diabetes; adolescents; discrepancies; adherence.

Transcription

1 Discrepancies Between Mother and Adolescent Perceptions of Diabetes-Related Decision-Making Autonomy and Their Relationship to Diabetes-Related Conflict and Adherence to Treatment Victoria A. Miller, 1 MA, and Dennis Drotar, 1,2 PhD 1 Case Western Reserve University and 2 Rainbow Babies and Children s Hospital Objective To document the relationship between discrepancies in mother and adolescent perceptions of diabetes-related decision-making autonomy, diabetes-related conflict, and regimen adherence. Methods The sample was composed of 82 mother adolescent dyads. Measures included adolescent and mother reports of diabetes-related decision-making autonomy, diabetes-related conflict, and regimen adherence. Nurses reports of adherence and number of glucose tests performed each day were also obtained. Results Discrepancies between mother and adolescent perceptions of decision-making autonomy were related to greater maternal report of diabetes-related conflict. In particular, when adolescents reported that they were more in charge of decisions than reported by their mothers, mothers reported more conflict. Discrepancies between mother and adolescent perceptions of decision-making autonomy were not related to regimen adherence. Conclusions The findings suggest that discrepancies between mother and adolescent perceptions of diabetes-related decision-making autonomy may be a potentially important area for intervention. Key words diabetes; adolescents; discrepancies; adherence. Insulin-dependent diabetes mellitus, also known as type 1 diabetes, is usually diagnosed in childhood and requires exogenous insulin replacement for survival (Johnson, 1995). The management of type I diabetes is complex and requires daily insulin injections, attention to diet and exercise, and blood glucose monitoring (Johnson, 1995). In our clinic, children are prescribed comparable treatment regimens, with subtle individual differences. The standard regimen includes three to four glucose tests per day, three insulin shots, 30 minutes to 1 hour of exercise per day, and a carbohydrate specific diet. The goal of treatment for type 1 diabetes is to maintain normal blood glucose values ( Johnson, 1995). Adherence to the treatment regimen is important for avoiding both short-term and long-term health complications (Delameter, 2000). During puberty, adequate adherence and metabolic control may become more difficult due to decreased insulin sensitivity (Bloch, Clemons, & Sperling, 1987). A variety of other factors, such as family conflict and decreased parental involvement in diabetes care, may also contribute to the decreases in adherence and metabolic control during adolescence (Delameter, 2000). While the relationship between family conflict and adherence to treatment in type 1 diabetes has been relatively well established (Anderson, Miller, Auslander, & Santiago, 1981; Hauser et al., 1990; Jacobson et al., 1994; Marteau, Bloch, & Baum, 1987; Miller-Johnson et al., 1994; Rubin, Young-Hyman, & Peyrot, 1989; Wysocki, 1993), the factors that contribute to such conflict have not been well documented. Potentially important triggers of family conflict include the influence of the child s behavioral autonomy and discrepancies between parent and child perceptions of autonomy. Holmbeck s (1996) model of parent child relational change during adolescence suggests that significant changes in the adolescent s physical, social, and cognitive development may trigger discrepancies between parent and adolescent perceptions of and expectations of one another. Such discrepancies in parent adolescent perceptions may result in conflict and precipitate changes in the parent adolescent relationship, including changes in All correspondence should be sent to Victoria Miller, Department of Psychology, Case Western Reserve University, Bellflower Rd., Cleveland, Ohio vam4@po.cwru.edu. Journal of Pediatric Psychology, Vol. 28 No. 4, 2003, pp Society of Pediatric Psychology DOI: /jpepsy/jsg014

2 266 Miller and Drotar the adolescent s decision-making autonomy (Collins & Luebker, 1994; Hill & Holmbeck, 1986; Holmbeck, 1996; Holmbeck & O Donnell, 1991). Through a series of conflicts and negotiations regarding the adolescent s level of autonomy, the perceptions of mothers and adolescents may converge over time (Collins, Laursen, Mortenson, Luebker, & Ferreira, 1997; Holmbeck & O Donnell). Discrepancies in parent child perceptions of autonomy and responsibility for diabetes care may also have implications for the successful clinical management of type 1 diabetes. In support of this notion, Anderson, Auslander, Jung, Miller, and Santiago (1990) examined discrepancies between parents and children s perceptions of responsibility for diabetes tasks in a sample of children and adolescents ages 6 to 21 years. Higher levels of dyadic scores indicating no one takes responsibility (e.g., both the adolescent and the mother reported that the other is responsible for the task) predicted worse metabolic control, even after controlling for levels of treatment adherence. However, Anderson et al. (1990) examined only one type of discrepancy between parent and child perceptions of responsibility for diabetes-related tasks, which occurs when both the parent and the child report that the other person takes more responsibility for a specific diabetesrelated task. In such dyads, the child believes that he or she does not have autonomy, but the parent believes that the child does have this autonomy. Another type of discrepancy, which was not identified by Anderson et al. (1990), occurs when children or adolescents feel they are more in charge of diabetes-related tasks than their parents report (Holmbeck & O Donnell, 1991). Previous research suggests that both types of discrepancies in perceptions of decision-making autonomy are important in the changing parent child relationship during adolescence (Holmbeck & O Donnell, 1991). This study was designed to extend the scientific research concerning self-management of diabetes among adolescents in several ways. First, in contrast to previous studies, it examined patterns of discrepancies in perceptions of autonomy in a sample of adolescents with diabetes and their mothers and their relationship to diabetesrelated conflict and adherence to diabetes treatment. Second, while previous studies on self-care autonomy have examined responsibility for the performance of diabetes tasks (i.e., who gives insulin injections, who tests blood), to our knowledge, few studies have examined parent and adolescent perceptions of autonomy concerning specific decisions related to diabetes tasks. Perceived diabetesrelated decision-making autonomy refers to the degree to which the parent or child feels that he or she is responsible for making decisions about diabetes-related issues (i.e., when to give injections; how often to test blood). The development of decision-making autonomy is a major task of adolescence (Liprie, 1993) but may also become a source of conflict between parents and adolescents because parents may not accept increased decision-making autonomy (Emery, 1992). Given the complex nature of the treatment regimen for diabetes, a detailed description of perceptions of diabetes-related decision-making autonomy during adolescence and its relevant correlates is particularly important. Third, this study employed a more refined methodological approach to examine discrepancies in perceptions of decision-making autonomy than any used in previous studies. Holmbeck, Li, Schurman, Friedman, and Coakley (2002) have suggested that regression analyses can be used as an alternative to difference scores to test the significance of parent adolescent perspectives in predicting relevant psychological outcomes. This method limits some of the disadvantages typically associated with the examination of discrepancies in the perceptions of multiple informants, such as curvilinear distributions and loss of information about the direction of discrepancies (see Holmbeck et al., 2002, for a detailed discussion). Designed to address these gaps in previous research, this study assessed the relationships among discrepancies between mother and adolescent perceptions of diabetesrelated decision-making autonomy, frequency of conflict between mothers and adolescents about diabetes-related issues, and adherence to treatment. Based on Holmbeck s (1996) model of relational transformation and previous findings, our first hypothesis was that greater discrepancies between adolescent and mother reports of diabetes-related decision-making autonomy would be associated with more frequent diabetes-related conflict. Our second hypothesis was that greater discrepancies between adolescent and mother reports of diabetes-related decision-making autonomy would relate to decreased adherence. The absence of a mutual understanding between adolescents with type 1 diabetes and their parents concerning decision making about diabetes-related tasks presumably undermines the efficiency of task management and compliance with diabetes treatment (Anderson et al., 1990). Method Participants This study included 82 mother adolescent dyads. The demographics are shown in Table I. The adolescents were between the ages of 11 and 17 years and had a diagnosis of type 1 diabetes for at least a year. Adolescents had no other major chronic health conditions requiring daily

3 Discrepancies in Perceptions of Decision-Making Autonomy 267 Table I. Characteristics of Child Participants Characteristic Value Gender Male 45 (54.9%) Female 37 (45.1%) Age, years M 13.9 SD 1.85 Range Pubertal status M 2.91 SD.69 Range Child race Caucasian 75 (91.5%) African American 6 (7.3%) Oppositional behavior, mother report M 6.33 SD 3.33 Range 1 17 Duration of illness, years M 5.61 SD 3.16 Range Age of onset, years M 8.73 SD 3.94 Range Current glycohemoglobin M SD 2.29 Range Prior glycohemoglobin M SD 2.55 Range medications. All of the participants showed some development in three key areas of pubertal change (for girls, menarche, pubic hair, and breast development; for boys, pubic hair, facial hair, and voice changes) (Peterson, Crockett, Richards, & Boxer, 1988). The mean glycohemoglobin value of the sample was (SD = 2.29), which is similar to that of other adolescents in our clinic. Mothers were primarily married (n = 68, 82.9%), held a college or graduate degree (n = 36, 43.9%), and tended to be middle to upper-middle class. Measures Pubertal Development. The Pubertal Development Scale (Peterson et al., 1988) measures pubertal status and was completed by adolescents. Pubertal status was measured to control for its potential effects on diabetes-related conflict and adherence to treatment. Pubertal status, rather than age, was used because pubertal processes are believed to initiate the changes in the parent child relationship during adolescence (Holmbeck, 1996; Paikoff & Brooks-Gunn, 1991; Steinberg, 1987). Higher scores on this scale indicate greater physical changes related to puberty. The coefficient alpha was.81 for boys and.80 for girls. Adequate validity was established in a previous study (Peterson et al., 1988). Oppositional Behavioral Symptoms. Category C of the Adolescent Symptom Inventory-4 was used to assess adolescent oppositional behavior as perceived by mothers (Gadow & Sprafkin, 1997). This measure was used to control for oppositional symptoms in the analysis of the relationships between discrepancies in perceptions of decisionmaking autonomy, diabetes-related conflict, and adherence to treatment. It included eight items and asks mothers to rate how frequently each behavior occurs on a scale from never to very often. Higher scores indicate a higher frequency of oppositional behaviors. The coefficient alpha was.85. Prior research demonstrates adequate validity (Gadow & Sprafkin, 1997). A demographic questionnaire completed by mothers was used to collect information about the adolescent (age, gender, grade, race, and duration of illness) and the mother and family (age, marital status, family composition, occupation, education, and income). Diabetes-Related Autonomy. The Deciding About Diabetes Treatment Scale measures both adolescents and parents perceptions of the degree of autonomy the adolescent has in making decisions about diabetes self-care tasks (Saletsky, 1991). For each item, the respondent indicated whether (a) the mother tells the child to complete the task; (b) the mother and child discuss the task, but the mother has the final say about it; (c) the mother and child discuss the task, but the child has the final say about it; or (d) the child decides on his or her own to complete the task. Higher scores indicate greater adolescent decisionmaking autonomy as perceived by the respondent. In this sample, the coefficient alpha was.87 for adolescent report and.93 for mother report. Diabetes-Related Conflict. The Conflict subscale of the Diabetes Responsibility and Conflict Scale measures the frequency of parent child conflict over 15 diabetes tasks (Rubin et al., 1989). Higher scores indicate frequent diabetes-related conflict. The coefficient alpha was.85 for mother report and.94 for adolescent report. Scores on this subscale were significantly related to scores on the Conflict subscale of the Family Environment Scale, suggesting that this subscale is a valid measurement of conflict (Rubin et al., 1989).

4 268 Miller and Drotar Adherence. The Self-Care Inventory measures adherence to the diabetes treatment regimen over the past month (Greco et al., 1990). In this sample, the 14 items yielded an alpha of. 83 for mother report and.86 for adolescent report. The questionnaire correlates well with the 24-hour recall interview method, suggesting adequate validity (Greco et al. 1990). The mean values obtained for mother and adolescent report of adherence were similar to previous research using the same measure (Harris, Greco, Wysocki, Elder-Danda, & White, 1999; Wysocki et al., 2000). Each child s nurse completed a Health Care Provider Rating questionnaire based on an adherence measure used by La Greca, Follansbee, and Skyler (1990). It assessed the degree to which the child and his or her family have been compliant for nine aspects of diabetes care. Higher scores indicate greater adherence to the treatment regimen. In this sample, the coefficient alpha was.91. The mean value for nurse report of adherence was similar to that in previous research using this measure (La Greca et al., 1990). Each adolescent s medical chart was reviewed to obtain the average number of glucose tests performed each day over 2 weeks prior to the clinic appointment, which is recorded in the adolescent s glucose meter as a part of the treatment regimen. This number was used as an objective measure of how well the adolescent adheres to blood glucose testing. When more tests were performed each day, adolescents were considered to be more adherent to blood glucose testing. Procedure The study was approved by the institutional review board. Physicians were informed of the study and gave their consent for parents to be contacted. Letters were sent informing potential participants about the study. If the mother agreed to participate over the phone, the investigator or research assistant met the families prior to their regularly scheduled clinic appointments. After obtaining informed consent from the mother, assent was obtained from the adolescent. Participants then completed the study packets at the clinic visit. Both adolescents and mothers were compensated $5.00 for their participation in the study. Of the original 190 families who were sent letters, 133 were reached by phone. Of these 133 families, 49 did not qualify(16%), refused to participate (9%), or were unable to participate due to scheduling difficulties (12%). Eighty-four (63%) mother adolescent dyads completed the questionnaires. Of these, two dyads were eventually excluded because they did not meet the previously described inclusion criteria. Participants were equivalent to the nonparticipants in terms of gender and age. However, nonparticipants were more likely to be African American than Caucasian compared to participants, χ 2 = 8.69, p <.003. Results Descriptive Findings The means, standards deviations, and ranges for perceptions of diabetes-related decision-making autonomy, diabetesrelated conflict, and adherence are presented in Table II. Table III presents Pearson product-moment correlations among the major variables, using a Bonferroni correction for multiple tests. Description of Approach to Regression Analyses Regressions using pairwise deletion for missing data were used to test the hypothesized relationships between discrepancies in mother and adolescent perceptions of diabetes-related decision-making autonomy, diabetesrelated conflict, and adherence to the diabetes treatment regimen. First, pubertal status and adolescent oppositional behaviors were entered into the regression to control for their potential effects on diabetes-related conflict and adherence to the diabetes treatment regimen. Next, adolescent and mother main effects for perceptions of decisionmaking autonomy were entered as a single step in the regression. Finally, the interaction of the adolescent and mother terms was entered. Regression Analyses Predicting Maternal Report of Diabetes-Related Conflict First, we examined the main effects of adolescent and mother reports of diabetes-related decision-making au- Table II. Means, Standard Deviations, and Ranges for Diabetes- Related Decision-Making Autonomy, Diabetes-Related Conflict, and Adherence to the Diabetes Treatment Regimen Adolescent Mother Nurse Glucose Variable Report Report Report Tests/Day Diabetes-related decision-making autonomy M SD Range Diabetes-related conflict M SD Range Adherence M SD Range

5 Discrepancies in Perceptions of Decision-Making Autonomy 269 Table III. Correlations Variable Pubertal status 2. Duration of illness Age of onset.24.85** 4. Adolescent oppositional symptoms 5. Adolescent autonomy, mother report 6. Adolescent autonomy,.37*.19.46**.04.50** adolescent report 7. Diabetes-related conflict, ** mother report 8. Diabetes-related conflict, ** adolescent report 9. Adherence, mother report **.20 (SCI) 10. Adherence, adolescent ** report (SCI) 11. Adherence, nurse report *.52**.52** 12. No. of glucose tests per day ** 13. Glycohemoglobin **.68** Prior glycohemoglobin **.12.77** SCI = Self-Care Inventory. *p <.001. **p < tonomy on diabetes-related conflict. There were main effects on maternal report of diabetes-related conflict for mother and adolescent report of adolescent autonomy (R 2 change =.07, p <.04; see Table IV). In other words, when adolescents perceived that they were more in charge of diabetes-related decisions, mothers perceived more diabetes-related conflict. As illustrated by the values in Table V, the direct effects of mother and adolescent report of adolescent decisionmaking autonomy on diabetes-related conflict were larger than the zero-order (unpartialed) effects. This pattern of results, confirmed by additional calculations described by Cohen and Cohen (1983), indicated that pubertal status was a suppressor variable. In other words, because pubertal status was related positively to adolescent decisionmaking autonomy but negatively to diabetes-related conflict, the relationship between adolescent decision-making autonomy and diabetes-related conflict was obscured in zero-order correlations. When pubertal status was controlled for in the regression analyses, a significant positive relationship between adolescent decision-making autonomy and diabetes-related conflict emerged. We then examined the significance of the interaction term to test the hypothesis that greater discrepancies between adolescent and mother perceptions of adolescent au- Table IV. Multiple Regression Effects for Mother and Adolescent Reports of Diabetes-Related Decision-Making Autonomy on Maternal Report of Diabetes-Related Conflict Step β R 2 R 2 F a p a 1. Pubertal status Oppositional symptoms Mother report of autonomy 2.20 Adolescent report of autonomy Interaction of mother and adolescent report of autonomy Total model variance =.54. a F test and significance level for variance due to addition of each variable. Table V. Zero-Order, Partial, and Part Correlations Based on Multiple Regression Effects of Mother and Adolescent Reports of Diabetes- Related Decision-Making Autonomy on Maternal Report of Diabetes- Related Conflict Variable Zero-order Partial Part 1. Pubertal status Oppositional symptoms Mother report of autonomy Adolescent report of autonomy Interaction of mother and adolescent report of autonomy

6 270 Miller and Drotar tonomy would relate to greater maternal report of diabetesrelated conflict. There was a significant effect on mother report of diabetes-related conflict for the interaction of mother and adolescent report of diabetes-related decisionmaking autonomy (R 2 change =.20, p <.0001), indicating that greater discrepancies were related to greater diabetesrelated conflict. However, the presence of significant main effects (Holmbeck, 1989) indicated that this was true only for discrepancies in which adolescents perceived that they were more in charge of making diabetes-related decisions than was attributed to them by mothers. The overall regression model accounted for 54% of the variance in mother report of diabetes-related conflict. The results remained significant after controlling for duration of illness. For illustrative purposes, we used median splits to create four possible adolescent-mother groups based on reports of adolescent diabetes-related decision-making autonomy. Two of these groups involved discrepancies between mother and adolescent reports of diabetes-related decision-making autonomy in individual dyads: mother high/adolescent low, and mother low/adolescent high. Two other groups reflected congruence between mother and adolescent reports of diabetes-related decision-making autonomy: mother high/adolescent high, and mother low/adolescent low. The means for these groups are presented in Table VI. As illustrated by the regression analyses, the direction of the means shows that the highest mother report of diabetes-related conflict scores was found when adolescents reported more diabetes-related decisionmaking autonomy than was attributed to them by mothers (mother low/adolescent high; see Figure 1). Regression Analyses Predicting Adolescent Report of Diabetes-Related Conflict There were no significant main effects or interactions when adolescent report of diabetes-related conflict was used as Table VI. Group Means for Mother and Adolescent Reports of Diabetes-Related Decision-Making Autonomy Discrepancy Groups the dependent variable. Only adolescent oppositional symptoms were related to adolescent report of diabetesrelated conflict. More adolescent oppositional symptoms predicted more diabetes-related conflict as reported by adolescents (R 2 change =.06, p <.05). Regression Analyses Predicting Adherence to the Diabetes Treatment Regimen The second hypothesis was that discrepancies in mother and adolescent perceptions of diabetes-related decisionmaking autonomy would relate to decreased adherence to the treatment regimen. There were no main effects for mother report or adolescent report of adolescent diabetesrelated decision-making autonomy on adherence. Contrary to the hypothesis, the interaction of mother and adolescent reports of autonomy was not significant in predicting adherence. Greater discrepancies between mother and adolescent perceptions of decision-making autonomy were not related to worse adherence. This was true for each of the four measures of adherence (mother report, adolescent report, nurse report, and number of glucose tests per day). Only adolescent oppositional symptoms were related to reports of adherence. More adolescent oppositional symptoms predicted lower mother report of adherence (R 2 change =.11, p <.01) and lower nurse report of adherence (R 2 change =.08, p <.02). Exploratory Analyses To examine whether discrepancies between adolescent and mother perceptions of diabetes-related decisionmaking autonomy were related to metabolic control of diabetes, a regression analysis was run using glycohemoglobin as the dependent variable. Glycohemoglobin provides information about average blood glucose values over the previous 2 to 3 months and is an accepted measure of diabetic control. The reference range for the lab value used Congruence Groups Mother High, Mother Low, Mother High, Mother Low, Adolescent Low Adolescent High Adolescent High Adolescent Low 1. Adherence, mother report 3.93 (n = 10) 4.06 (n = 11) 3.85 (n = 27) 3.98 (n = 23) 2. Adherence, adolescent report 3.91 (n = 10) 4.12 (n = 11) 3.90 (n = 27) 3.80 (n = 23) 3. Adherence, nurse report (n = 9) (n = 11) (n = 27) (n = 22) 4. Adherence, glucose tests/day 2.30 (n = 8) 2.30 (n = 8) 2.70 (n = 25) 2.88 (n = 21) 5. Diabetes-related conflict, (n = 9) (n = 11) (n = 24) (n = 21) mother report 6. Diabetes-related conflict, (n = 10) (n = 11) (n = 27) (n = 23) adolescent report For both mother and adolescent report, high indicates that the adolescent was rated high (above the median) on diabetes-related decision-making autonomy and low indicates that the adolescent was rated low (below the median) on diabetes-related decision-making autonomy.

7 Discrepancies in Perceptions of Decision-Making Autonomy 271 in this study is 4 to 8. The results of the regression were not significant in predicting metabolic control of diabetes, indicating that greater discrepancies between adolescent and mother perceptions of diabetes-related decisionmaking autonomy did not predict worse metabolic control (R 2 change =.01, p <.61). Discussion Figure 1. Relationship of discrepancies in mother and adolescent perceptions of diabetes-related decision-making autonomy to diabetes-related conflict. For both mother and adolescent report, High indicates that the adolescent was rated high (above the median) on diabetes-related decision-making autonomy and Low indicates that the adolescent was rated low (below the median) on diabetes-related decisionmaking autonomy. To our knowledge, our finding that greater discrepancies in mother and adolescent perceptions of diabetes-related decision-making autonomy were related to higher diabetesrelated conflict has not been previously documented. Specifically, when adolescents perceived that they had more autonomy for diabetes-related decision making than mothers attributed to them, mothers reported more diabetes-related conflict. In contrast, discrepancies in which adolescents reported that they were less in charge of decisions than was reported by mothers did not relate to more diabetes-related conflict. Increased conflicts may be related to the first type of discrepancy because, in this case, mothers may be unwilling to grant decision-making autonomy to the adolescent. Consequently, the adolescents may attempt to gain control over these decisions, a process that may be associated with more conflict between parents and adolescents (Holmbeck & O Donnell, 1991). Conflicts between adolescents and mothers may allow them to confront the discrepancies in their perceptions through a series of conflicts and negotiations regarding the adolescent s level of autonomy (Holmbeck & O Donnell, 1991). While such conflict may promote changes in the parent adolescent relationship that allow it to attain greater maturity, it may also affect adherence and metabolic control in adolescents with diabetes. For example, consistent with previous studies (Jacobson et al., 1994; Miller- Johnson et al., 1994; Rubin et al., 1989), these findings indicated that greater diabetes-related conflict was related to worse adherence to the diabetes treatment regimen. Though there were no specific hypotheses regarding main effects of mother and adolescent report of diabetesrelated decision-making autonomy on diabetes-related conflict, an interesting finding emerged from the regression analyses suggesting that pubertal status was a suppressor variable. The pattern of findings indicated that after partialing out increases in decision-making autonomy related to puberty, increased adolescent autonomy was related to increased diabetes-related conflict as reported by mothers. A possible explanation for this finding is that increases in adolescent autonomy that occur independently of pubertal development may be associated with greater conflict because they may be occurring at unexpected or inappropriate times (e.g., not in accordance with physical or cognitive development). This hypothesis warrants further study, given the importance of appropriate transfer of diabetes-related responsibilities to the adolescent (Ingersoll, Orr, Herrold, & Golden, 1986; Wysocki et al., 1996). Contrary to predictions, discrepancies between mother and adolescent perceptions of diabetes-related decisionmaking autonomy were not related to adherence to the diabetes treatment regimen. Similarly, there was no relationship between discrepancies in perceptions of autonomy and metabolic control of diabetes. One explanation for this finding is the lack of correspondence between perceptions of decision making about diabetes tasks and adherence to the diabetes treatment regimen, which is concerned with the actual performance of diabetesrelated management tasks. For example, the mother may decide that it is time for the child to test his or her blood, but the child may actually perform the test. In this way, the decision about when to test blood can be differentiated from the responsibility for performing the task. Adherence is concerned with the actual performance of

8 272 Miller and Drotar the task, regardless of who makes decisions related to those tasks. This study has several limitations, each with implications for future research. First, we relied on self-reports of decision-making autonomy. Self-reports of diabetesrelated decision-making autonomy may not reflect actual behavior regarding who makes decisions about diabetes management tasks. A second, related limitation is that, while the aim was to assess perceptions of decision making about diabetes management tasks, parents and adolescents may not actually experience these as day-to-day decisions that require discussion and planning. For example, several mothers who participated asserted that there is little discussion about these decisions in their families, because they follow an automatic routine regarding diabetes management. Future research should employ observational measures of family interactions, including the expression and facilitation of adolescent autonomy (e.g., Maharaj, Rodin, Olmsted, Connolly, & Daneman, 2001). A third limitation of the study is its lack of generalizability to older adolescents, ethnic minority families, and adolescents from lower-income families. Our sample was representative of the population served by our diabetes clinic and included predominantly younger adolescents, who were Caucasian and from middle to uppermiddle-class families. However, the sample may be biased in that it may not be representative of the general population of adolescents with type 1 diabetes. Additional research is necessary to determine if discrepancies in perceptions of diabetes-related decision-making autonomy operate in a similar way in adolescents who represent a broader range of ethnicities and socioeconomic levels. In addition, we considered only the mother adolescent dyad. Therefore, our findings are not necessarily generalizable to the father adolescent dyad or to other caregivers of children with diabetes (e.g., grandparents). Finally, while the conceptual model we used was designed to explain changes in parent adolescent relationships over time (Holmbeck, 1996), this study was crosssectional. The precise direction of the association between discrepancies in perceptions and conflict is impossible to determine in a cross-sectional study. For this reason, longitudinal designs are necessary to address the causal and directional relationship between discrepancies in parent adolescent perceptions of decision-making autonomy and conflict. Our findings have potential clinical implications for the management of diabetes in adolescents. For example, future interventions that aim to reduce conflict in families of adolescents with diabetes might target discrepancies in perceptions of diabetes-related decision-making autonomy, because these discrepancies may precipitate or maintain conflict. However, in our data, it is unclear if targeting discrepant perceptions will improve diabetes-related health behaviors such as adherence to the treatment regimen. In addition, it may be beneficial for health care professionals who treat children and adolescents with diabetes to provide education and guidance regarding the likely changes during adolescence with respect to parent adolescent relationships and diabetes management. For example, visits to the diabetes specialist, which occur every 3 to 4 months, provide a regular opportunity for adolescents and parents to discuss changing perceptions and roles concerning diabetes management tasks. In addition, the transfer of diabetes-related decision-making autonomy from parents to adolescents can be monitored and emerging conflicts regarding the impact of such transfer can be addressed on an ongoing basis (Koocher, Mc- Grath, & Gudas, 1990). Our findings suggest several possible areas for future investigation. First, future studies should examine how discrepancies in parent and adolescent perceptions of autonomy operate at different ages. Second, it would be useful to compare how decision-making autonomy is achieved and how discrepant perceptions and conflict operate for normative versus diabetes-related issues. For example, parents may be more reluctant to grant autonomy for diabetes-related issues due to a concern for the potential short-term (e.g., hypoglycemia) and long-term (e.g., neuropathy or nerve damage) complications of diabetes. Finally, future studies should examine the role of both mothers and fathers in diabetes management tasks and conflict about diabetes-related issues. Like previous research, this study considered only the mother adolescent dyad. However, the father s role may be equally important or may have a different relationship to diabetes management than the mother s role (Leonard, Kratz, Skay, & Rheinberger, 1997), and this relationship warrants further investigation. Acknowledgments This research was supported in part by grants from the National Institutes of Mental Health (#18830) and from the Armington Research Program on Values in Children at Case Western Reserve University. We thank members of the Division of Pediatric Endocrinology/Metabolism at Rainbow, including Dr. William Dahms, Dr. Douglas Kerr, Dr. Leona Cuttler, Paul McGuigan, Carol Meszaros, and Wendy Campbell for their support throughout this proj-

9 Discrepancies in Perceptions of Decision-Making Autonomy 273 ect. This article is based on the master s thesis of Victoria A. Miller. Received February 22, 2002; revisions received May 23, 2002, and August 5, 2002; accepted August 7, 2002 References Anderson, B., Auslander, W., Jung, K., Miller, J. P., & Santiago, J. (1990). Assessing family sharing of diabetes responsibilities. Journal of Pediatric Psychology, 15(4), Anderson, B., Miller, J. P., Auslander, W., & Santiago, J. (1981). Family characteristics of diabetic adolescents: Relationship to metabolic control. Diabetes Care, 4(6), Bloch, C. A., Clemons, P. S., & Sperling, M. A. (1987). Puberty decreases insulin sensitivity. Journal of Pediatrics, 110, Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum. Collins, W. A., Laursen, B., Mortenson, N., Luebker, C., & Ferreira, M. (1997). Conflict processes and transitions in parent and peer relationships: Implications for autonomy and regulation. Journal of Adolescent Research, 12(2), Collins, W. A., & Luebker, C. (1994). Parent and adolescent expectancies: Individual and relational significance. New Directions for Child Development, 66, Delameter, A. (2000). Critical issues in the assessment of regimen adherence in children with diabetes. In D. Drotar (Ed.), Promoting adherence to medical treatment in childhood chronic illness (pp ). Mahwah, NJ: Lawrence Erlbaum. Emery, R. (1992). Family conflicts and their developmental implications: A conceptual analysis of meanings for the structure of relationships. In C. Shantz & W. Hartup (Eds.), Conflict in child and adolescent development (pp ). New York: Cambridge University Press. Gadow, K., & Sprafkin, J. (1997). Adolescent Symptom Inventory-4 (ASI-4). Stonybrook, NY: Checkmate Plus. Greco, P., La Greca, A., Ireland, S., Wick, P., Freeman, C., Agramonte, R., et al. (1990). Assessing adherence in IDDM: A comparison of two methods [Abstract]. Diabetes, 39(suppl. 1), 108A. Harris, M., Greco, P., Wysocki, T., Elder-Danda, C., & White, N. (1999). Adolescents with diabetes from single-parent, blended, and intact families: Healthrelated and family functioning. Families, Systems & Health, 17(2), Hauser, S., Jacobson, A., Lavori, P., Wolfsdorf, J., Herskowitz, R., Milley, J., et al. (1990). Adherence among children and adolescents with insulindependent diabetes melltius over a four-year longitudinal follow-up: II. Immediate and long-term linkages with the family milieu. Journal of Pediatric Psychology, 15(4), Hill, J., & Holmbeck, G. (1986). Attachment and autonomy during adolescence. Annals of Child Development, 3, Holmbeck, G. (1989). Masculinity, femininity, and multiple regression: Comment on Zeldow, Daugherty, and Clark s Masculinity, femininity, and psychosocial adjustment in medical students: A 2-year followup. Journal of Personality Assessment, 53(3), Holmbeck, G. (1996). A model of family relational transformations during the transition to adolescence: Parent-adolescent conflict and adaptation. In J. Graber, J. Brooks-Gunn, & A. Petersen (Eds.), Transitions through adolescence: Interpersonal domains and context. Mahwah, NJ: Lawrence Erlbaum. Holmbeck, G., Li, S., Schurman, J., Friedman, D., & Coakley, R. (2002). Collecting and managing multisource and multimethod data in studies of pediatric populations. Journal of Pediatric Psychology, 27(1), Holmbeck, G., & O Donnell, K. (1991). Discrepancies between perceptions of decision making and behavioral autonomy. New Directions for Child Development, 51, Ingersoll, G., Orr, D., Herrold, A., & Golden, M. (1986). Cognitive maturity and self-management among adolescents with insulin-dependent diabetes mellitus. Journal of Pediatrics, 108(4), Jacobson, A., Hauser, S., Lavori, P., Willett, J., Cole, C., Wolfsdorf, J., et al. (1994). Family environment and glycemic control: A four-year prospective study of children and adolescents with insulin-dependent diabetes mellitus. Psychosomatic Medicine, 56, Johnson, S. B. (1995). Insulin-dependent diabetes mellitus in childhood. In M. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp ). New York: Guilford. Koocher, G., McGrath, M., & Gudas, L. (1990). Typologies of nonadherence in cystic fibrosis. Developmental and Behavioral Pediatrics, 11(6),

10 274 Miller and Drotar La Greca, A., Follansbee, D., & Skyler, J. (1990). Developmental and behavioral aspects of diabetes management in youngsters. Children s Health Care, 19(3), Leonard, B., Kratz, B., Skay, C., & Rheinberger, M. (1997). Comparison of mother-father perceptions of their child s self-management of diabetes. Issues in Comprehensive Pediatric Nursing, 20, Liprie, M. L. (1993). Adolescents contributions to family decision making. Marriage and Family Review, 18, Maharaj, S., Rodin, G., Olmsted, M., Connolly, J., & Daneman, D. (2001). Eating problems and the observed quality of mother-daughter interactions among girls with Type I diabetes. Journal of Consulting and Clinical Psychology, 69(6), Marteau, T., Bloch, S., & Baum, D. (1987). Family life and diabetic control. Journal of Child Psychology and Psychiatry, 28(6), Miller-Johnson, S., Emery, R., Marvin, R., Clarke, W., Lovinger, R., & Martin, M. (1994). Parent-child relationships and the management of insulindependent diabetes mellitus. Journal of Consulting and Clinical Psychology, 62(3), Paikoff, R., & Brooks-Gunn, J. (1991). Do parent-child relationships change during puberty? Psychological Bulletin, 110(1), Peterson, A., Crockett, L., Richards, M., & Boxer, A. (1988). A self-report measure of pubertal status: Reliability, validity, and initial norms. Journal of Youth and Adolescence, 17, Rubin, R., Young-Hyman, D., & Peyrot, M. (1989). Parent-child responsibility and conflict in diabetes care [Abstract]. Diabetes, 38(suppl. 2), 7A. Saletsky, R. (1991). Autonomy and mother-child relations in a sample of adolescents with insulindependent diabetes (Doctoral dissertation, Case Western Reserve University, 1990). Dissertation Abstracts International, 52(2-B), Steinberg, L. (1987). Impact of puberty on family relations: Effects of pubertal status and pubertal timing. Developmental Psychology, 23(3), Wysocki, T. (1993). Associations among teen-parent relationships, metabolic control, and adjustment to diabetes in adolescents. Journal of Pediatric Psychology, 18(4), Wysocki, T., Harris, M., Greco, P., Bubb, J., Danda, C., Harvey, L., et al. (2000). Randomized, controlled trial of behavior therapy for families of adolescents with insulin-dependent diabetes mellitus. Journal of Pediatric Psychology, 25(1), Wysocki, T., Taylor, A., Hough, B., Linscheid, T., Yeates, K., & Naglieri, J. (1996). Deviation from developmentally appropriate self-care autonomy. Diabetes Care, 19(2),