Effects of Parental Involvement on Glycemic Control in Adolescents With Type 1 Diabetes Mellitus: A Scoping Review

Abstract

Type 1 diabetes mellitus (T1DM) is typically diagnosed in pediatric patients. Transitioning from supported management in childhood to self-management in adolescence is an important step. Parental psychosocial influence is a possible factor in adolescents’ disease control. This review summarized the effects of parental involvement on glycemic control in adolescents with T1DM by focusing on hemoglobin A1c (HgbAIc). A scoping review per the Guidance for Systematic Scoping Reviews was conducted with the following inclusion criteria: (a) studies in English, (b) focused on adolescents with T1DM, (c) outcomes included HgbAIc, and (d) focused on parental influence of children with T1DM. Of 476 articles, 14 were included. The study outcomes were classified based on direct or indirect influence. “Parental support for adherence” and “parental conflict” significantly affected HgbAIc control. This study provides current evidence on parental influence on glycemic control in adolescents.

Keywords

adolescents glycemic control parental influence scoping review type 1 diabetes

Type 1 diabetes mellitus (T1DM) is a disease that tends to develop in children and adolescents and is one of childhood’s most common chronic diseases (Chiang et al., 2020). Moreover, its occurrence is gradually increasing (Ruiz-Aranda et al., 2018), with a global incidence of 15 per 100,000 people (Mobasseri et al., 2020). In Japan, 500-600 pediatric patients are registered yearly for T1DM (Information Center for Specific Chronic Diseases, Japan, 2022). T1DM requires strict lifelong care and blood glucose control to maintain well-being. Patients are typically diagnosed with T1DM in childhood; thus, their parents must provide day-to-day care. This includes serving healthy foods, administering insulin injections, and controlling hyperglycemia and hypoglycemia (Centers for Disease Control and Prevention, 2022). Parental support is indispensable for patients with T1DM during childhood.

Adolescence, defined by the World Health Organization as ages 10-19 years, is a period of rapid and often asynchronous development in the physical, psychosocial, cognitive, and emotional realms (Sanders, 2013). Generally, adolescents are in a developmental period of transition from being children cared for by their parents to young adults capable of self-care, independent judgment, and self-directed problem-solving (Carroll et al., 2011). Children transforming into adolescents and preparing for emerging adulthood encounter psychosocial changes, and independence from parents is one challenge. For chronic diseases diagnosed in childhood, such as T1DM, although parents have several years of experience in managing their child’s disease and have developed a parental instinct, many parents remain unsure of how to instill this knowledge and intuition in the adolescent, and they fear this wealth of knowledge may be lost (Kayle et al., 2016). Thus, parents are concerned and conflicted about whether to protect or foster independence in their adolescent child. Therefore, transitioning of adolescents to self-management is a common challenge for children with chronic diseases and their parents (Kayle et al., 2016; Knopf et al., 2008; Lerch & Thrane, 2019; Sawicki et al., 2015). Notably, children with T1DM encounter challenges in the self-handling of daily care and overseeing blood glucose control (Babler & Strickland, 2015), and adolescence is a period associated with poor glycemic control (Ibfelt et al., 2022). Adolescent patients’ psychological and psychosocial functioning plays a vital role in disease control (Khadilkar & Oza, 2022; Tuohy et al., 2019). King et al. (2014) reported that associations between both maternal acceptance and diabetes monitoring and subsequent adolescent adherence were mediated by the adolescents’ self-efficacy. As King et al. (2014) suggested, parental involvement might affect the adolescents’ psychosocial function and glucose control. Parental psychosocial support during this transition may be considered one of the most significant factors. A systematic review comprising 40 studies concluded that family conflict, critical parenting, support, involvement, and relationship quality are associated with psychological health outcomes in youth with T1DM (Trojanowski et al., 2021).

Furthermore, single-parent families are reported to display worse adherence to self-monitoring of blood glucose (Lv et al., 2021). Lv et al. reported that adolescents with two parents have more resources that may contribute to better diabetes management, including self-monitoring of blood glucose, and they conclude that the adolescents gain support from both parents in terms of motivation for self-care. Thus, parental support for motivation remains important during adolescence to transition toward independence, suggesting that the psychosocial influence of parents is important during adolescence. In other words, parents, including their attitudes, communication, or familial relationships with the adolescents, can be the facilitative or inhibitory psychosocial factor for disease control.

Previous studies support an indirect association between parental involvement and their influence on T1DM self-control in adolescents, which is mediated by the adolescents’ psychosocial status. However, there is no clear consensus on the effects of parental involvement; thus, we were unable to use this information on parental influence as a predictor of family nursing intervention for families of children with T1DM. Presenting the predictors of family nursing interventions would assist in improving self-care for children with T1DM, a common challenge worldwide. The specific aim of this scoping review was to summarize and determine the effects of parental involvement on glycemic control in adolescents with T1DM. Additional objectives were to provide suggestions for clinically useful family nursing interventions. We intended to focus on hemoglobin A1c (HgbAIc) as an assessment measure, which is considered a better objective index than short-term indices (i.e., the frequency of blood glucose monitoring) for psychosocial function.

To date, no such review or synthesis on this topic has been identified in the Cochrane Database of Systematic Reviews and Joanna Briggs Institute Evidence Synthesis.

Methods

A scoping review (Munn et al., 2018) was deemed the most suitable approach for analyzing the reliability of evidence for the parental psychosocial influence on HgbAIc. It generally includes diverse sources of evidence and can be used to identify the types of available evidence in a field (O'Grady et al., 2022). Therefore, scoping reviews are useful when the literature has not been comprehensively reviewed or is not amenable to a more detailed systematic review of the evidence owing to complex or heterogeneous studies. This review was conducted according to the “Guidance for Systematic Scoping Review” (Peters et al., 2020). According to this guideline, we developed an a priori protocol.

Research Question

The study objective focused on the parental psychosocial influence on self-controlled blood glucose levels in adolescents with T1DM with HgbAIc as the outcome. This question was guided by the following research questions: (a) What were the facilitative/inhibitory psychosocial influences of parents of adolescents with T1DM? (b) What was the reliability of the studies comprising evidence of parental influences assessed in relation to HgbAIc control?

Inclusion Criteria

The inclusion criteria for the selected studies were as follows: (a) published in English, (b) primary focus on adolescents with T1DM, (c) the study outcomes included HgbAIc, and (d) the studies focused on parental influence on their children with T1DM. All study designs were considered eligible. The exclusion criteria for the studies were as follows: (a) not published in English, (b) conducted on animals, and (c) conducted more than 20 years ago.

Search Strategy

The first electronic search was conducted from June 10, 2020, to June 25, 2020, with the guidance of a librarian of the Medical Literature Analysis and Retrieval System Online (MEDLINE) and the Cumulated Index to Nursing and Allied Health Literature (CINAHL) databases. As the MEDLINE database was available in PubMed, the PubMed online database was used. The search focused on studies published in the previous two decades (2000–2020). Initially, a limited search of these online databases was performed to identify relevant articles on this topic. In the identification search, 190 articles from CINAHL and 286 articles from PubMed were included. The index terms and search history are shown in Table 1.

Table 1.

The Search History.

Search ID#	Search terms	Results
CINAHL
S1	(MH “Child+”) OR (MH “Adolescence+”) OR (MH “Infant+”)	848,723
S2	(MM “Child+”) OR (MM “Adolescence+”) OR (MM “Infant+”)	34,955
S3	(MH “Nuclear Family+”) OR (MH “Family Relations+”)	138,280
S4	(MH “Patient-Family Relations”)	2,196
S5	(MH “Family Nursing”)	1,644
S6	S3 or S4 or S5	139,667
S7	(MM “Parent-Child Relations+”)	16,716
S8	S1 and S6	82,136
S9	S2 and S6	7,043
S10	S1 and S7	12,435
S11	S9 or S10	18,423
S12	(MH “Diabetes Mellitus+”)	142,383
S13	S11 and S12	190
PubMed
1	adolescent/ or exp child/ or exp infant/	3,416,481
2	exp nuclear family/ or single-parent family/	126,834
3	exp Family Relations/	88,289
4	Family Nursing/	1,397
5	or/2-4	191,813
6	1 and 5	131,918
7	adolescent/ or exp child/ or exp *infant/	67,811
8	7 and 5	5,373
9	exp *parent-child relations/	26,668
10	exp nuclear family/ or single-parent family/	72,973
11	exp *Family Relations/	48,988
12	or/4,10-11	112,412
13	1 and 12	76,791
14	1 and 9	22,967
15	or/8,14	27,384
16	exp Diabetes Mellitus/	403,195
17	15 and 16	286

Note. Subsequently, the text words, titles, and abstract were assessed to remove duplicates. In the screening search, three researchers (M.Y., MF, and J.H.) independently reviewed the titles and abstracts to find articles written about parental involvement and HgbAIc. The articles were reviewed to exclude those that did not meet the inclusion criteria. Only studies with agreement from all the three researchers were selected. In the subsequent eligibility search, full-text articles were screened by three independent researchers (M.Y., MF, and J.H.) to determine if they met the study objective. In this step, disagreements in the study selection were resolved by discussion between the three reviewers. Eventually, studies were identified for the current analysis (Figure 1). All search procedures were performed using the EndNote database system. CINAHL = Cumulated Index to Nursing and Allied Health Literature; HgbAIc = hemoglobin A1c; MH = CINAHL Exact Subjects Headings; MM = CINAHL Exact Major Subject Headings.

Figure 1.

Flow Diagram Summarizing the Database Search.

Data Collection and Synthesis

The three reviewers discussed their key findings and found a high level of consistency in the data extracted from the studies. However, if a study did not contain significant results, the nonsignificant results were reported when all the three researchers agreed that the findings were important for the focus of this review. Finally, MY created a data list and extracted the following from the selected articles: authors, title, country, design, sample size, participants’ age, demographics, measurement tools (containing HgbAIc), and key findings. After data extraction, the results were collated and summarized to include the study characteristics based on the research question. The key findings were outlined in the reported results and then synthesized based on the viewpoint of the effect of parental influence and HgbAIc outcome.

Study Design Appraisal

The “Guidance for Systematic Scoping Review” (Peters et al., 2020) states that a formal assessment of the methodological quality of the included studies is generally not performed. However, there are now discussions about scoping reviews regarding the usefulness of additional assessments of the quality and methodological rigor of the included studies (Levac et al., 2010). Thus, we used the Quality Assessment Tool for Studies with Diverse Designs (QATSDD) to appraise the study design quality (Kwan et al., 2020) (Table 2) and ensure that the data are rigorous. QATSDD is a 16-item quality assessment tool that can be applied to various study designs (Sirriyeh et al., 2012).

Table 2.

Quality Assessment of the Included Studies Based on the QATSDD Tool.

Criteria	Author
	1	2	3	4	5	6	7	8	9	10	11	12	13	14
	Monaghan et al.	Goldberg A & Wiseman H.	Rohan et al.	Seiffge-Krenke et al.	Moore et al.	Hanna et al.	Sood et al.	Hilliard et al.	Carroll et al.	Hsin et al.	Rosenberg & Shields	Horton et al.	Lloyd et al.	Lewin, Heidgerken et al.
Explicit theoretical framework	3	3	3	2	3	3	3	3	3	3	3	3	3	3
Statement of the aims/objectives in the main body of the report	3	3	3	3	3	2	3	3	3	3	3	3	3	3
Clear description of research setting	3	3	3	3	3	2	3	2	3	2	1	3	2	3
Evidence of the sample size considered in terms of the analysis	1	0	2	0	1	0	1	1	0	0	0	3	0	1
Representative sample of the target group of a reasonable size	1	0	2	0	0	0	0	0	0	0	0	0	0	1
Description of the procedure for data collection	3	3	3	3	3	2	3	2	3	2	2	3	1	3
Rationale for the choice of data collection tool(s)	3	3	3	2	2	3	3	2	1	1	1	3	1	3
Detailed recruitment data	3	2	3	2	3	2	3	3	3	2	3	2	2	2
Statistical assessment of the reliability and validity of measurement tool(s) (quantitative)	3	3	3	3	2	2	3	3	n/a	1	1	2	1	2
Fit between stated research question and method of data collection (quantitative)	3	3	3	2	3	2	3	2	n/a	1	2	3	1	3
Fit between the stated research question and the format and content of data collection tool, e.g., interview schedule (qualitative)	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	2	n/a	n/a	n/a	n/a	n/a
Fit between research question and method of analysis	1	3	3	3	3	3	3	3	3	2	2	3	2	3
Good justification for the selected analytical method	3	1	3	3	3	3	3	2	3	2	2	3	3	3
An assessment of the reliability of analytical process (qualitative)	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	3	n/a	n/a	n/a	n/a	n/a
Evidence of user involvement in the design (research process)	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Critically discussed strengths and limitations	3	3	3	3	3	3	3	2	3	3	3	3	3	3
Score	33	30	37	29	32	27	34	28	30	22	23	34	22	33

Note. n/a = not applicable; QATSDD = Quality Assessment Tool for Studies with Diverse Designs.

Results

Figure 1 depicts the number of studies identified at each search stage. A total of 476 articles were identified in the initial search, including 286 and 190 articles from PubMed and CINAHL, respectively. We removed 70 duplicate articles and screened the titles and abstracts for the remaining 406 articles. Moreover, we assessed the titles and abstracts of the selected studies. Subsequently, the full text of the remaining 144 articles were independently reviewed by three authors to determine if they met the inclusion criteria and objectives. In this step, we excluded the studies conducted on medical specialists, educational specialists, young children/adults with T1DM, their siblings, parents only, not using HgbAIc as the outcome, and about leisure/camp or peer support. Eventually, this scoping review included 14 articles (see Table 3).

Table 3.

Summary of the Included Studies.

No.	Author	Title	Journal	Country	Year	Design	Sample size	Adolescent’s age range (mean)	Measurements (other than HgbAIc)	Primary results
1	Monaghan et al.	Checking In: A Pilot of a Physician-Delivered Intervention to Increase Parent-Adolescent Communication about Blood Glucose Monitoring	Clinical Pediatrics. 54(14),1346-1353	United States	2015	Prospective	30	11-15 (13.67 ± 1.20) years	Daily BG monitoring frequencyDaily BG levelSelf-Care Inventory (SCI)Collaborative parent involvementParental Monitoring of Diabetes ScaleDiabetes Family Conflict Scale-Revised (DFCS-R)	Thirty adolescent/parent dyads received the physician-delivered intervention. Despite changes in the expected direction for the indicators of glycemic control, changes from preintervention to postintervention for HgbAIc, BG monitoring frequency, or mean BG level did not reach significance.
2	Goldberg A. & Wiseman H.	Parents’ Sense of Coherence and the Adolescent’s Health and Emotional and Behavioral Adjustment: The Case of Adolescents With Diabetes	Journal of Pediatric Nursing. 29, e15–e21	Israel	2014	Cross-sectional	75	13-18 (14.73 ± 1.57) years	Sense of Coherence ScaleMedical Outcomes StudyHow to Control DiabetesDiabetesSelf-Management Profile (DSMP)Self-management of the diseaseThe Achenbach Child Behavior Checklist (CBCL)	Parents’ SOC was positively correlated with adolescents' physical health and negatively correlated with internalizing problems. The SOC increased among mothers and fathers, besides improved health of their adolescent children. However, parental SOC was not correlated with adolescents' self-management or HgbAIc levels.
3	Rohan et al.	Identification and Prediction of Group-Based Glycemic Control Trajectories during the Transition to Adolescence	Health Psychology. 33(10), 1143–1152	United States	2014	Prospective	222	11.9-15.6 (13.62 ± 0.97) years (at the end of 3-year follow-up)	Behavior Rating Inventory of Executive Functioning (BRIEF)DFCS-RBlood glucose monitoring frequencyDSMPPubertal status	Higher levels of parental (family) conflict, lower frequency of blood glucose monitoring, and female gender were associated with a high risk of HgbAIc control. Children with T1DM with a low risk of future diabetes-related complications based on the HgbAIc trajectories demonstrated less diabetes-related family conflicts than those at a high risk.
4	Seiffge-Krenke et al.	Declining Metabolic Control and Decreasing Parental Support Among Families With Adolescents With Diabetes: The Risk of Restrictiveness	Journal of Pediatric Psychology. 38(5), 518-530	Germany	2013	Prospective	109	12-14 (13.77 ± 1.41) years into 14-16 years at the end of the 2-year follow-up	Family Environment ScaleNetwork of Relationships InventoryCBCLPubertal status	Adolescent-perceived maternal social support was associated with stable HgbAIc. Initially, poor HgbAIc control anticipated greater declines in the perceived maternal social support.
5	Moore et al.	Adolescents With Type 1 Diabetes: Parental Perceptions of Child Health and Family Functioning and Their Relationship to Adolescent Metabolic Control	Health and Quality of Life Outcomes. 11, 50	Australia	2013	Cross-sectional	76	12-18 (14.57 ± 1.67) years	Child Health Questionnaire Parent report (CHQ-PF50)Diabetes Self-Care Inventory (SCI-R)	Higher HgbAIc was associated with lower levels of family functioning and less adequate adolescent self-care.
6	Hanna et al.	Parent-Adolescent Dyads: Association of Parental Autonomy Support and Parent-Adolescent Shared Diabetes Care Responsibility	Child: Care, Health and Development. 39(5), 695–702	United States	2013	Cross-sectional	89	12-18 (14.5 ± 1.4) years	Parental Support for Adolescents’ Autonomy Development scaleResponsibility Subscale	Parents’ and adolescents’ perceptions of parental autonomy support were associated with their respective reports of shared diabetes care responsibility. Adolescents’ reports of parental autonomy support was associated with parents’ reports of shared responsibility. However, the relationship between autonomy or responsibility and HgbAIc was unclear.
7	Sood et al.	Mother-Father Informant Discrepancies Regarding Diabetes Management: Associations With Diabetes-Specific Family Conflict and Glycemic Control	Health Psychology. 31(5), 571-579	United States	2012	Prospective	136	9-12 (10.5 ± 0.9) years	DSMPDiabetes Family Conflict Scale (DFCS)Dads’ Active Disease Support (DADS)	Mother-father discrepancies regarding diabetes management were positively associated with the frequency of diabetes-specific family conflict and predicted poorer HgbAIc control for the youth with less involved fathers only.
8	Hilliard et al.	Fathers’ Involvement in Preadolescents’ Diabetes Adherence and Glycemic Control	Journal of Pediatric Psychology. 36(8), 911-922	United States	2011	Cross-sectional	136	9-12 (10.5 ± 0.9) years	DADSDSMP	The data supported a model indicating correlations between greater paternal involvement and higher HgbAIc and between lower adherence and higher HgbAIc.
9	Carroll et al.	Contracting and Monitoring Relationships for Adolescents With Type 1 Diabetes: A Pilot Study	Diabetes Technology & Therapeutics. 13(5), 543-549	United States	2011	Qualitative study (combined prospective)	10	14-18 years	Varney’s Pediatric Quality of Life (PedsQL) Diabetes ModuleDSMPCornell Parent Behavior Scale	A significant reduction in HgbAIc occurred at 3 months following the use of mobile technology.
10	Hsin et al.	Adherence and Glycemic Control Among Hispanic Youth With Type 1 Diabetes: Role of Family Involvement and Acculturation	Journal of Pediatric Psychology. 35(2), 156-166	United States	2010	Cross-sectional	111	10–17 (13.33 ± 2.82) years	Acculturation, Habits and Interests Multicultural Scale for Adolescents Acculturation Scale (AHIMSA)Youth independent responsibilityDiabetes Family Responsibility Questionnaire (DFRQ)Diabetes Social Support Questionnaire-FamilyDSMP	Better adherence was associated with less adolescent independent responsibility, increased family support for diabetes, and more recent immigration (fewer generations of the family living in the United States). Family support mediated the relationship between responsibility and adherence. Better glycemic control was associated with higher levels of parental education and adherence.
11	Rosenberg & Shields	The role of Parent–Adolescent Attachment in the Glycemic Control of Adolescents With Type 1 Diabetes: A Pilot Study	Families, Systems, & Health. 27(3), 237-248	United States	2009	Cross-sectional	31	12-18 (15.33 ± 1.76) years	Inventory of Parent and Peer Attachment	Attachment appears to be associated with HbAc1 control despite unclear mechanisms. Mothers’ perceptions of attachment displayed the strongest associations with control, and not adolescent reports.
12	Horton et al.	The Role of Parental Monitoring in Metabolic Control: Effect on Adherence and Externalizing Behaviors During Adolescence	Journal of Pediatric Psychology. 34(9), 1008-1018	United States	2009	Cross-sectional	252	10-14 (12.49 ± 1.53) years	Diabetes Self-Care Inventory (SCI) (adapted version)General parental monitoringDiabetes-specific scale of parental monitoringYouth Self-Report	Path analyses revealed that perceived mothers’ general monitoring was indirectly associated with lower HgbAIc through lower externalizing behaviors and higher adherence.Perceived fathers’ general monitoring was differently associated with HgbAIc at the extremes as follows: Low fathers’ monitoring was associated with higher HgbAIc through higher externalizing behaviors; high fathers’ monitoring was associated with HgbAIc through higher adherence.
13	Lloyd et al.	Brief Report: Hope, Perceived Maternal Empathy, Medical Regimen Adherence, and Glycemic Control in Adolescents With Type 1 Diabetes	Journal of Pediatric Psychology. 34(9), 1025-1029	Canada	2009	Cross-sectional	50	14.8 ± 1.6 years	Children’s Hope ScaleChild Empathy QuestionnaireSCI	Significant correlations were observed among hope, perceived maternal empathy, and medical regimen adherence and among hope, perceived maternal empathy, and glycemic control. Adolescents’ perceptions of maternal empathy were positively correlated with the level of hope. Hope appeared to mediate the relationship between perceived maternal empathy and adherence, as well as that between perceived maternal empathy and HgbAIc control.
14	Lewin et al.	The Relation Between Family Factors and Metabolic Control: The Role of Diabetes Adherence	Journal of Pediatric Psychology. 31(2), 174-183	United States	2006	Cross-sectional	109	8-18.4 (13.7 ± 2.5) years	Diabetes Family Behavior ScaleDiabetes Family Behavior ChecklistDFRQDSMP	Family functioning and adherence were strongly associated with metabolic control. Combined with demographic information, these constructs accounted for 49% of the variance in metabolic control. Path analyses suggested that adherence mediated the relationship between family functioning and HgbAIc control.

Note. BG = blood glucose; SOC = sense of coherence; T1DM = Type 1 diabetes mellitus.

Study Characteristics

The selected studies were published between 2006 and 2015. Ten studies were conducted in the United States. The remaining studies were from Australia, Israel, Germany, and Canada. There were nine and four cross-sectional and longitudinal studies, respectively. Only one study comprised a qualitative analysis (combined statistical prospective study).

Study Participants

The sample sizes varied from 10 to 252, and 1,436 adolescents with T1DM (mean age: 13.08 years) participated in these studies (see Table 3 for each study’s sample size). All studies except one were based on a dyad of children with T1DM and either of their parents. Only one study comprised children with T1DM as the participants (article no. 13) and investigated the relationship between adolescents’ perception of maternal empathy and glycemic control.

The Measurement of Parental Influence

Table 3 summarizes the included articles. All articles used HgbAIc as the primary outcome. Parental psychosocial influences were directly or indirectly assessed using different scales. Family conflict was one of the psychosocial environments. Therefore, the Diabetes Family Conflict Scale and its module-type scale (Hood et al., 2007) were used in three studies (articles 1, 3, and 7). Six studies used the Diabetes Self-Management Profile (Harris et al., 2000) (articles 2, 3, 7, 8, 10, and 14), whereas four studies used the Self-Care Inventory for specific diabetes self-care (La Greca, 2004; La Greca et al., 1995; Lewin et al., 2009) (articles 1, 5, 12, and 13) to measure the adherence to self-care or management behaviors in adolescents affected by parental psychosocial influences. Two studies focused on the fathers’ involvement in diabetes management and used the Dads' Active Disease Support Scale (Wysocki & Gravin, 2004) (articles 7 and 8). The Diabetes Family Responsibility Questionnaire (Anderson et al., 1990) was used in two studies (articles 10 and 14) to assess the number of independent diabetes management tasks for which the adolescents were responsible. Other measurements or scales were used in each study sequentially for the following aspects: parent-adolescent collaboration (article 1), network (article 4), attachment (article 11), behavior (articles 4, 9, 14), and empathy (article 13); the parents’ sense of coherence (article 2); the adolescents’ sense of control (article 2), self-management (article 2), autonomy (article 6), independence (article 10), and hope (article 13); and the adolescent’s quality of life (article 9). This scoping review analyzed these scales or their subconcepts (as required). The family function was a comprehensive concept for assessing families; this study focused on parental influences without siblings or the total function of familial members. Thus, we decided not to include family function among the influencing factors. Instead, we analyzed the subconcepts of family function as required. Figure 2 depicts an evidence map of the 14 articles, with evidence of the importance of study outcomes and quality appraisal.

Figure 2.

Evidence Map of Studies on the Effect on Glycated Hemoglobin (HgbAIc).

Evidence of Study Outcomes

The study outcomes were classified according to the effects of direct or indirect parental influence and were divided into four evidence levels: (a) Two or more studies provided evidence for a facilitative/inhibitory significant relation or correlation for the reduction of HgbAIc; (b) one study provided evidence for a facilitative/inhibitory significant relation or correlation for the reduction of HgbAIc/partial or indirect evidence for a facilitative significant relation or correlation for the reduction of HgbAIc; (c) insignificant evidence but confirmed trends; and (d) insignificant evidence and unconfirmed trends. Figure 2 depicts the inhibitory significant relation or correlation for the reduction of HgbAIc. Each study was grouped in relation to its outcome as the subitems of parental psychosocial influence, and the level of evidence was determined for each study group. Each group is described with the theme of subitems and detailed information in the following sections.

Parental Support for Adherence

Promoting adolescent adherence linked to parental influence significantly affected HgbAIc. Article 1 hypothesized that an intervention program to improve adherence might improve HgbAIc control. The results did not report significant changes in preintervention and postintervention adolescent adherence. However, it demonstrated trends in improved HgbAIc (Monaghan et al., 2015). Article 8 showed a significant relationship between lower adolescent adherence and higher HgbAIc. Parental involvement was associated with poorer HgbAIc. Despite no direct association between adolescent adherence and parental involvement, the authors confirmed the trend (Hilliard et al., 2011). Article 10 demonstrated better adherence related to greater family support and better HgbAIc control associated with improved adherence (Hsin et al., 2010). Article 12 hypothesized the path model that parental glucose monitoring influences adolescent adherence, which in turn influences HgbAIc. It revealed that parental glucose monitoring was indirectly associated with lower HgbAIc through higher adherence (Horton et al., 2009). Article 13 confirmed significant correlations of adolescent-perceived maternal empathy with adolescent adherence and HgbAIc. Despite no confirmation of the direct relationship between HgbAIc and adolescent adherence, these related factors were influenced by mediators, such as adolescent-perceived hope (Lloyd et al., 2009). Article 14 was an integrated analysis of family function with adherence and HgbAIc. Moreover, an analysis of both standardized regression weights and structure coefficients suggested that adherence was strongly related to HgbAIc despite its multicollinearity with family functioning (Lewin et al., 2006). In other words, parental involvement was substantially correlated with adolescent adherence, which was related to HgbAIc.

Parental Conflict

Parental conflict was significantly related to the HgbAIc of adolescents with T1DM, as confirmed by the evidential influencing factors. Article 3 concluded that children with T1DM at low risk of future diabetes-related complications based on the HgbAIc trajectories demonstrated lower diabetes-related parental conflict than those at high risk (Rohan et al., 2014). Article 5 concluded that higher HgbAIc (poorer metabolic control) was associated with lower levels of the specific items from the Child Health Questionnaire Parent report that target parental conflict. Therefore, it was associated with family functioning (Moore et al., 2013). Article 14 focused on parental conflict as a part of family function; HgbAIc was associated with parental conflict (Lewin et al., 2006). Article 7 studied the relationship among parental conflict, mother-father discrepancies, and HgbAIc. Mother-father discrepancies were positively associated with family conflict. These discrepancies regarding diabetes management predicted poorer HgbAIc control for youth with less-involved fathers; nonetheless, family conflict and HgbAIc were not irrelevant in this study (Sood et al., 2012). Thus, articles 3, 5, 7, and 14 provided evidence for the relationship between poor HgbAIc control and high familial conflict. Article 1 used the Diabetes Family Conflict Scale-Revised (DFCS-R). However, the DFCS-R score was not assessed in relation to HgbAIc levels. Instead, it was used to compare the preintervention and postintervention findings, and the results reported that family conflict improved after the intervention (Monaghan et al., 2015). The mentioned studies did not confirm a causal relationship between HgbAIc and family conflict; however, they demonstrated the importance of reducing family conflict for the psychosocial stability of adolescents with T1DM, which may be indirectly associated with HgbAIc control.

Parental Coherence

Article 2 was the only study focusing on the parents’ sense of coherence, which was not correlated with the adolescents’ self-management or HgbAIc (Goldberg & Wiseman, 2014).

Maternal Social Support

Article 4 focused on parental social support and HgbAIc control in adolescents. It confirmed statistically significant associations between adolescents’ maternal social support and HgbAIc control (Seiffge-Krenke et al., 2013). However, no other studies supported this outcome.

Parental Autonomy Support

Article 6 studied the importance of parental autonomy support. However, it could not demonstrate the relationship between parental autonomy support and HgbAIc in adolescents (Hanna et al., 2013).

The Joint Management of Glucose

Article 9 aimed to develop a mobile technology system to manage negotiable points of conflict within the parent-child relationship regarding self-monitoring. It predominantly adopted a qualitative approach to interview data. It conducted a supplementary statistical analysis and demonstrated a significant reduction in HgbAIc because of the joint management of glucose monitoring with technology intervention and adolescent-parent relationships (Carroll et al., 2011).

Mothers’ Perception of Attachment

Article 11 focused on mothers’ perception of attachment. Despite unclear mechanisms, mothers’ perceptions of adolescents’ attachment were significantly correlated with HgbAIc (Rosenberg & Shields, 2009).

Quality Appraisal

A quality assessment was performed using the QATSDD (see Table 2). The included studies scored between 22 and 37 (mean 29.6).

Discussion

This novel review included articles that focused on parental influences as psychosocial factors of HgbAIc control in adolescents with T1DM.

Previous clinical data have repeatedly demonstrated that patients have difficulty reaching and maintaining glucose control during adolescence (Amiel et al., 1986; Dabadghao et al., 2001; Eilander et al., 2015). The Diabetes Control and Complications Trial demonstrated that better glycemic control during adolescence lowers the risk of developing complications later in life (White et al., 2001). This scoping review comprised studies performed across several countries. The issue of T1DM and glucose control during adolescence and into adulthood is an important study area to improve health care.

Interestingly, this review highlighted two evidential parental influences. First, parental support for adherence exerted a facilitative effect on HgbAIc control, whereas parental conflict exerted an inhibitory effect on HgbAIc reduction.

Adherence commonly describes a patient who appropriately follows medical advice based on positive patient-medical specialist relationships. The development of children into young adults through adolescence necessitates medical specialists and parents to understand the changing needs of youth with T1DM to improve the quality and efficacy of pediatric diabetes care. This study’s findings were consistent with those of most recent studies. In a random sampling study (Temmen et al., 2022), the high-parental-collaborative involvement group demonstrated the best adherence, glycemic control, and psychosocial well-being compared with the low-parental-collaborative group. Hsin et al. (2010) mentioned that better adherence was associated with lower adolescent independence and greater parental support. To summarize these findings, parental involvement in diabetes care is important in adolescence, but the optimal form of involvement may need to be adjusted to be consistent with the child’s level of development. Nurses must guide the parents to watch their children carefully and provide the necessary support. Parents should continually act as primary advisers to adolescents to maintain good patient-medical relationships and follow their medical instructions.

As T1DM requires frequent medical follow-up and ongoing intensive self-care (Garvey et al., 2014), it is clear that the psychosocial context may influence their self-care. Our study supports the previous studies’ (Drotar et al., 2013; Miller-Johnson et al., 1994) conclusion that parental conflicts exert a negative impact on an adolescent’s recuperation. Family conflict affects glucose control by interfering with the quality of diabetes management through increased stress levels in the child and parents. However, our study could not distinguish the conflict between or within the adolescent, mother, or father. The latest study (Campbell et al., 2022) revealed that adolescents with greater conflict with their mothers and fathers (average of 14 days) had higher blood glucose levels. Additional studies are needed to further understand their conflicts. In addition, as some studies (Matsumoto et al., 2022; Saßmann et al., 2022) reported, more research is needed to understand the parents’ burden and stress management.

New technology makes it possible to support adolescents to be capable of self-care and self-directed problem-solving. A pilot study used a cellphone-based glucose monitoring system and shared the health care information with parents. A recent study on diabetic adults reported an app-based monitoring system (Johnston, 2022). More technology applications are needed for T1DM adolescents.

Parental coherence is an important factor for parenting T1DM children, as it may disable children (Farhadi et al., 2022). However, as the evidence is not sufficient to make conclusions, further research is needed.

Additional parental influence was reported in the present study: Maternal social support, attachment, and autonomy support were also important for adolescent-parent relationships. These themes possibly relate to the parents’ psychosocial status; thus, more studies focusing on T1DM adolescents are needed in the future.

Our findings have important implications for both clinical and future research. Parental psychosocial factors may facilitate or inhibit glucose control in adolescents. However, we did not comprehensively clarify other or unknown parental psychosocial influences. This warrants future research to determine the influencing factors for better glycemic control with adolescents experiencing the developmental issues of transition to adulthood.

Our scoping review showed that only one study conducted a qualitative analysis (combined statistical prospective study). Further qualitative or mixed studies are needed to explore the experiences of adolescents and their parents, which may negatively influence HgbAIc levels.

Study Limitations

Numerous studies were based on adolescence and parental objective or self-report questionnaires to provide the leading sources that examined the psychosocial parental effects. However, as parental psychosocial influences on T1DM adolescence are complex and diverse, it cannot be said that these target studies have determined all parental influences. Therefore, one limitation was that our review could not provide all evidence of parental influence. However, it can suggest interventions to clinical specialists for adolescents with T1DM experiencing difficulties in glycemic control. Furthermore, it demonstrated that parents might exert either facilitative or inhibitory effects on adolescents with T1DM. Therefore, specialists should support both adolescents and their parents. Ultimately, further studies on alternative parental influences that have not been adequately studied (such as parental attachment or autonomy support) are warranted.

Conclusion

This scoping review included studies conducted in the last 20 years about the psychosocial influence of parents on HgbAIc control in adolescents with T1DM. This review presented new evidence and concluded that “parental support for adherence” and “family (parental) conflict” were the facilitative and inhibitory influences, respectively, and the study assessed their effect on HgbAIc in adolescents. As parental psychosocial influences on adolescents with T1DM are complex and diverse, our review cannot provide all evidence of parental influence. Further studies must focus on alternative parental influences that have not been adequately studied.

Footnotes

Acknowledgements

The authors wish to thank librarian Toshiyuki Suwa, Osaka University, for cooperating to compose a literature database. They would like to thank Editage () for English language editing and journal submission support. The authors have authorized the submission of this manuscript through Editage.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding from the JSPS KAKENHI (grant number J222004155) is gratefully acknowledged.

ORCID iD

Miku Yamaguchi

Author Biographies

Miku Yamaguchi, PhD, RN, PHN, is a registered nurse and an assistant professor in the Department of Nursing, Faculty of Medicine, University of Kyoto Prefectural University of Kyoto, Japan. Her research focuses on parental competence, stress, and family members’ perspectives concerning children with special health care needs. Her recent publications include “Impact of Informal Care With Multiple Medical Devices on Caregiver Burden: A Cross-Sectional National Survey in Japan” in Health and Social Care in the Community (2022, with M. Ogita & K. Harada), “The Experience of Parents of Adult Sons With Duchenne Muscular Dystrophy Regarding Their Prolonged Roles as Primary Caregivers: A Serial Qualitative Study” in Disability and Rehabilitation (2019, with E. Sonoda & M. Suzuki), and “Becoming a Back-Up Carer: Parenting Sons With Duchenne Muscular Dystrophy Transitioning Into Adulthood” in Neuromuscular Disorders (2015, with M. Suzuki).

Junko Honda, PhD, RN, PHN, MBA, CTN-A, is a registered nurse and professor at the Research Institute of Nursing Care for People and Community, University of Hyogo, Japan. She is currently serving as a member of the Board of Directors of the International Family Nursing Association. Her research focuses on the development of methods of family nursing in every field of practice and tools for teaching family nursing practice competencies. Her recent publications include “Intensive Care Nurse-Family Engagement From a Global Perspective: A Qualitative Multi-Site Exploration” in Intensive and Critical Care Nursing (2021, with R. Naef et al.), and “Development and Psychometric Testing of a Family Concordance Competency Scale for Families With Children Having Chronic Illnesses” in Japan Journal of Nursing Science (2021, with S. Takatani & N. Hohashi).

Minae Fukui, MSN, RN, PHN, is a registered nurse and an assistant professor in the Department of Nursing, Faculty of Nursing of Mukogawa Women’s University. Her research focuses on children with special health care and their family, particularly siblings. Her recent publications include “Children’s Psychosocial and Behavioral Consequences During Their Siblings’ Hospitalization: A Qualitative Content Analysis From Caregivers’ Perspectives” in Journal of Clinical Nursing (2022, with K. Niinomi), “The Effectiveness of Vibratory Stimulation in Reducing Pain in Children Receiving Vaccine Injection: A Randomized Controlled Trial” in Vaccine (2021, with S. Ueki et al.), and “Related Variables of Behavioral and Emotional Problems and Personal Growth of Hospitalized Children’s Siblings: Mothers’ and Other Main Caregivers’ Perspectives” in Inquiry: The Journal of Health Care Organization, Provision, and Financing (2018, with K. Niinomi).

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