The effects of parental depression and parenting practices on depressive symptoms and metabolic control in urban youth with insulin dependent diabetes.
ABSTRACT Examine relationships between parental depressive symptoms, affective and instrumental parenting practices, youth depressive symptoms and glycemic control in a diverse, urban sample of adolescents with diabetes.
Sixty-one parents and youth aged 10-17 completed self-report questionnaires. HbA1c assays were obtained to assess metabolic control. Path analysis was used to test a model where parenting variables mediated the relationship between parental and youth depressive symptoms and had effects on metabolic control.
Parental depressive symptoms had a significant indirect effect on youth depressive symptoms through parental involvement. Youth depressive symptoms were significantly related to metabolic control. While instrumental aspects of parenting such as monitoring or discipline were unrelated to youth depressive symptoms, parental depression had a significant indirect effect on metabolic control through parental monitoring.
The presence of parental depressive symptoms influences both youth depression and poor metabolic control through problematic parenting practices such as low involvement and monitoring.
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ABSTRACT: The purpose of this study was to describe coping in mothers of adolescents with type 1 diabetes and to examine the association among mothers' diabetes-related stress and coping strategies and maternal psychological distress (e.g., symptoms of anxiety and depression), adolescent adjustment (e.g., symptoms of depression, quality of life), diabetes-related family conflict, and glycemic control. One hundred and eighteen mother-adolescent dyads completed measures of diabetes-related stress, coping, symptoms of anxiety and depression, quality of life, and family conflict. Data on glycemic control were collected from adolescents' medical charts. Single/divorced mothers and mothers of color were significantly more likely to use disengagement coping strategies (e.g., avoidance) than White and married/partnered mothers. Mothers' use of primary control coping (e.g., problem solving) and secondary control coping (e.g., acceptance) strategies was related to fewer symptoms of anxiety (r = - .51, -.39) and depression (r = - .32, -.37) and less family conflict (r = - .22, -.30, all p < .05). Mothers' use of disengagement coping strategies was related to greater symptoms of anxiety (r = .30) and depression (r = .27, both p < .01). Further, secondary control coping was found to mediate the relationship between diabetes-related stress and maternal symptoms of anxiety and depression. Maternal coping was not significantly associated with adolescent outcomes. The ways in which mothers of adolescents with type 1 diabetes cope with diabetes-related stress are associated with psychological distress and family conflict. By identifying and improving mothers' coping through screening and targeted interventions, we may have the potential to improve both maternal and adolescent outcomes.Maternal and Child Health Journal 02/2013; · 2.24 Impact Factor
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ABSTRACT: Declining diabetes management and control are common as children progress through adolescence, yet many youths with diabetes do remarkably well. Risk factors for poor diabetes outcomes are well-researched, but fewer data describe processes that lead to positive outcomes such as engaging in effective diabetes self-management, experiencing high quality of life, and achieving in-range glycemic control. Resilience theory posits that protective processes buffer the impact of risk factors on an individual's development and functioning. We review recent conceptualizations of resilience theory in the context of type 1 diabetes management and control and present a theoretical model of pediatric diabetes resilience. Applications to clinical care and research include the development of preventive interventions to build or strengthen protective skills and processes related to diabetes and its management. The ultimate goal is to equip youths with diabetes and their families with the tools to promote both behavioral and health-related resilience in diabetes.Current Diabetes Reports 09/2012; · 3.17 Impact Factor
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ABSTRACT: Despite the increasing number of studies on the health-related quality of life (HRQOL) of children with type 1 diabetes (T1D), little is known about the influence of family and parental factors on this outcome. This study aimed to explore whether family cohesion and children’s HRQOL were connected through three indicators of parental psychological adjustment (parenting stress, depressive symptoms, and anxious symptoms) as well as whether these links varied according to the child’s age. Levels of family cohesion, parenting stress, and depression/anxiety symptoms of parents of children with T1D and parents of healthy children were compared. The sample included 88 child-parent dyads composed of children/adolescents (8-18 years old) with T1D and one of their parents and 121 dyads composed of healthy children/adolescents and one of their parents. The parents completed self-report measures of family cohesion, parental stress, and emotional adjustment, and the children completed measures of HRQOL. Testing of the hypothesized moderated mediational model showed that higher HRQOL ratings in children were associated with higher levels of cohesion through lower levels of parental stress, regardless of the child’s age. Parents of children with T1D perceived less cohesion and felt more anxiety and stress about parenting tasks compared to parents of healthy children. Our findings suggest that parents of children with T1D are at an increased risk of psychological maladjustment. Moreover, this study highlights the interrelation between family/parental functioning and child adjustment and makes an innovative contribution by identifying a mechanism that may account for the link between family and child variables.Journal of Child and Family Studies 01/2013; · 1.42 Impact Factor
The Effects of Parental Depression and Parenting Practices on
Depressive Symptoms and Metabolic Control in Urban Youth with
Insulin Dependent Diabetes
Dikla Eckshtain,1PHD, Deborah A. Ellis,2PHD, Karen Kolmodin,2PHD, and Sylvie Naar-King,2PHD
1Judge Baker Children’s Center, Harvard Medical School and2Carman and Ann Adams Department of
Pediatrics, Wayne State University
practices, youth depressive symptoms and glycemic control in a diverse, urban sample of adolescents with
diabetes.MethodsSixty-one parents and youth aged 10–17 completed self-report questionnaires. HbA1c
assays were obtained to assess metabolic control. Path analysis was used to test a model where parenting
variables mediated the relationship between parental and youth depressive symptoms and had effects on
metabolic control. Results Parental depressive symptoms had a significant indirect effect on youth
depressive symptoms through parental involvement. Youth depressive symptoms were significantly related to
metabolic control. While instrumental aspects of parenting such as monitoring or discipline were unrelated to
youth depressive symptoms, parental depression had a significant indirect effect on metabolic control through
parental monitoring.ConclusionsThe presence of parental depressive symptoms influences both youth
depression and poor metabolic control through problematic parenting practices such as low involvement
Examine relationships between parental depressive symptoms, affective and instrumental parenting
Key words diabetes; depression; metabolic control; parental depression; parental monitoring.
Depression in children and adolescents is associated with
significant impairments in both current psychosocial func-
tioning and functioning in adulthood (Harrington, Fudge,
Rutter, Pickles, & Hill, 1990; Kandel & Davies, 1986;
Lewinsohn, Rohde, Seeley, Klein, & Gotlib, 2003). Youth
with type 1 diabetes appear to be at particularly high risk
for depression (Dantzer, Swendsen, Maurice-Tison, &
Salamon; 2003; Kovacs, Goldston, Obrosky, & Bonar,
1997), with rates ranging from 17% (Massengale, 2005)
to 20% (Grey, Whittemore, & Tamborlane, 2002) as com-
pared to general population rates of 0.4–8.3% (Mash &
Wolfe, 2007). Depression in youth with type 1 diabetes is
of particular concern in light of the known links between
depression, poor metabolic control (Grey et al., 2002;
La Greca, Swales, Klemp, Madigan, & Skyler, 1995;
Leonard, Jang, Savik, Plumbo, & Christensen, 2002;
Lernmark, Persson, Fishert, & Rydelius, 1999), increased
risk for hospitalizations due to medication non-compliance
(Garrison, Katon & Richardson, 2005; Liss et al., 1998;
Stewart, Rao, Emslie, Klein, & White; 2005), and, for
females, treatment adherence (Korbel, Wiebe, Berg, &
Childhood depression emerges in the context of the
family (Hammen, 1991). Such relationships are due in part
to the well known relationship between child depression
and caregiver depression (Racusin & Kaslow, 2004).
The general consensus is that parental depression increases
the risk for child depression (Beardslee, Versage, &
Gladstone, 1998; Beck, 1999; Downey & Coyne, 1990;
Elgar, McGrath, Waschbusch, Stewart, & Curtis, 2004;
Kane & Garber, 2004; LaRoche, 1989; Phares &
Compas, 1992). Although research on depression in par-
ents of youth with type 1 diabetes is more limited, studies
have suggested that higher levels of parenting stress in
All correspondence concerning this article should be addressed to Dikla Eckshtain, PhD, Judge Baker Children’s
Center, Harvard Medical School, 53 Parker Hill Avenue, Boston, MA 02120-3225, USA.
Journal of Pediatric Psychology 35(4) pp. 426–435, 2010
Advance Access publication August 26, 2009
Journal of Pediatric Psychology vol. 35 no. 4 ? The Author 2009. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: email@example.com
mothers are associated with increased rates of youth inter-
nalizing problems (Lewin et al., 2005) and depressive
symptoms (Mullins et al., 2004).
One mechanism by which parental depression affects
the child is through its influence on parenting behavior
(Cummings & Davies, 1994). Parenting behaviors that
have been widely explored in community samples of
youth include instrumental aspects of parenting, such as
discipline, limit setting and parental monitoring, and
affective aspects of parenting such as warmth, support,
and psychological control. Compared to parents with no
psychiatric diagnosis, depressed parents have been found
to display more hostile/critical, negative, rejecting, and
unsupportive behavior (Burbach & Borduin, 1986;
Kaslow, Deering, & Racusin, 1994; McCauley & Myers,
1992; Sheppard, 1994), and to struggle to effectively
discipline and manage their child’s behavior (Cummings
& Davies, 1994; Downey & Coyne, 1990; Kaslow et al.,
1994). However, although depressed parents may display
poor parenting skills in both instrumental and affective
domains, it is low warmth and high levels of parental
criticism or intrusion in particular that have been found
to directly influence depressive symptoms in the general
population of youth (Barber, Stolz, & Olsen, 2005; Gray
& Steinberg, 1999).
For youth with diabetes, the knowledge base regarding
the relationship between parenting behaviors and youth
depression and health outcomes, as well as factors that
influence parenting behaviors, is relatively limited. Using
a sample of young children, Davis et al. (2001) found that
high parental warmth was associated with better adherence
while high parental restrictiveness was associated with
poorer metabolic control. In an adolescent sample,
Butler, Skinner, Gelfand, Berg, & Wiebe (2007) found
that a maternal parenting style characterized as controlling,
intrusive, and rejecting, was associated with higher levels
of depression in youth but that parenting variables did not
predict regimen adherence behavior. Ellis et al. (2007)
found that high levels of parental supervision and monitor-
ing were directly related to higher youth regimen
adherence and indirectly related to better glycemic control.
However, neither of these studies investigated the relation-
ship between parental depression and parenting style
nor the influence of these factors on both mental health
(youth depression) and physical health status (glycemic
control) simultaneously. In addition, at least two of the
studies investigated parenting style in samples that were
primarily white and/or middle class. Therefore the applic-
ability of findings to minority or low income samples of
youth with diabetes, for whom higher rates of depression
are typically documented (Roberts, Roberts, & Chen,
1997; Rushton, Forcier, & Schectman, 2002), is largely
The purpose of the present study was to (a) further
investigate relationships between affective (i.e., warmth)
and instrumental (e.g., monitoring and discipline) parent-
ing practices, youth depressive symptoms and glycemic
control in a diverse, urban sample of adolescents with
diabetes and (b) determine whether parental depressive
symptoms would be related to problematic parenting
practices in a chronic illness sample. In light of findings
from prior studies on the effect of parenting on youth
depression, the primary hypothesis was that parenting
variables would mediate the relationship between parental
depressive symptoms and youth depressive symptoms.
Given the considerable literature regarding links between
low levels of parental warmth and youth depressive symp-
toms in the broader child psychopathology literature,
we hypothesized that low warmth, but not poor monitor-
ing or inconsistent discipline, would be related to higher
levels of youth depressive symptoms. A secondary
hypothesis was that parenting variables would have both
direct effects on metabolic control and indirect effects on
metabolic control via youth depressive symptoms. Figure 1
shows the theoretical model that operationalizes these
Youth and their primary caregivers were participants
in a larger clinical trial investigating the effectiveness
of intensive, home-based psychotherapy for improving
regimen adherence in youth with diabetes in chronically
poorly metabolic control. Data used in the present
analyses were drawn from the participant’s baseline data
collection prior to study randomization or receipt of any
In order to be eligible for the parent study, partici-
pants had to be between 10 and 18 years of age, have a
diagnosis of type 1 or type 2 diabetes for at least one year
that required management with insulin, have a current
HbA1C of 8% or higher and a mean HbA1c of 8% or
higher during the year before study entry, and be residing
in a home setting (e.g., not in residential treatment).
No child psychiatric diagnoses were exclusionary with
the exception of moderate or severe mental retardation,
and psychosis. Families were also excluded if they were
not English speaking or could not complete study mea-
sures in English. Potential participants were initially
approached in person by medical staff at the time of
a regularly scheduled visit to a university-affiliated pediatric
Effect of Parental Depression on Youth Outcome
diabetes clinic or during an inpatient hospitalization.
This was followed up by contacts from study research
staff and home-based consent visits if families indicated
an interest in participating. Ninety percent of eligible
families agreed to participate. The final sample consisted
of 61 adolescents and their primary caregivers. The research
was approved by the Human Investigation Committee of
the university affiliated with the hospital where the adoles-
cents were seen for medical care. All participants provided
informed consent and assent to participate.
are shown in Table I. The average age of adolescents
participating in the study was 14.3 years. Of the 61 parti-
cipants, 62% were female. Eighty-seven percent were
African-American, 10% were white, and the rest were of
other race/ethnicity. Mean family income was $39,831.
Seventy percent of adolescents resided in two parent
families, which included two biological parents, a biologic-
al parent and step-parent and single parents living with
a partner, and 30% resided in single parent families.
Ninety-two percent of caregivers participating in the
study were female and 97% were the biological parent of
the child. 85% had type 1 diabetes. There were no signifi-
cant differences between type 1 and type 2 children with
regard to HbA1c level, duration of diabetes, and total dose
of insulin per day. Overall, the demographics of the sample
were representative of the diverse, urban population served
by the clinic where subjects were recruited. Youth had
been diagnosed with diabetes for an average of 4.6 years
at the time of study entry. Mean hemoglobin A1c was
11.78%, suggesting that the sample was in poor metabolic
control, as expected.
of the participants
All measures were collected by a trained research assistant
in the participants’ homes. Both the youth and the primary
caregiver completed questionnaires. Families were pro-
vided $50 to compensate them for participating in the
data collection session.
Figure 1. Theoretical model of relationships between parental depressive symptoms, parenting variables youth depressive symptoms and metabolic
Table I. Demographics and Characteristics of Adolescents and
Their Families (N¼61)
PercentageM (SD) Range
Annual Family Income
Number of parents in home
Duration of diabetes
4.42 (2.8) 0.48–15.06
aTwo parents included two biological parents, a biological parent and a step-parent
or a biological parent living with a partner.
Eckshtain, Ellis, Kolmodin, and Naar-King
Adolescent depressive symptoms were measured by the
Child Behavior Checklist (CBCL; Achenbach & Rescorla,
2001) and the Youth Self Report (YSR; Achenbach &
Rescorla, 2001), completed by the parents and youth,
respectively. The CBCL and the YSR yield T-scores for
eight narrow-band syndrome scales (Anxious-Depressed,
Withdrawn-Depressed, Somatic Complaints, Attention
Problems, Thought Problems, Social Problems, Aggressive
Behavior, and Rule-Breaking Behavior), two broad-band
Externalizing), and a Total Problems scale. Because prior
research with chronically ill children suggests that the
broad-band internalizing scale may inflate depressive
symptoms due to the inclusion of physical symptoms
Withdrawn/Depressed subscale was used in the present
analyses. The CBCL and YSR T-scores of 65 or higher are
within the clinical range and scores between 60 and 64 are
within the sub-clinical range. Higher scores indicate more
depressive symptoms. The CBCL and YSR have extensive
reliability and validity data and have been used with
various populations of children, including children with
chronic illness. To ensure comparability across youth of
different ages and genders, T-scores rather than raw
scores were used.
Parental depressive symptoms were measured by the
Brief Symptom Inventory 18 (BSI 18; Derogatis, 2004),
an abbreviated version of the BSI instrument that was
designed to assess psychological status in persons over
18 years of age. The BSI 18 measures three primary symp-
tom dimensions: Somatization, depression, and anxiety.
The depression subscale was used in the present analyses;
the clinical cut-off score for this measure is 65. Higher
scores on the BSI 18 indicate more depressive symptoms.
Internal consistency for the current sample was 0.84.
Parenting skills were measured by the Alabama
Parenting Questionnaire (APQ;
Wootton, 1996). The APQ is a widely used, self-report
instrument that measures multiple parenting constructs.
Internal consistency for all scales is moderate to high
(Shelton et al., 1996) and test-retest reliability across
a 3-year interval is adequate (McMahon et al., 1997).
Diabetes-specific measures were not used because no
such measures with adequate psychometrics are currently
available to measure warmth or limit-setting; furthermore,
we intended to measure general parenting behavior rather
than parenting specific to diabetes-care tasks. Initial
reliability and validity were reported with 6- to 13-year
old youth. However, the APQ has also been used been
with adolescent populations (Wootton, Frick, Shelton, &
Silverthorn, 1997) as well as with chronically ill youth
(Tompkins & Wyatt, 2008). Five scales can be derived
from the instrument: use of corporal punishment, incon-
sistent discipline, poor monitoring, involvement, and
clarity of rules and expectations. The APQ ‘‘involvement’’
scale measures warmth of the relationship between the
youth and parent, that is, strength of the affective bond,
rather than other related constructs such as parental
instrumental support or help. Therefore, for the purpose
of the present study, the scales that were closest to the
constructs of interest were poor monitoring (e.g., ‘‘You
don’t check that your child comes home from school
when s/he is supposed to’’), involvement (e.g., ‘‘You hug
or kiss your child when s/he has done something well’’),
and inconsistent discipline (e.g., ‘‘You threaten to punish
your child and then do not actually punish him/her’’).
Higher scores on these scales reflect more involvement
(warmth), less supervision and monitoring and less
effective discipline. Internal consistency for the current
sample for these three scales was 0.81, 0.51 and 0.65,
Metabolic control was calculated using hemoglobin
A1c (HbA1c), a retrospective measure of average blood
glucose during the past 2–3 months. Typical HbA1C for
a person without diabetes is between 4 and 6%; the target
range for adolescents with diabetes is less than 7.5%
(Silverstein et al., 2005). Values were obtained using the
Accubase A1c test kit, which is FDA approved. The test
uses a capillary tube blood collection method instead
of venipuncture and is therefore suitable for home-based
Bivariate analyses were conducted to assess simple rela-
tionships between variables. The hypotheses that parenting
would fully mediate the relationship between parental
depressive symptoms and child depressive symptoms and
that parenting variables would have both direct effects on
metabolic control and indirect effects on metabolic
control via child depressive symptoms were evaluated via
structural equation modeling (SEM) using AMOS Version
7.0. The theoretical model is shown in Figure 1.
Because only parent report was available for the parent
depressive symptoms and parenting style variables, models
were evaluated using path analysis, a form of SEM that uses
all single indicator constructs. Path analysis is similar to
ordinary least squares regression but retains the advantage
Effect of Parental Depression on Youth Outcome
of allowing both the assessment of goodness of fit of
a specified model and testing of each estimated path
coefficient. In the case of child depression, both parent
and child reports were available and used in the analyses.
Consistent with other samples of youth with diabetes,
a significant number of youth in the present sample had
depressive symptoms in the clinical range (i.e., above a
T-score of 65). Based on parent report on the CBCL,
20% of youth had clinically significant levels of depressive
symptoms. Based on youth report on the YSR, 17% of
youth fell in the clinical range. 10% of parents fell in
the clinically significant range for depression on the BSI.
Bivariate analyses were conducted to test associations
between variables (Table II). Parental depressive symptoms
were significantly related to each parenting variable such
that higher levels of parental depression were related
to lower monitoring (r¼0.26, p<.05), inconsistent
involvement/warmth (r¼?0.37, p<.01). However, of
the three parenting variables, only monitoring was related
to metabolic control with lower levels of monitoring
associatedwith worse metabolic
p<.01). When youth depression was assessed by parent
report, high levels of inconsistent discipline (r¼0.28,
p<.05) andlow involvement/warmth
p<.05) were each significantly related to higher levels of
youth depression. In addition, youth depressive symptoms
were significantly related to metabolic control such that
higher levels of depression were associated with poorer
metabolic control (r¼0.35, p<.01). However when
youth depression was assessed by youth report, youth
p<.05)and lower parental
depression was not significantly related either to parenting
nor metabolic control. As youth reported depression was
unrelated to either objective measures or questionnaire
measures, path analyses to test study hypotheses were
conducted with parent reported youth depression only.
A structural equation model with all single indicator
variables was fit to the variance/covariance matrix using a
maximum likelihood solution to model relationships
between variables. Initially, the theoretical model shown
in Figure 1 was tested. The model had one exogenous
variables (monitoring, discipline, involvement/warmth,
youth depressive symptoms and metabolic control), with
parental depressive symptoms having indirect effects on
youth depressive symptoms through parenting variables
and parenting variables having both direct effects on
metabolic control and indirect effects through youth
depressive symptoms. Three fit indices were evaluated:
that the likelihood ratio w2test of model fit was non-
significant, the comparative fit index (CFI) was >0.95,
and the root mean square error of approximation
(RMSEA) was <0.08. Using these criteria, no fit index
Therefore, an alternative model was tested where all non-
significant paths were trimmed. In addition, because
the relationships between discipline and youth outcome
variables were also non-significant, this variable was
dropped from the alternative model. Examination of
modification indices revealed a high covariance between
error terms for child depressive symptoms and adult
and five endogenous
Table II. Correlations Among Psychosocial and Health Outcome Variables
5. CBCL Dep
6. YSR Dep
Note. BSI, Brief Symptom Inventory; APQ-Mon, Alabama Parenting Questionnaire Monitoring Subscale, higher scores reflect less monitoring; APQ-Inv, Alabama Parenting
Questionnaire Involvement Subscale; APQ-Ind, Alabama Parenting Questionnaire Inconsistent Discipline Subscale, higher scores reflect less effective discipline; CBCL Dep,
parent-reported depressive symptoms; YSR, youth-reported depressive symptoms; HbA1c, hemoglobin A1c.
Eckshtain, Ellis, Kolmodin, and Naar-King
depressive symptoms, so they were allowed to covary. The
model fit statistics for the trimmed model indicated excel-
In this model (Figure 3), all paths were significant.
Statistical tests of the indirect effect of parent depressive
symptoms on youth depressive symptoms and parental
depressive symptoms on metabolic control were performed
using bootstrapped standard errors as recommended by
Shrout & Bolger (2002). Parental depressive symptoms
had significant indirect effects on youth depressive symp-
toms through involvement/warmth (standardized indirect
effect¼0.136, p<.01). Youth depressive symptoms in
turn were significantly related to metabolic control.
Parental depressive symptoms also had a significant
indirect effect on metabolic control through parental
monitoring (standardized indirect effect¼0.13, p<.05);
this path was independent of youth depression.
The present study sought to clarify the relationship
between affective (i.e.,warmth)
(i.e., monitoring and discipline) parenting practices,
youth depressive symptoms and glycemic control, and to
determine whether depressive symptoms in parents were
related to problematic parenting in a diverse, urban sample
of adolescents with insulin-managed diabetes. Although
there have been several recent studies pointing to the
importance of parenting in understanding outcomes in
youth with diabetes, risk factors for ineffective parenting
practices in this population remain poorly understood.
In particular, there is little information on the relationships
between particular parenting difficulties and youth depres-
sion, which is important to the development of effective
interventions. Moreover, there has been limited family
research on minority youth with diabetes and how
Figure 2. Full structural model. Standardized path coefficients are shown (*p<.05, **p<.01), with youth depression measured by parent report.
Figure 3. Trimmed structural model predicting HbA1c from youth depressive symptoms, parenting variables and parental depressive symptoms.
Standardized path coefficients are shown (*p<.05, **p<.01).
Effect of Parental Depression on Youth Outcome
parenting practices or parental mental health may influ-
ence outcomes in this population.
Overall, rates of youth depression did not appear
higher in this low income, predominantly minority
sample than have been reported in samples of white,
middle class youth with diabetes. Approximately 20% of
youth fell in the at-risk range or above on measures of
depressive symptoms. Given the high-risk contexts in
which these youth resided, the fact that rates of depression
are comparable to those of middle-class youth may attest to
their resiliency. However, findings from the study suggest
that adolescents who experienced
depressive symptoms also had significantly poorer meta-
bolic control. These findings are consistent with the
significant body of evidence documenting a relation
between depression and poor metabolic control in youth
with diabetes (e.g., Dantzer et al., 2003; Grey et al., 2002).
Depression and poor metabolic control are likely to have
bidirectional effects on one another. Youth with depression
are unlikely to adequately complete their self-care,
compounding inadequate glycemic control and poor
metabolic control may exacerbate depression through
increasing feelings of lethargy or fatigue. Depression is
also particularly concerning when it presents in youth
with diabetes due to its known association with hospitali-
zations for diabetic ketoacidosis (Garrison et al., 2005;
Stewart et al., 2005), a dangerous and potentially life-
When parent-report of depressive symptoms was
considered, higher levels of parental depressive symptoms
were found to be associated with youth outcomes via two
independent pathways. First, parental depressive symp-
toms were significantly associated with lower parental
warmth towards the youth. In turn, lower warmth was
associated with higher levels of youth depressive symp-
toms. Parental depressive symptoms were found to be
associated with youth depressive symptoms through
parental warmth. Although results from studies on general
population samples of adolescents have documented the
relation between depression in parents and low levels of
parental involvement, support, and warmth (e.g., Barber et
al., 2005; Kaslow et al., 1994), such relationships have
not been documented within the diabetes population.
The current study suggests that parenting behavior, specif-
ically parental involvement and warmth, is one mechanism
by which parental depression is associated with the
development of depressive symptoms in youth with
Second, parents with higher levels of depressive
symptoms reported lower levels of parental monitoring
and more inconsistent discipline. Such parenting styles
higher levels of
However, low levels of monitoring by parents with more
depressive symptoms were directly related to poorer meta-
bolic control and low monitoring mediated the relationship
metabolic control. The association between low parental
monitoring and poor metabolic control is supported by
prior studies showing an association between monitoring
and glycemic control (e.g., Ellis et al., 2007; Berg et al.,
2008). Results from prior studies in general population
samples of adolescents have not suggested strong associa-
tions between parental monitoring (high or low) and
depression; rather, low parental monitoring and inconsist-
ent discipline have frequently been shown to contribute
to the development of aggression and conduct disorder
(Barber et al., 2005). The present study did not evaluate
externalizing behavior problems in youth, but it is possible
that low monitoring and inconsistent discipline by parents
could be associated with increased risk for such behavioral
difficulties in youth with diabetes which in turn would
be expected to be associated with risk for poor metabolic
control (Leonard et al, 2002).
In the present study, study hypotheses were sup-
ported when parent report was used as the measure
of youth depression. However, although the direction of
findings was similar, youth-reported depression was not
significantly related to either parenting variables or to
HbA1c. Although such a finding may be accounted for
by small sample size, it is more usual to find that youth
report of internalizing symptoms is a better predictor of
outcome. Parents in this sample also reported slightly
higher rates of clinically significant youth depressive symp-
toms than did youth themselves, suggesting that youth
may have been underreporting symptoms due to either
social desirability factors or other reasons that are not
known. Butner et al. (2009) found that greater discrepan-
cies in reports between caregivers and adolescents were
associated with poor management of diabetes and with
mother’s depressive symptoms which also suggests there
may be greater potential for differences in perceptions
when the caregiver is more depressed.
The current study suggests that parents of youth with
diabetes with depressive symptoms are at risk for engaging
in parenting behaviors that both directly and indirectly
contribute to depressive symptoms and poor metabolic
control in youth. Such findings suggest that there may be
benefits to screening for parents at risk of depression as
a way to prevent the development of health difficulties
among youth with diabetes. In addition, interventions for
youth depressive symptoms in this population may benefit
from the inclusion of specific parenting interventions
not relatedto youthdepressivesymptoms.
Eckshtain, Ellis, Kolmodin, and Naar-King
that focus upon improving the affective bond between the
child and parent through increasing opportunities for posi-
tive interactions, problem solving, and targeting negative
Study limitations include the fact that participants
were drawn from the baseline sample of an intervention
study targeting youth with poorly controlled diabetes.
Hence, although overall recruitment rates into the study
were high (90%), the sample may not be representative of
youth with well controlled diabetes. Parenting style was
assessed only from the parent’s perspective and not from
the youth’s perspective. Previous studies have documented
inconsistent agreement between caregivers and children on
family experiences (Rutter & Sroufe, 2000) and future
studies should include an assessment of the child’s
perspective on their parents’ parenting style. As the data
were cross-sectional in nature, the potential reciprocal
nature of the influences between parents and adolescents
was not evaluated. For example, Kaslow et al. (1994)
suggested that depressed youth also may influence parental
mood by contributing to consistently negative parent-child
interactions. Longitudinal studies are warranted to better
understand such bi-directional relationships between
youth and parent factors. The analyses relied primarily
on self-report measures rather than objective ratings and
internal consistency of some parenting scales was only
moderate. Although in the present study parents appeared
to be more accurate reporters than youth, other research
has suggested that parents with depressive symptoms may
over-estimate youth depressive symptoms (Hood, 2009).
Replication of these findings using more comprehensive
Furthermore, the sample in this study was primarily
minority and low income. Therefore, it is unclear whether
findings might differ in a higher SES or White sample.
Depression is also more common among females and
older adolescents; however, the relatively small sample
size precluded further analyses to determine whether the
model was affected by age or gender. Similarly, separate
analyses were not conducted for youth with type 1 vs. type
2 diabetes. Future studies may wish to further evaluate
this, youth with type 2 diabetes are typically obese and
youth obesity is associated with higher rates of depression.
In summary, the results of the present study provide
empirical support for a model in which low parental
involvement and warmth and low parental monitoring
have adverse effects upon both mental and physical
health outcomes in youth with diabetes. Parental depres-
sive symptoms are likely to significantly increase the risk
for such ineffective parenting styles and should be a focus
of screening attempts for mental health professional when
attempting to prevent the development of depressive
symptoms and poor metabolic control in youth with
Grant #R01 DK59067 from the National Institute of
Diabetes, Digestive and Kidney Diseases.
Received December 15, 2008; revisions received June 17,
2009; accepted July 10, 2009
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Effect of Parental Depression on Youth Outcome