental psychological resources as mediators of the association of income with adherence and metabolic control, J Fam Psychol, 2011;25:751–8.
  33. Pereira MG, Berg-Cross L, Almeida P, Machado JC, Impact of family environment and support on adherence, metabolic control, and quality of life in adolescents with diabetes, Int J Behav Med, 2008;15:187–93.
  34. Dashiff C, Bartolucci A, Wallander J, Abdullatif H, The relationship of family structure, maternal employment, and family conflict with self-care adherence of adolescents with type 1 diabetes, Fam Syst Health, 2005;23:66–79.
  35. Lewandowski A, Drotar D, The relationship between parent-reported social support and adherence to medical treatment in families of adolescents with type 1 diabetes, J Pediatr Pychol, 2007;32:427–36.
  36. Hansen JA, Weissbrod C, Schwartz DD, Taylor WP, Paternal involvement in pediatric type 1 diabetes: fathers' and mothers' psychological functioning and disease management, Fam Syst Health, 2012;30:47–59.
  37. Shorer M, David R, Schoenberg-Taz M, et al., Role of parenting style in achieving metabolic control in adolescents with type 1 diabetes, Diabetes Care, 2011;34:1735–7.
  38. Palmer DL, Osborn P, King PS, et al., The structure of parental involvement and relations to disease management for youth with type 1 diabetes, J Pediatr Psychol, 2011;36:596–605.
  39. Wiebe DJ, Gelfand D, Butler JM, et al., Longitudinal associations of maternal depressive symptoms, maternal involvement, and diabetes management across adolescence, J Pediatr Psychol, 2011;36:837–46.
  40. Peters CD, Storch EA, Geffken GR, et al., Victimization of youth with type-1 diabetes by teachers: relations with adherence and metabolic control, J Child Health Care, 2008;12:209–20.
  41. Drew LM, Berg C, Wiebe DJ, The mediating role of extreme peer orientation in the relationships between adolescent-parent relationship and diabetes management, J Fam Psychol, 2010;24:299–306.
  42. Storch EA, Heidgerken AD, Geffken GR, et al., Bullying, regimen self-management, and metabolic control in youth with type I diabetes, J Pediatr, 2006;148:784–7.
  43. Hains AA, Berlin KS, Davies WH, et al., Attributions of adolescents with type 1 diabetes related to performing diabetes care around friends and peers: the moderating role of friend support, J Pediatr Psychol, 2007;32:561–70.
  44. Greco P, Pendley JS, McDonell K, Reeves G, A peer group intervention for adolescents with type 1 diabetes and their best friends, J Pediatr Psychol, 2001;26:485–90.
  45. Croom A, Wiebe DJ, Berg CA, et al., Adolescent and parent perceptions of patient-centered communication while managing type 1 diabetes, J Pediatr Psychol, 2011;36:206–15.
  46. Becker MH, The health belief model and personal health behavior, Health Edu Man, 1974;2:324–473.
  47. Nabors L, McGrady M, Kichler J, Children’s attitudes toward their diabetes, locus of control, and HbA1c levels, J Dev Disabil, 2010;22:475–84.
  48. Rabiau MA, Knauper B, Nguyen TK, et al., Compensatory beliefs about glucose testing are associated with low adherence to treatment and poor metabolic control in adolescents with type 1 diabetes, Health Educ Res, 2009;24:890–6.
  49. Lloyd SM, Cantell M, Pacaud D, et al., Brief report: hope, perceived maternal empathy, medical regimen adherence, and glycemic control in adolescents with type 1 diabetes, J Pediatr Psychol, 2009;34:1025–9.
  50. Miller VA, Drotar D, Decision-making competence and adherence to treatment in adolescents with diabetes, J Pediatr Psychol, 2007;32:178–88.
  51. Hains AA, Berlin KS, Davies WH, et al., Attributions of adolescents with type 1 diabetes in social situations: relationship with expected adherence, diabetes stress, and metabolic control, Diabetes Care, 2006;29:818–22.
  52. Haynes R, Introduction, In: Haynes R, Taylor D, Sackett D (eds), Compliance in Health Care, Maryland: Johns Hopkins University Press, 1979;1–7.
  53. Johnson SB, Carlson DN, Medical regimen adherence: concepts, assessment, and interventions, In: Raczynski JM, Leviton LC (eds.), Handbook of Clinical Health Psychology, Volume 2: Disorders of Behavior and Health, Washington, DC: American Psychological Association Press; 2004;329–354.
  54. Johnson SB, Measurement and detection of treatment non-adherence in the adolescent, Proceedings of the National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health on Non-Adherence in Adolescent with Chronic Illness, 2008 September, Bethesda, MD, 2008.
  55. Quittner AL, Modi AC, Lemanek C, et al., Evidence-based assessment of adherence to medical treatments in pediatric psychology, J Pediatr Psychol, 2008;33:916–36.
  56. Hood KK, Peterson CM, Rohan JM, Drotar D, Association between adherence and glycemic control in pediatric type 1 diabetes: a meta-analysis, Pediatrics, 2009;124:1171–9.
  57. Anderson B, Ho J, Brackett J, et al., Parental involvement in diabetes management tasks: relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus, J Pediatr, 1997;130:257–65.
  58. Hood KK, Butler DA, Volkening LK, et al., The blood glucose monitoring communication questionnaire: an instrument to measure affect specific to blood glucose monitoring, Diabetes Care, 2004;27:2610–5.
  59. Levine B, Anderson B, Butler D, et al., Predictors of glycemic control and short-term adverse outcomes in youth with type 1 diabetes, J Pediatr, 2001;139:197–203.
  60. Lewin AB, La Greca AM, Geffken GR, et al., Validity and reliability of an adolescent and parent rating scale of type 1 diabetes adherence behaviors: the Self-Care Inventory (SCI), J Pediatr Psychol, 2009;34:999–1007.
  61. Guilfoyle SM, Crimmins NA, Hood KK, Blood glucose monitoring and glycemic control in adolescent with type 1 diabetes: meter downloads versus self-report, Pediatr Diabetes, 2011;12:560–6.
  62. Salamon KS, Hains AA, Fleischman KM, et al., Improving adherence in social situations for adolescents with type 1 diabetes mellitus (T1DM): a pilot study, Primary Care Diabetes, 2010;4:47–55.
  63. Ellis DA, Frey MA, Naar-King S, et al., Use of multisystemic therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control. A randomized control trial, Diabetes Care, 2005;28:1604–10.
  64. Wysocki T, Harris M, Greco P, et al., Randomized, controlled trial of behavior therapy for families of adolescents with insulin-dependent diabetes mellitus, J Pediatr Psychol, 2000;25:23–33.
  65. Wysocki T, Harris MA, Buckloh LM, et al., Randomized trial of behavioral outcomes in adolescents. Maintenance of effects on diabetes outcomes in adolescents, Diabetes Care, 2007;30:555–60.
  66. Anderson BJ, Wolf MT, Burkhart RG, et al., Effects of peer-group intervention on metabolic control of adolescents with IDDM. Randomized outpatient study, Diabetes Care, 1989;12:179–83.
  67. Kaplan RM, Chadwick MW, Schimmel LE, Social learning intervention to promote metabolic control in type I diabetes mellitus: pilot experiment results, Diabetes Care, 1985;8:152–5.
  68. Boland EA, Grey M, Oesterle A, et al., Continuous subcutaneous insulin infusion: a new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with type 1 diabetes, Diabetes Care, 1999;22:1779–84.
  69. Grey M, Boland E, Davidson M, et al., Short-term effects of coping skills training as adjunct to intensive therapy in adolescents, Diabetes Care,1998;21:902–8.
  70. Boardway RH, Delamater AM, Tomakowsky J, Gutai JP, Stress management training for adolescents with diabetes, J Pediatr Psychol, 1993;18:29–45.
  71. Mendez FJ, Belendez, M, Effects of a behavioral intervention on treatment adherence and stress management in adolescents with IDDM, Diabetes Care, 1997;20:1370–5
  72. Opipari-Arrigan L, Kichler J, Fredericks E, et al., Self-management intervention improved diabetes-related functioning in at-risk adolescents with type 1 diabetes [abstract], Presented at: American Diabetes Association 65th Scientific Sessions, San Diego CA, 2005.
  73. The DCCT Research Group, The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus, New Engl J Med, 1993;329:977–86.
  74. Stark LJ, Mulvihil MM, Powers SW, et al., Behavioral intervention to improve calorie intake of children with cystic fibrosis: treatment versus wait list control, J Pediatr Gastr, 1996;22:240–53.
  75. Delamater AM, Jacobson AM, Anderson B, et al., Psychosocial therapies in diabetes: report of the psychosocial therapies working group, Diabetes Care, 2001;24:1286–92.

Further Resources

Share this Article
Related Content In Diabetes
  • Copied to clipboard!
    accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72