The association between attachment styles, illness representations, coping strategies, social support and adherence among type 1 diabetic adolescents: A comparison between boys and girls

Background and aims: Type 1 diabetes, also known as juvenile diabetes, is considered one of the most common chronic diseases among children and adolescents. Managing this condition requires adherence to complex instructions and often necessitates changes in lifestyle and behavior. Compliance with type 1 diabetes treatment is essential, in order to prevent both immediate and long-term health complications (Kristensen et al., 2018). This period coincides with the transfer of therapeutic responsibility from parents or caregivers to adolescents themselves. Managing type 1 diabetes adds an additional layer of complexity to the already challenging time of puberty. Adolescents with type 1 diabetes face the added challenge of assuming responsibility for their treatment (Araia et al., 2017; Datye et al., 2019; Iskander et al., 2015; Miller et al., 2020).Research suggests that the response to type 1 diabetes treatment may decline during puberty. Various psychosocial factors can influence how adolescents cope with the demands of diabetes management and their overall response to treatment. Identifying and understanding these factors can help improve treatment outcomes and reduce the risks associated with the disease. (Shayeghian et al., 2020).

Several studies have highlighted the role of psychosocial factors in treatment compliance among adolescents with type 1 diabetes. The quality of the relationship between a significant caregiver (such as a parent) and the adolescent, as well as social support, have been found to be related to treatment adherence (Datye et al., 2015; Delamater et al., 2018; Duinkerken, 2020; de Wit et al., 2022). Supportive relationships and a strong social support system can positively influence an adolescent's ability to manage their diabetes effectively. Adolescents with type 1 diabetes often experience distress related to the challenges of living with the disease. The cognitive and emotional processes associated with the perceived threat of the illness can affect how they cope with their condition (Datye et al., 2015; Delamater et al., 2018; de Wit et al., 2022). Addressing these cognitive and emotional aspects is crucial in supporting adolescents' adjustment and treatment adherence.

The self-regulation model (Leventhal et al., 1980) provides a framework for understanding how adolescents develop beliefs and perceptions about their illness, which in turn influence their coping strategies, emotional reactions, and behavior related to their illness (Leventhal et al., 1980(. This model has been applied in the context of type 1 diabetes to investigate how psychosocial factors influences treatment response and risk perception among adolescents.

Methods: 110 adolescents (48 boys) aged 12-19 years were recruited at a tertiary diabetes center (4/2021-5/2022) and through on-line questionnaires distributed on social media.Psychosocial outcome measures were retrieved from self-reported validated translated questionnaires: Self-Care Inventory (SCI), Attachment Styles Assessment, Illness Perceptions Questionnaire Revised, Multidimensional Coping Inventory and Scale of Perceived Social Support.

Results: The participants' mean age at assessment was 16.5±2.4 years, with a mean diabetes duration of 7.6±4.2 years. Sociodemographic and diabetes-related characteristics were similar among the boys and girls. The mean glycated hemoglobin level was 7.63±1.58%, 62.8% used insulin pumps and 89% used sensors. The SCI-determined mean self-reported compliance level was relatively high (3.5±0.6; maximum score 5) and significantly superior among boys (p<0.05), while girls had significantly higher negative illness perception levels (p<0.01). A stepwise linear regression model revealed psychosocial variables which contributed to better compliance to treatment [F(8,85)=4.46, p<0.001, R²=0.30]: male sex, older age, lower negative illness perception, greater use of problem-focused coping strategies, fewer emotion-focused coping strategies and perception of better social support.

Conclusions: Sex differences exist in illness perceptions and coping strategies among adolescents with T1D. Interventions based upon a self-regulation model may promote optimal compliance in adolescents experiencing challenges with managing T1D, especially girls.