The Impact of Mothers' Sense of Empowerment oh the Metabolic Control of Their Children With Juvenile Diabetes

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1 Journal of Pediatric Psychology, Vol. 23, No. 4, 1998, pp The Impact of Mothers' Sense of Empowerment oh the Metabolic Control of Their Children With Juvenile Diabetes Victor Florian, 1 PhD, and Dina Elad, 2 MSW 'Bar-Ilan University and 2 Schneider Children's Medical Center of Israel Objective: To examine the relationship between mothers' sense of empowerment as a psychological resource and the level of adherence to treatment and metabolic control of their adolescent children with insulin-dependent diabetes mellitus (IDDM). Methods: Eighty-eight mothers filled out the Family Empowerment Scale, the Mastery Scale, the Self- Esteem Scale, and the Demographic Questionnaire. Their children with IDDM filled out the Self-Care Behaviors Questionnaire. At the same time, the level of glycohemoglobin was retrieved from their medical files. Results: Data analysis revealed that mothers' sense of empowerment contributes significantly to their children's adherence to treatment. Moreover, mothers' sense of empowerment and their education explain a significant proportion of the variance in their children's metabolic control. Conclusions: The findings support the importance of developing and enhancing the parents' sense of empowerment toward better adherence and metabolic control of their children's IDDM. Key words: juvenile diabetes; mothers' sense of empowerment; metabolic control. In the last two decades, there has been an increasing professional interest in the relationships between parental adaptation and the adjustment of their children to their own chronic illness and its treatment demands. This recent professional interest can best be observed in the case of insulindependent diabetes mellitus (IDDM), which is one of the most prevalent and serious health conditions in childhood and adolescence (Laporte & Tajima, 1985). It is well recognized that parents, in particular the mothers of children with IDDM, confront many daily, sometimes difficult tasks such as coping with a regimen that includes administering insulin injec- All correspondence should be sent to Victor Florian, Dept. of Psychology, Bar-Ilan University, Ramat-Gan S2900, Israel. florian@ashur. cc.biu.ac.il. tions, monitoring glucose levels, maintaining a strict and balanced diet and an exercise plan. In addition, they have to deal with regular follow-up visits, with episodes of hypoglycemia, hyperglycemia, and ketoacidosis, as well as with rehospitalizations, when necessary. All these demands impose primary constraints on the entire family's lifestyle (Etwiler & Sines, 1962; Johnson, 1988; Kovacs et al., 1990). Although the psychological factors that may determine mothers' successful coping with their children's illness are important to ascertain, previous studies of maternal adaptation mainly examined negative outcomes, focusing particularly on measures of distress, like depression and anxiety (Hauenstein, Marvin, Snyder, & Clarke, 1989; Koski & Kumento, 1977; Pond, 1979). However, what Kovacs et al. (1990) define as lack of distress 1998 Society of Pediatric Psychology

2 240 Florian and Elad does not provide a relevant explanation to successful coping and adaptation to their predicament. Substantial literature exists on the relationships between parentsand particularly mothers' psychological adjustment to the illness-related demandsand their children's adaptation to IDDM (Chisholm, Bloomfield, & Atkinson, 1994; Mullins et al., 1995; Wysocki, 1993). For example, Wysocki (1993) found that higher scores on the Skill Deficits- Overt Conflicts Scale and a clear differentiation of family roles and boundaries reported by the mothers contributed significantly to better diabetes outcomes in their adolescent children. Hamp (1984) explained that "maternal attitudes and coping styles may influence both the control of the diabetes and the child's acceptance of the diabetes and its therapy" (p. 222). Furthermore, this author emphasizes that mothers with indifferent and rejecting maternal styles are associated with poor control of diabetes as well as disturbed psychological functioning of their children. In contrast, mothers who are consistent, yet flexible and who encourage and support self-sufficiency and self-management in their children with diabetes will tend to have children with fair-to-good metabolic control and healthy personalities. Some empirical studies documented a positive relationship between maternal self-esteem and a healthy locus of control and the adjustment of their children with IDDM (Grey, Genel, & Tamborlane, 1980; Perrin & Shapiro, 1985). Keeping the above approach, the present study attempted to further explore the contribution of mothers' psychological resources to the adjustment of their children with IDDM. Specifically, we examined the contribution of the relatively new concept of mothers' sense of empowerment to the adherence to treatment and metabolic control of their adolescents with IDDM. Empowerment may be generally defined as "the ongoing capacity of individuals or groups to act on their own behalf to achieve a greater measure of control over their lives and destinies" (Staples, 1990, p. 30). In a recent analysis of the literature, Jones, Garlow, Turnbull, and Barber (1996) suggested that empowerment, both at the individual and family levels, consists of the five following ideas: 1. Perceived control and efficacy over the course of life events; 2. Effectiveness in influencing life conditions through problem-solving skills, coping strategies, and effective use of resources; 3. Family-professional partnerships; 4. Community participation, including leadership in organizations; 5. Situational and temporal variability, in that empowerment takes different forms in different contexts, differs across individuals in the same context, and may change over time for the same individual. Although much theoretical material and proposals for empowerment programs have been published (Jones et al., 1996), little effort has been invested in the operationalization and assessment of the empowerment concept. Based on Staples' (1990) definition, Koren, DeChillo, and Friesen (1992) developed an instrument measuring the empowerment of mothers whose children have psychiatric disabilities. The authors conceptualized their instrument by the combination of two key theoretical dimensions. The first dimension is the level of empowerment, relating to its three domains: (a) the immediate family (sense of efficacy in handling difficulties at home); (b) dealing with the service system (taking action to obtain appropriate services for one's own child); (c) the community (parents' activities that improve services for families and children in general). The second dimension refers to the ways empowerment is expressed: (a) attitudes (what a parent feels and believes regarding the management of the illness); (b) knowledge (what a parent knows about the illness and its treatment and what he or she can potentially do with its demands); (c) behaviors (what a parent actually does when handling the management of the illness). Each expression of empowerment can be linked to each one of the empowerment levels described above. Table I illustrates some of the items that reflect the mothers' sense of empowerment. Although Koren et al. (1992) reported that factor analysis produced three relatively independent factors, they also emphasized that these factors are highly correlated one with another (more than.63). This fact probably indicates the existence of a core component of the sense of empowerment. Based on the empowerment literature, we hypothesized that mothers who handle imore difficulties at home, know how to deal with the service providers, and are involved in improving community services will better help their children in deal-

3 Mother's Internal Resources 241 Table I. Conceptual Framework and Selected Items for Empowerment Scale Way of expression Family Service system Community Attitudes Knowledge Behaviors I feel confident in my ability to help my child grow and develop. I feel my family life is under control. I believe I can solve problems with my child when they happen. I know what to do when problems arise with my child. I am able to get information to help me better understand my child. When I need help with problems in my family, I am able to ask for help from others. When problems arise with my child, I handle them pretty well. I make efforts to learn new ways to help my child grow and develop. When dealing with my child, I focus on the good things as well as the problems. I feel that I have a right to approve all services my child receives. My opinion is just as important as a professional's opinion in deciding what services my child needs. Professionals should ask me what services I want for my child. I know the steps to take when I am concerned my child is receiving poor services. I am able to make good decisions about what services my child needs. I am able to work with agencies and professionals to decide what services my child needs. I make sure that professionals understand my opinions about what services my child needs. I make sure I stay in regular contact with professionals who are providing services to my child. ing with the demands of the illness and in achieving a better diabetic control. Adjustment to juvenile diabetes, particularly during the vulnerable period of adolescence, may be a difficult and complex task (Cerreto & Travis, 1984; Hamp, 1984). On top of the normative physical, emotional, and social challenges, the adolescent with IDDM must also cope with and adjust to the demands and stressors of the treatment regimen. In light of the above literature review, the aim of this study is twofold: (1) to further validate the sense of empowerment instrument by examining its relationship with other well-established psychological constructs, and (2) to examine the impact of mothers' sense of empowerment on their adolescents' adherence to diabetes treatment and metabolic control. In the current study we examined both subjective/self-report evaluations of compliance/adherence and more objective measures of medical adaptationmetabolic control. I tell professionals what I think about services being provided to my child. Method Participants I feel I can have a part in improving services for children in my community. I believe that other parents and I can have an influence on services for children. I feel that my knowledge and experience as a parent can be used to improve services for children and families. I understand how the service system for children is organized. I have ideas about the ideal service system for children. I know how to get agency administrators or legislators to listen to me. I get in touch with my legislators when important bills or issues concerning children are pending. I help other families get the services they need. I tell people in agencies and government how services for children can be improved. The sample of the present study was recruited at the National Juvenile Diabetes Clinic of the Schneider Children's Medical Center of Israel. The following criteria were used to select the participants: Jewish adolescents between the ages of 12 to 17living in urban areas and attending regular schoolswhose juvenile diabetes was diagnosed at least two years prior to their participation in the study. Based on these criteria, a total of 120 adolescents were identified, of whom 88 patients and their mothers gave their consent to participate in the study, yielding an overall participation rate of 73.3% (initial analysis revealed no significant differences between the main demographic variables of those who agreed to participate in the study and those who did not). Fifty of the adolescents (56%) were boys and 38 (44%) were girls. Table II presents the main demographic characteristics of the sample.

4 242 Florian and Elad Table II. Intercorrelations Between Dependent and Independent Variables, Means, and Standard Deviations (n = 88) Variable M(SD) Range Empowerment Mother's age Mother's educ. Econ. status No. children Child's age Child's gender Length of illness Adherence GhB 'p <.05. "p <.01. ***p <.001. Measures * * * -.33" * "* -.39*" *** -.27" Demographic Questionnaire. This questionnaire includes the self-report of the mother's age, years of education, and the number of her children. In addition, mothers were asked to indicate their economic status on a 5-point scale (ranging from 1very bad to 5very good). Details on the children's age, gender, and duration of illness were obtained as well. Sense of Empowerment. Mothers completed the Family Empowerment Scale, which was developed by Koren et al. (1992). The Family Empowerment Scale is a 34-item rating scale originally designed to assess empowerment in parents whose children have emotional disabilities. Each item is rated on a 5-point, Likert-type scale (1 = not true at all to 5 = very true). The items are all scored in the same direction and a higher score indicates more sense of empowerment (see item samples in Table I). For the purpose of the present study, the Family Empowerment Scale was translated into Hebrew, using the back translation technique (Brislin, 1980). Intercorrelation between the subscores in the Hebrew version was high, ranging from.63 to.83. We decided, therefore, to use only the total score of the Family Empowerment Scale for further analysis. In the current sample, Cronbach's alpha of the total score was * *.18* -.19* " 3.47 (.63) (4.78) (3.74) 2.90 (.71) 3.82 (1.99) (1.70) 6.60 (3.60) 3.70 (.58) 12.78(3.51) Self-Esteem Scale (Rosenberg, 1965). This scale measured mothers' self-esteem. The 10 items refer to a general feeling toward the self (e.g., "I have some positive traits"), with responses on a 5-point scale, ranging from strongly agree (5) to strongly disagree (1); a higher score indicates more positive self-esteem. In the present study, the Hebrew version (Hobfoll & Walfisch, 1984) has been used and Cronbach's alpha was.85. Mastery Scale. The mother's mastery was assessed by the Mastery Scale developed for stress research by Pearlin and Schooler (1978). This scale consists of seven items with responses on a 5-point scale, ranging from strongly agree (5) to strongly disagree (1); a higher score indicates greater mastery. This measure concerns the extent to which one regards one's life chances as being under one's own control in contrast to being fatalistically ruled. The items relate to the feeling of control over one's environment and future (e.g., "What happens to me in the future mostly depends on me"). In the present study, the Hebrew version (Hobfoll & Walfisch, 1984) has been used and Cronbach's alpha was.79. Self-Care Questionnaire. Adolescents' adherence behaviors to the treatment regimen were assessed by a questionnaire of self-care behaviors compiled by Glasgow, McCaul, and Schafer (1987). To investigate the degree of adherence to the day-by-day demands of the treatment of diabetes, 14 self-report items that relate directly to different aspects of the diabetic treatment regimen (insulin injections, diet, meals, regimen, exercise) were included. Participants had to report how much of their behavior concerning the treatment was typical for the last month (e.g., "Did it happen that you had to skip meals during last month?"). The response was measured on a 5-point scale, ranging from on all days (1) to never (5). Since no psychometric data had been published in the Hebrew version, one item (no. 9) was excluded due to low interitem correlation. In the present study, the final homogeneity coefficient Cronbach's alpha was.76. One score was produced from the mean assessments of the 13

5 Mother's Internal Resources 243 items, with a higher score indicating a better adherence to the treatment. Glycemic Control. The level of glycemic control was assessed by GHb assaysglycosylated hemoglobin. The blood test was taken on the same day the adolescent had filled out the questionnaires. GHb is thought to provide an aggregate measure of blood glucose level over a period of two to three months (Ziel & Davidson, 1987). The kit used by the laboratory was Glyc-Affin GHb, by Isolab, Inc. (1992). All blood samples were analyzed in the same laboratory unit in order to reduce possible variations in the procedures. Nondiabetic children and adults have an average GHb level of 6%. The normal range of values is 4.0 to 8.0%. Lower GHb levels indicate better diabetic control. Procedure After receiving the necessary formal approval from the hospital officials to conduct the study, the Juvenile Diabetes Clinic's staff approached the patients and their mothers requesting their voluntary consent to participate (without payment) in the study. The data were collected from the mothers and their children in the waiting room prior to their routine medical checkup. A certified social worker, serving as a research assistant, briefly introduced the purpose of the study and presented a separate questionnaire package to each mother and each child. Mothers and children filled out their questionnaires individually in the presence of the research assistant. This procedure took each participant about 30 minutes. The entire data collection took approximately 12 consecutive months. Results The first stage of the data analysis provides some validation for the Family Empowerment Scale. Since this is a new instrument, its concurrent validity was examined by assessing its relationship with more traditional and well-established psychological constructsself-esteem and self-mastery. Pearson correlations revealed significant associations between the mother's sense of empowerment and self-esteem (r =.54, p <.001), sense of empowerment and mastery (r =.23, p <.05). These results seem to provide further validation to the concept of the sense of empowerment. In addition, a series of Pearson correlations between sense of empowerment and mothers' demographic variables revealed only one significant correlation. Mothers' higher sense of empowerment has been associated with a better report on their economic status (r =.22, p <.05). Quite interestingly, a very low and nonsignificant correlation was found between mothers' years of education and their sense of empowerment (see Table II). In the second stage of the data analysis, the relationship between the independent variables (mothers' sense of empowerment, their demographic variables, children's demographic variables) and the dependent variables (children's self-report of adherence to treatment and the more objective measure, metabolic control) were examined. Table II presents the interrelations between these variables obtained through Pearsons correlations. As can be seen from Table II, a higher sense of empowerment is significantly related to children's better adherence to treatment and even more to metabolic control. Only two of the children's demographic variablesgender and duration of illness were significantly related to adherence to treatment. Girls reported as less adherent than boys. The longer the duration of the illness, the lower the adherence to the treatment score. Mother's education was significantly related to metabolic control (GHb levels): the higher the mother's education, the better the metabolic control. In addition, there is a significant correlation between adherence and GHb: the better the adherence to treatment, the better the metabolic control. The third stage of the data analysis examined which of the independent variables contributes most to the explained variance of the dependent variables. Specifically, two separate hierarchical regression analyses were conducted: one for children's adherence to treatment and the second for the levels of metabolic control. Each of these regressions includes four steps. In the first step, children's demographic variables (gender, age, and duration of illness) were entered. In order to examine whether mothers' demographic variables added significantly to the explained variance, these variables (mother's age, years of education, economic status, and number of children) were entered in the second step of the regression. To examine whether mother's sense of empowerment contributed significantly to the variance of children's adherence to treatment and metabolic control, we entered this variable in the third step. Since interaction effects between sense of empowerment and other variables may contrib-

6 244 Florian and Elad Table III. Summary of Hierarchical Regression Analysis of Scores on Adherence to Treatment Based on Demographic Factors and Mothers' Sense of Empowerment (n = 88) Variable Stepi Length of illness Step 3 Length of illness Mother's sense of empowerment Step 4 Length of illness Mothers' sense of empowerment Sense of empowerment x gender B f B ^ -.23* * -.18*.19* -.23* -.16 Adjusted R 2 for steps: step 1: R 2 =.07 (p <.05); step 3: R 2 =.09 (p <.05); step 4: R 2 =.12 (p <.01). *p >.05. Table IV. Summary of Hierarchical Regression Analysis of Glycohemoglobin Levels Based on Demographic Factors and Mothers' Sense of Empowerment (n = 88) Variable Stepi Step 2 Mothers' educ. No. children Step 3 Mothers' educ. No. children Mothers' sense of empowerment Step 4 Mothers' educ. No. children Mothers' sense of empowerment Sense of empowerment x child's age B B *.20* B.18*.21* -.37* -.20*.21* -.33" -.18* -.29**.22* -.33" -.21* -.26" -.18* Adjusted R 2 for steps: step 1: R 2 =.02 (p <.05); step 2: R 2 =.12 (p <.01); step 3: R 2 =.20 (p <.001); step 4: R z =.22 (p <.001). *p >.05. **p >.01. ute to the explained variance, interactions of sense of empowerment ( demographic variables were entered in the fourth step. The summaries of the hierarchical regression analysis for variables predicting children's adherence to treatment and metabolic control are presented in Tables III and IV, respectively. As can be seen from these tables, the explained proportion of variance in GHb levels (22%) was higher than the explained variance in the adherence to treatment (12%). Inspection of the data in Table III revealed that children's gender and illness duration accounted for a significant proportion of the variance (7%). Boys showed more adherence to treatment than girls and longer illness duration led to lower levels of adherence. The mothers' demographic variables had no significant contribution to the adherence level of their children. Mother's sense of empowerment added significantly (2%) to the explained variance in the child's adherence to treatment. In the fourth step, an interaction of mother's sense of empowerment x child's gender added 3% to the explained variance. Pearson correlations were calculated for boys and girls separately. Mother's high sense of empowerment was associated with better reported adherence to treatment among girls (r =.42, p <.01), while among boys this correlation was not significant (r =.02, p >.05). The corresponding regression analysis for glycohemoglobin can be seen in Table IV. The data in this table indicate that in the first step children's gender contributed significantly to GHb levels (2%); girls showed a higher GHb than boys, indicating better metabolic control. Mothers' education and the number of their children were the only demographic variables that contributed significantly (10%) to the explained variance in GHb levels. Higher education and more children contributed to mothers' children's better metabolic control. Most interestingly, in the third step the mother's sense of empowerment added significantly (9%) to the explained variance. The higher the mother's sense of empowerment, the better the child's metabolic control. In the fourth step, an interaction of mother's sense of empowerment (child's age added 3% of the explained variance. In order to examine the source of this interaction, the sample was divided into two age groups based on the mean age score. The first group included 12- to 15-year-olds (56%), labeled early adolescence, and the second group included 16- to 17-year-olds (44%), labeled mid-adolescence. Pearson correlations revealed that mothers' higher sense of empowerment was significantly associated with better diabetic control only for midadolescence (r = -.45, p <.01). A nonsignificant correlation was found for the early adolescence group (r = -.16, p >.05). In order to clarify the meanings of the findings in the above regression (Tables III and IV), we con-

7 Mother's Internal Resources 245 ducted additional analyses using other variables that may influence the presented findings. To examine whether children's self-report of adherence to treatment may contribute to the explained variance of metabolic control, another regression analysis was conducted. In this analysis, adherence was entered in the second step. In addition, all the possible interactions between adherence and the other variables in the regression were examined. We found no significant contribution of adherence to metabolic control, despite the correlation between adherence to treatment and metabolic control (see Table II). The other variables already included in the regression equation were probably more powerful in explaining the variance of the GHb scores. To examine whether the variables of mothers' self-esteem and self-mastery may contribute to the explained variance of both level of adherence and metabolic control, beyond what has already been explained by empowerment, we entered these variables into the regression analysis after the empowerment variable. The data clearly indicate that these variables do not contribute significantly to the explained variance of either one of the dependent variables. Overall, it seems that mothers who reported a higher sense of empowerment are those whose children revealed better glycemic control and a relatively better adherence behavior to the treatment regimen. Discussion The results of the present study provided further validation to the sense of empowerment instrument as a tool for assessing mothers' psychological resources. The mother's sense of empowerment expresses her attitudes, knowledge, and behavior within the context of her family in her dealings with her child, the service system, and with her involvement in the community. The sense of empowerment can be viewed as a separate psychological resource, since the findings of this study have revealed only moderate correlations with other previously recognized psychological resourcesself-esteem and mastery. Moreover, the results also indicate that this special psychological resource is relatively independent of the demographic characteristics measured and only slightly related to the self-reported economic status. Based on the present study's findings, we would like to propose an important theoretical differentiation between general psychological resources, such as selfesteem and mastery, and specific target-oriented resources, such as the sense of empowerment. While the first type of resources seems to be valuable and efficient in dealing with normative roles and common life events (Pearlin & Schooler, 1978), sense of empowerment, specifically, seems to be more functional in coping with the unique demands and strains of taking care of a child with a chronic illness such as juvenile diabetes. Support for this line of thinking can be found in an explorative study that investigated a family support program conducted in the United States (Jones et al., 1996). The authors of this study reveal that parents of children with disabilities who feel empowered and in control are more likely to act in a way that will change the provision of services and quality of life for their family. Furthermore, the results of the current study provide additional empirical support for Koren et al.'s (1992) findings that key aspects of parents' empowerment can be assessed in a valid and reliable fashion across diverse populations. Probably the most interesting finding of the present study is related to the pattern of association between mothers' sense of empowerment and their adolescent children's adherence to treatment and metabolic control. The data (Table II) reveal that mothers' sense of empowerment is associated with their children's adherence to treatment and even more significantly with the objective indicator of diabetes control (GHb levels). Although the children's variables (age, gender, duration of illness) explained a sizeable proportion of the variance in adherence to treatment, their mothers' sense of empowerment had a small, yet significant contribution to their children's compliance. One should notice that girls with IDDM were found in this study to be less adherent than boys to the treatment. Therefore, mothers with a higher sense of empowerment seem to be especially efficient in helping their daughters achieve improved compliance to the demands of their illness. Whether this result reflects the same gender role identification or another psychological mechanism remains to be examined in future studies. In congruence with previous studies (Auslander, Haire-Joshu, Rogge, & Santiago, 1991; Bond, Aikan, & Somerville, 1992; Kovacs et al., 1990), the present research found that mothers' level of education contributes significantly to metabolic control (Table IV). Mothers with higher education have the

8 246 Florian and Elad ability to better understand the illness, its procedure, and demands, and thus make informed choices and cany out more efficient strategies of action. However, in the present study, mothers' sense of empowerment is not related to their level of education (Table II). Therefore, the contribution of these two variables to the child's metabolic control should be viewed as independent; thus, one may assume that even mothers who have not obtained a higher level of education can develop a reasonable sense of empowerment and thereby enhance their children's diabetic control. It seems that mothers with a high sense of empowerment acquired the necessary knowledge regarding the clinical management of diabetes. They are actively involved in monitoring the insulin injections and maintaining a proper diet and exercise plan for their children. Somewhat unexpectedly, a higher sense of mothers' empowerment seems to be efficient, particularly in the case of mid-adolescence, an age usually characterized by defiance and disobedience. Although there is no simple explanation for this finding, we may speculate that this age group begins to develop some responsibility for their special needs. This responsibility is enhanced and encouraged by the empowered mothers, who possess the necessary strategy of problem solving within their families. Finally, it is important to note that mothers' empowerment does not influence their children's metabolic control through improved adherence, as one may expect; rather, it seems that empowerment affects both adherence and metabolic control independently. We can only speculate References Auslander, W. R, Haire-Joshu, D., Rogge, M., & Santiago, J. V. (1991). Predictors of diabetes knowledge in newly diagnosed children and parents. Journal of Pediatric Psychology, 16, Bond, G. G. Aikan, S. L., & Somerville, S. C. (1992). The health belief model and adolescents with IDDM. Health Psychology, 11, Brislin, R. W. (1980). Translation and content analysis of oral and written material. In H. C. Triandis & R. W. Brislin (Eds.), Handbook of cross-cultural psychology/social psychology (pp ). Boston: Allyn & Bacon. Cerreto, M. C, & Travis, L. B. (1984). Implications of psychological and family factors in the treatment of diabetes. Pediatric Clinics of North America, 31, Chisholm, V., Bloomfield, S., & Atkinson, L. (1994). Diabetes: Its differential impact on child and family. British Journal of Medical Psychology, 67, that perhaps empowered mothers are capable of communicating more efficiently with the professional team, and they may also have an increased ability to obtain quality care for their children. These two factors, in turn, may directly affect metabolic control. The exact mechanism involved in this process should be investigated in future studies. Thefindingsof the present study may have several clinical and empirical implications. First, it seems that the Family Empowerment Scale may serve as a useful assessment tool regarding parental initiation, involvement, and caring efforts in the treatment program of their children with IDDM. Second, the results of the current study and their interpretation support the importance of developing and enhancing the sense of empowerment for parents of children and adolescents with IDDM. Future studies should further examine the psychosocial factors underlying the efficiency of empowerment programs on various groups of families with chronically ill children, with particular emphasis on longitudinal follow-ups. Acknowledgments We thank the National Juvenile Diabetes Clinic of the Schneider Children's Medical Center of Israel for its involvement in the study and also Dov Har- Even for his help in the statistical analysis. Received December 11, 1996; accepted December 17, 1997 Etwiler, D. D., & Sines, L. K. (1962). Juvenile diabetes and its management: Family, social and academic implications. Journal of the American Medical Association, 181, Glasgow, R. E., McCaud, K. D., & Schafer, L. C. (1987). Self-care behaviors and glycemic control in Type I diabetes. Journal of Chronic Disease, 40, Grey, M., Genel, M., & Tamborlane, W. (1980). Psychosocial adjustment of latency-aged diabetics: Determinants and relationship to control. Pediatrics, 65, Hamp, M. (1984). The diabetic teenager. In R. W. Blum (Ed.), Chronic illness and disabilities in childhood and adolescence (pp ). New York: Grune & Stratton. Hauenstein, E. J., Marvin, R. S., Snyder, A. L, & Clarke, W. L. (1989). Stress in parents of children with diabetes mellitus. Diabetes Care, 12,

9 Mother's Internal Resources 247 Hobfoll, S. E., & Walfisch, S. (1984). Coping with a threat to life: A longitudinal study of self-concept, social support, and psychological stress. American Journal of Community Psychology, 12, Isolab, Inc. (1992). KitGlyc-Affin GHb. Akron, OH: USA. Johnson, S. B. (1988). Psychosocial factors in juvenile diabetes: A review. Journal of Behavioral Medicine, 3, Jones, T. M., Garlow, J. A., Turnbull, H. R., & Barber, P. A. (1996). Family empowerment in a family support program. In G. H. Singer, L. E. Powers, & A. L. Olson (Eds.), Redefining family support. P. H. Brookes Publishing. Koren, P. E., Dechillo, N., & Friesen, B. (1992). Measuring empowerment in families whose children have emotional disabilities: A brief questionnaire. Rehabilitation Psychology, 37, Koski, M. L., & Kumento, A. (1977). The interrelationship between diabetic control and family life. Pediatric and Adolescent Endocrinology, 3, Kovacs, M, Iyenger, S., Goldstone, D., Obrsky, S., Stewart, J., & Marsh, J. (1990). Psychological functioning among mothers of children with IDDM: A longitudinal study. Journal of Consulting and Clinical Psychology, 58, Laporte, R. E., & Tajima, N. (1985). Prevalence of insulindependent diabetes. In Diabetes in America (NIH Publication No , pp. 1-8). Washington, DC: U.S. Department of Health and Human Services. Mullins, L., Chaney, J., Hartman, V., Olson, R., et al. ( Child and maternal adaptation to cystic fibrosis and insulin-dependent diabetes mellitus: Differential patterns across disease states. Journal of Pediatric Psychology, 20, Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19, Perrin, E., & Shapiro, E. (1985). Who's in charge: Health locus of control beliefs of healthy children, children with a chronic physical illness, and their mothers. Journal of Pediatrics, 107, Pond, H. (1979). Parental attitudes toward children with a chronic medical disorder: Special reference to diabetes mellitus. Diabetes Care, 2, Rosenberg, M. (1965). Society and adolescent self-image. Princeton, NJ: Princeton University Press. Staples, L. H. (1990). Powerful ideas about empowerment. Administration in Social Work, 14, Wysocki, T. (1993). Associations among teen-parent relationships, metabolic control, and adjustment to diabetes in adolescents. Journal of Pediatric Psychology, 18, Ziel, F. H., & Davidson, M. B. (1987). The role of glycosylated serum albumin in monitoring glycemic control in stable insulin-requiring diabetic outpatients. Journal of Clinical and Endocrinological Metabolism, 64,

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