Journal of Pediatric Psychology, 40(9), 2015, 878–887

doi: 10.1093/jpepsy/jsv041
Advance Access Publication Date: 15 May 2015
Original Research Article

Protective Factors in Young Children With Type 1

Diabetes
Maureen Monaghan,1,2 PHD, Lauren Clary,1,2 PHD, Alexa Stern,1 BA,
Marisa E. Hilliard,3 PHD, and Randi Streisand,1,2 PHD, CDE
1
Children’s National Health System, Washington, DC, 2George Washington University School of Medicine, and

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3
Baylor College of Medicine
All correspondence concerning this article should be addressed to Maureen Monaghan, PHD, Center for
Translational Science, Children’s National Health System, 111 Michigan Ave NW, Washington, DC 20010, USA.
E-mail: mmonagha@childrensnational.org
Received November 26, 2014; revisions received April 9, 2015; accepted April 16, 2015

Abstract
Objective To characterize protective factors in young children with type 1 diabetes, and evaluate
associations among child protective factors and indicators of diabetes resilience, including better
child and parent psychosocial functioning and glycemic control. Methods Parents of 78 young
children with type 1 diabetes reported on child protective factors, child quality of life, parent de-
pressive symptoms, and disease-specific parenting stress. A1c values were collected from medical
records. Results Young children with type 1 diabetes were rated as having similar levels of
protective factors as normative samples. Greater child protective factors were associated with indi-
cators of diabetes resilience, including higher child quality of life and lower parent depressive
symptoms and parenting stress. Regression analyses demonstrated that child protective factors
were associated with 16% of the variance in parent-reported depressive symptoms.
Conclusions Attention to child protective factors can enhance understanding of adjustment to
type 1 diabetes and may have implications for intervention.

Key words: glycemic control; parent stress; resilience; type 1 diabetes; young children.

Introduction simultaneously striving to meet developmental needs,

Children aged 5 years represent one of the fastest
growing populations of patients newly diagnosed with
type 1 diabetes (T1D; Vehik et al., 2007). These young
children and their parents are faced with many poten-
tial challenges that may derail the typical developmen-
tal experience and negatively impact both child and
parent functioning. Diabetes management for young
children requires adherence to a consistent, relatively
inflexible schedule of blood glucose monitoring, insu-
lin administration, predictable carbohydrate intake,
and supervised physical activity. Acute complications,
including hyperglycemia and hypoglycemia, are com-
mon (Monaghan, Younge, McCarter, Cogen, &
Streisand, 2014). Coupling the complexity of care
needed to achieve good glycemic control while
young children with T1D and their parents are at in-
creased risk for psychosocial concerns, including in-
creased depressive symptoms and diminished quality
of life (Jaser, Whittemore, Ambrosino, Lindemann, &
Grey, 2009; Reynolds & Helgeson, 2011). However,
even with the significant demands that diabetes care
places on a child and family, many young children and
their parents are able to effectively manage T1D-re-
lated challenges and thrive despite early diagnosis of a
lifelong chronic illness. Greater understanding of pro-
tective factors or processes that contribute to resilient
outcomes in these young children is needed.
Resilience occurs when a child achieves a positive
outcome in at least one domain despite the presence of
significant risk factors or adverse events, such as the

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V
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Protective Factors in Young Children With Type 1 Diabetes
diagnosis of a complex and demanding chronic illness.
Protective factors such as maturity, self-control, and
positive parent–child relationships may influence or
reduce the impact of adversity on an child’s develop-
ment and functioning and contribute to resilient out-
comes (Masten, 2001; Masten, Best, & Garmezy,
1990). For youth with T1D and their parents, resilient
outcomes include high health-related quality of life,
low levels of distress, and good disease management
(Hilliard et al., 2012).
Research with children with T1D has largely fo-
cused on the presence of risk factors and suboptimal
outcomes, such as low quality of life, parent depres-
sion or stress, and poor glycemic control, with fewer
examinations of positive qualities or resilient indica-
tors (Cohen, Lumley, Naar-King, Partridge, & Cakan,
2004; Hilliard, Monaghan, Cogen, & Streisand,
2011). However, the degree of positive qualities that a
child brings to dyadic interactions surrounding diabe-
tes management may be related to both child and par-
ent emotional response to T1D care and may
ultimately contribute to glycemic control. There is
some evidence to suggest that a child’s positive atti-
tude toward diabetes is viewed as a key contributor to
living well with T1D (Ginsburg et al., 2005).
Although data are lacking in young children with
T1D, research has found that general positive qualities
in adolescents with T1D were associated with
improved glycemic control, primarily through path-
ways of better family cohesion and better daily adher-
ence to the diabetes regimen, but this has not been
extended to younger children (Mackey et al., 2011).
Child development literature can guide evaluation
about specific protective factors present in young chil-
dren that may influence diabetes outcomes. Protective
processes that persist over time, are responsive to in-
tervention, or reside within an individual are thought
to be most closely linked with resilient outcomes
(Masten, 2001). Thus, possible factors relevant to and
measurable in a young child sample include interest in
participation in daily activities (initiative), behavioral
self-control, and positive relationships with caregivers
(attachment), each of which may have important im-
plications for cooperation with diabetes care.
Theoretical models of disease management posit that
taking initiative in daily activities is critical to good
health across development (Schulman-Green et al.,
2012) and providing young children with the opportu-
nity to participate in their care has been associated
with better T1D adherence and adjustment (Chisholm
et al., 2011). Research with preschoolers has found
that higher levels of child protective factors are associ-
ated with fewer behavioral concerns (Brinkman,
Wigent, Tomac, Pham, & Carlson, 2007; Lien &
Carlson, 2009), potentially through the path of greater
child self-control (Voris et al., 2013). As behavior
problems in young children have been associated with
879
greater parent stress and poor glycemic control
(Cohen et al., 2004; Hilliard et al., 2011), it is also im-
portant to examine the protective potential of self-
control. Positive parent–child relationships have been
associated with better family response to chronic ill-
ness and improved health (Feeney, 2000), and it is
likely that the child’s quality of attachment with his/
her caregivers influences daily interactions surround-
ing T1D management (Rosenberg & Shields, 2009).
Assessment of these key protective factors in a sample
of young children with T1D and related associations
with indicators of diabetes resilience is warranted.
This exploratory study is the first to evaluate
general protective factors in a sample of young
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children with T1D and identify associations with
general and diabetes-specific child and family indi-
cators of resilience. As this construct has not been
specifically evaluated in young children with T1D,
we present preliminary description of protective
factors in this vulnerable population and provide
comparisons with a normative sample. We exam-
ined associations among three common child gen-
eral protective factors (initiative, self-control, and
attachment), demographic characteristics, and
indicators of diabetes resilience (better child quality
of life, lower parent-reported depressive symptoms
and parenting stress, better glycemic control). We
hypothesized that parent report of greater child
protective factors would be associated with indica-
tors of resilience in the context of the many stres-
sors and challenges of T1D in young children.
Methods
Participants
Participants included 78 parents of young children
(ages 2–5 years) diagnosed with T1D. Participants for
this multisite trial were recruited from three diabetes
care centers in the Mid-Atlantic and Midwest for en-
rollment in a randomized controlled trial (RCT) of a
supportive intervention designed to promote T1D
management and parental adjustment. The larger trial
included parents of young children aged 1–7 years
who were diagnosed with T1D for at least 6 months;
data from a subset of participants (aged 2–5 years)
were used for the current study owing to the limited
age range for which the Devereux Early Childhood
Assessment (DECA) is validated. Additional inclusion
criteria included English fluency and absence of other
child chronic medical conditions or developmental dis-
ability. Enrolled participants completed baseline data
collection by telephone, an in-person orientation, five
phone calls related to intervention content or educa-
tion content, and follow-up data collection by tele-
phone at three follow-up time points (1, 6, and 12
months postintervention). The current study included
baseline data collected before randomization.
880
Procedure
Institutional review board approval was obtained
from each participating site. Potentially eligible partic-
ipants were mailed an informational letter detailing
study procedures and offering the opportunity to opt
out of contact with the research team. Participants
who did not opt out of contact were called by a re-
search assistant to further assess eligibility, explain
study procedures, and obtain initial consent.
Participants who provided verbal consent were invited
to complete baseline questionnaires by telephone and
meet with a study team member to complete written
consent and an in-person orientation session.
Participants were then randomized to either the inter-
vention group or the education-only control group.
The study team mailed recruitment letters to 285
potentially eligible parents and 219 (77%) were
reached by phone. Of the 219 parents, 203 (93%)
were eligible for participation and 167 (82%) ex-
pressed initial interest in participating; the most com-
mon reasons for declining participation were concerns
about the study’s time commitment and a lack of in-
terest. One hundred thirty-four parents (80%) com-
pleted all baseline and consent procedures and were
randomized. The DECA, the primary measure of pro-
tective factors administered for the current study, is
only validated for use with children aged 2–5 years.
Thus, a subsample of the total enrolled sample was
used for this study, representing 78 parents of young
children aged 2–5 years. All participants received a
modest incentive for completion of baseline
questionnaires.
Study Measures
Demographic Questionnaire
Parents completed a demographic questionnaire de-
signed for the purposes of this study, including infor-
mation on child and parent age, gender, and race;
parent education, marital status, and household in-
come; and child T1D regimen and illness duration.
Devereux Early Childhood Assessment
Parents completed the DECA (LeBuffe & Naglieri,
1999), a 37-item tool designed to evaluate protective
factors, which may foster emotional growth and resil-
ience and related behavioral concerns among young
children aged 2–5 years. For the purposes of this
study, only the 27 items on the Protective Factors scale
were administered, representing three subscale scores
(initiative, self-control, and attachment) and a total
protective factors score. Example items include:
“How often does your child try or ask to try new
things or activities?” (initiative); “How often does
your child control her/his anger?” (self-control); and
“How often does your child show affection for famil-
iar adults?” (attachment). Item frequency is rated on a
Monaghan, Clary, Stern, Hilliard, and Streisand
5-point Likert scale ranging from 0 ¼ never to 4 ¼ very
frequently. Scores are summed across each subscale
and raw scores are transformed into T scores for the
three subscales and total protective factors score. Each
subscale and total T score may also be categorized as a
“strength” (T score  60), “typical” (60 < T
score < 40), or a “concern” (T score  40) factor.
Protective factors are conceptualized as a continuous
construct, so DECA T scores are often used for de-
scriptive and comparison purposes and to evaluate
change over time. In addition, categorical scores are
used to interpret the meaning of the T scores and can
help prioritize interventions to promote or maintain
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existing strengths or to strengthen areas of relative
weakness (LeBuffe, Ross, Fleming, & Naglieri, 2013).
Reliability estimates are good, with internal consis-
tency ranging from .76 to .91 (Lien & Carlson, 2009),
and interrater reliability ranging from .55 to .80
(Bracken, Keith, & Walker, 1998). Reliability esti-
mates for this sample were adequate (total protective
factors a ¼ .86; initiative a ¼ .71; self-control a ¼ .82;
attachment a ¼ .64).
Pediatric Quality of Life Inventory
Participants completed the Pediatric Quality of Life
Inventory (PedsQL) Generic Core (Varni, Seid, &
Kurtin, 2001), a parent-report measure used to assess
child’s quality of life in the past month. Parents com-
pleted either a toddler (for ages 2–4 years; 21 items) or
young child version (for ages 5–7 years; 23 items). The
PedsQL has four subscales assessing physical, emo-
tional, social, and academic functioning. A Generic
Core score is calculated using all items. Items are rated
on a 5-point Likert scale ranging from 0 ¼ never to
4 ¼ almost always, are reverse scored, and linearly
transformed to a 0–100 scale. Higher scores represent
better quality of life. The PedsQL Generic Core has
been demonstrated to be reliable and valid, with inter-
nal consistencies ranging from .86 to .90 (Varni et al.,
2001). Internal consistency in this sample was good
(toddler Generic Core a ¼ .86; young child Generic
Core a ¼ .88).
Center for Epidemiological Studies–Depression Scale
Parents completed the Center for Epidemiological
Studies– Depression Scale (CES-D; Radloff, 1977), a
20-item self-report measure of depressive affect, so-
matic symptoms, positive affect, and interpersonal re-
lations. Items are rated on a 4-point Likert scale from
0 ¼ hardly or none of the time to 3 ¼ most or all of the
time and summed. Higher scores indicate greater se-
verity of depressive symptoms. The CES-D has ade-
quate test–retest reliability and correlates well with
clinical ratings of depression severity (Bartlett et al.,
2001; Radloff, 1977). Internal consistency for this
sample was excellent (a ¼ .92).
Protective Factors in Young Children With Type 1 Diabetes
Pediatric Inventory for Parents–Difficulty Scale
Participants completed the Pediatric Inventory for
Parents (PIP-D; Streisand, Braniecki, Tercyak, &
Kazak, 2001), a 42-item parent self-report rating of
stress associated with caring for a child with a medical
illness. Similar to other studies evaluating the magni-
tude of parent stress (Sulkers et al., 2014), only the
Difficulty Scale score was used for this study to cap-
ture the perceived stress experience of caring for a
child with T1D. Items are rated along a 5-point Likert
scale assessing the perceived level of difficulty, ranging
from 1 ¼ not at all to 5 ¼ extremely. Ratings are
summed for an overall Difficulty score; higher scores
indicate greater difficulty with pediatric parenting
stress. The PIP-D has been administered to parents of
children with T1D (a ¼ .95–.96; Hilliard et al., 2011;
Streisand, Swift, Wickmark, Chen, & Holmes, 2005),
as well other pediatric conditions (Mullen et al., 2014;
Sulkers et al., 2014). Internal consistency for this sam-
ple was excellent (PIP-D a ¼ .93).
Glycemic Control
Hemoglobin A1c represents the average glucose level
from the past 8–12 weeks and is a commonly used
measure of glycemic control (American Diabetes
Association, 2013). A1c values were obtained during
the course of routine clinical care and extracted from
medical charts for the clinic visit closest to the date of
baseline questionnaire completion. All assays were
conducted with the DCA 2000 Analyzer and used
high-performance liquid chromatography to assure
comparability between subjects (Tamborlane et al.,
2005).
Analyses
This study used secondary data analyses; the data
were drawn from baseline questionnaires administered
as part of a larger RCT for parents of young children
with T1D (Monaghan, Hilliard, Cogen, & Streisand,
2011; Monaghan et al., 2014). Descriptive statistics
were generated to determine the frequency or mean
for all study variables. T scores for each DECA sub-
scale and total protective factors were calculated and
used as continuous variables representing the degree
of protective factors. T scores were also used to clas-
sify young children as having an area of concern or
strength on each of the DECA subscales and total
score. Correlational analyses (Pearson product-mo-
ment correlation for two continuous variables; point-
biserial correlation for a continuous and a categorical
variable; Spearman q for continuous and an ordinal
variable) were conducted to identify associations
among demographic characteristics, child protective
factors, and resilient indicators of interest, including
better child quality of life, lower parent depressive
symptoms, less perceived difficulty with pediatric
881
parenting stress, and good glycemic control (A1c).
Analyses of variance or chi square analyses were con-
ducted to evaluate differences in demographic charac-
teristics and resilient indicators by DECA category
(concern, typical, or strength) for each subscale and
the total protective factors score. Finally, multiple sep-
arate hierarchical linear regressions were conducted to
evaluate the association of each child protective factor
in relation to each indicator of diabetes resilience, con-
trolling for covariates.
Results
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Demographic Characteristics, Glycemic Control,
and Psychosocial Characteristics
Participants were primarily mothers of young children
(M age ¼ 4.44 years) diagnosed with T1D for a mean
of 1.76 years. Children were primarily Caucasian
(70%). Of the 92% of participants reporting their
range for annual household income, distribution was
as follows: 15% <$50,000; 36% between $50,000
and $99,999; 41% >$100,000. The majority of young
children managed their diabetes using a basal-bolus
regimen (n ¼ 55; 70%) of multiple daily injections or
an insulin pump; the remainder used a fixed dose insu-
lin regimen without adjustments (n ¼ 23; 30%). Mean
A1c was 8.20%. Better glycemic control (i.e. lower
A1c) was associated with higher family income
(q ¼ .27, p < .05) and married parental status
(rpb ¼ .41, p < .01). Glycemic control was not related
to child gender, age, race, or insulin regimen.
Parents rated their young children as having gener-
ally good quality of life at levels similar to children
without chronic illness (Varni et al., 2001). Parents re-
ported similar levels of depressive symptoms and
slightly lower levels of difficulty with pediatric parent-
ing stress compared with other samples of parents of
young children with T1D (Hilliard et al., 2011; Jaser
et al., 2009). Fourteen parents (18%) reported clini-
cally significant elevated depressive symptoms (CES-D
 16); see Table I.
Child Protective Factors
Parent-reported child general protective factors were
evaluated using the DECA. Scores among young chil-
dren with T1D were comparable with the normative
sample, with mean T scores on the initiative
(M ¼ 49.38), self-control (M ¼ 49.18), and attachment
(M ¼ 48.53) subscales and total protective factors
(M ¼ 47.96) all similar to the normative sample mean
of 50 (p values > .05). Using the categorical classifica-
tions for areas of strength or concern, the distribution
was varied; see Table II. Three participants (4%) rated
their child in the strength category across all subscales,
and one participant (1%) rated their child in the con-
cern category across all subscales.
882 Monaghan, Clary, Stern, Hilliard, and Streisand

Table I. Sample Demographics

% Mean SD Range

Parent sex (% female) 91

Parent age (years) 35.66 5.54 22.21–50.10
Parent education (%  college degree) 69
Parent/guardian marital status (% married) 86
Household income
<$50,000/year 15
$50,000–$99,999/year 36
$100,000/year 41
Child sex (% female) 44
Child age (years) 4.44 1.07 2.01–5.99
Child race
Caucasian 70
African American 17

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Hispanic 8
Asian/Pacific Islander 4
American Indian 1
Disease duration (years) 1.76 0.90 0.58–4.90
Insulin regimen (% basal bolus/pump) 70
A1c 8.20% 0.95 6.4%–11.0%
Pediatric Quality of Life Inventory 82.73 10.10 48.91–97.83
Center for Epidemiologic Studies–Depression 10.05 9.90 0.00–49.00
Pediatric Inventory for Parents–Difficulty 77.63 23.61 43.00–157.00

Table II. Summary of Devereux Early Childhood Table III. Correlations

Assessment Scores in a Sample of Young Children (Ages
2–5 Years) With Type 1 Diabetes (n ¼ 78) DECA DECA DECA DECA total
initiative self-control attachment protective
Scale M (SD) Strength Typical Concern factors
(n, %) (n, %) (n, %)
Parent sex .14 .02 .15 .12
Initiative 49.4 (8.1) 10, 13 62, 79 6, 8 Parent age .07 .12 .01 .10
Self-control 49.2 (9.1) 10, 13 56, 72 12, 15 Parent educationa .03 .09 .25* .12
Attachment 48.5 (9.9) 10, 13 53, 68 15, 19 Parent marital .00 .06 .05 .02
Total protective 48.0 (8.5) 6, 8 60, 77 12, 15 statusb
factors Household .03 .01 .12 .09
incomea
Note. Strength (T  60), typical (40  T  60), concern (T  40). Child sexb .24* .01 .13 .15
Child age .21 .18 .13 .14
Child raceb .15 .23* .00 .15
Child Protective Factors, Demographic Disease duration .04 .01 .11 .02
Characteristics, and Psychosocial Functioning Insulin regimenb .13 .04 .01 .07
Associations among DECA subscale and total protec- A1c .16 .04 .00 .07
PedsQL .20 .31* .11 .26*
tive factors T scores, demographic characteristics, and CES-D .30** .36** .16 .35**
indicators of child and parent psychosocial function- PIP-D .23* .29* .01 .23*
ing were examined; see Table III. Using categorical
classifications, non-Caucasian children (v2(2) ¼ 16.20, Note. Parent and child sex: 1 ¼ male, 2 ¼ female; marital status:
1 ¼ married, 2 ¼ not married; child race: 1 ¼ Caucasian, 2 ¼ non-
p < .01) and children from lower income households
Caucasian; insulin regimen: 1 ¼ conventional, 2 ¼ intensive (basal/
(v2(2) ¼ 13.92, p < .01) were each more likely to have bolus).
a strength in self-control. A rating of strength or typi- DECA ¼ Devereux Early Childhood Assessment;
cal in total protective factors was associated with sig- PedsQL ¼ Pediatric Quality of Life Inventory; CES-D ¼ Center for
nificantly lower parent depression scores than a rating Epidemiological Studies–Depression Scale; PIP-D ¼ Pediatric
Inventory for Parents.
of concern F(2, 75) ¼ 9.09, p < .01, g2 ¼ .20. A rating a
Spearman q.
of strength or typical in self-control was associated b
Point-biserial correlation.
with significantly lower parent depressive symptoms *p < .05; **p < .01.
(F(2, 75) ¼ 12.16, p < .01, g2 ¼ .25) and lower pediat-
ric parenting stress (F(2,75) ¼ 3.86, p < .05, g2 ¼ .09) functioning. Demographic variables with a significant
than a rating of concern. association with the dependent variable (p < .05) were
Separate hierarchical multiple regression models included in the models. Accounting for race and fam-
were conducted to examine the association of child ily income, higher total protective factors significantly
protective factors with child and parent psychosocial contributed to lower parent depressive symptoms and
Protective Factors in Young Children With Type 1 Diabetes
the overall model was associated with 16% of the var-
iance in parent depressive symptoms (F(3, 74) ¼ 6.01,
p < .01; adjusted R2 ¼ 16.3). Regression models exam-
ining the contributions of child protective factors to
child quality of life and pediatric parenting stress were
not significant.
Post Hoc Analyses on Self-Control
As self-control appears to be one of the most salient
child protective factors, based on current literature
and categorical associations in this sample with parent
depressive symptoms and pediatric parenting stress,
separate hierarchical linear regressions were con-
ducted using the self-control subscale of the DECA.
Controlling for race and family income, higher child
self-control significantly contributed to lower parent
depressive symptoms; the overall model was associ-
ated with 17% of the variance in parent depressive
symptoms (F(3, 74) ¼ 6.36, p < .01; adjusted
R2 ¼ 17.3). Further, higher child self-control signifi-
cantly contributed to better child quality of life; the
overall model was associated with 7% of the variance
in child quality of life (F(3, 74) ¼ 2.78, p < .05; ad-
justed R2 ¼ .07).
Child Protective Factors and Glycemic Control
Correlational analyses examining DECA characteris-
tics and A1c were not significant; see Table III.
Children with a categorical strength in self-control
were more likely to have a poorer glycemic control
(F(2, 75) ¼ 5.06, p < .01) as compared with children
who were typical in this area. Separate hierarchical
multiple regression models were conducted to examine
the contribution of child protective factors to A1c.
Controlling for marital status, race, and family in-
come, the overall model evaluating protective factors
and A1c was significant (F(4, 72) ¼ 9.61, p < .01; ad-
justed R2 ¼ .31); however, total protective factors was
not a significant factor beyond the addition of family
income. The same pattern was found when examining
self-control and A1c (F(4, 72) ¼ 9.51, p < .01; ad-
justed R2 ¼ .31).
Discussion
This study is among the first to examine protective
processes in young children with T1D. Results are en-
couraging. Even faced with the significant adversity of
a chronic illness at a young age, children with T1D
were rated similar to peers without diabetes in three
key protective factors: initiative, self-control, and at-
tachment. There were few differences based on demo-
graphic characteristics, supporting the universality of
these strengths among children.
Total child protective factors were positively corre-
lated with child quality of life and inversely correlated
883
with parent-reported depressive symptoms and diffi-
culty with pediatric parenting stress. Further, the
DECA self-control subscale was positively correlated
with child quality of life, and initiative and self-control
subscales were inversely correlated with parent depres-
sive symptoms and pediatric parenting stress.
Behavioral self-control may be associated with less re-
fusal with or greater adaptation to diabetes-related
tasks, and initiative may facilitate openness to engag-
ing in T1D-related tasks, although further research to
support these possible links are needed. Given previ-
ous findings relating positive parent–child relation-
ships to diabetes health (Monaghan, Horn, Alvarez,
Cogen, & Streisand, 2012), it was surprising that at-
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tachment subscale scores were not associated with any
indicators of diabetes resilience in this sample. The
general attachment measured by the DECA may not
tap into the same construct as later parent–child rela-
tionships, or it may be that positive relationship quali-
ties directly related to T1D management such as
warmth and empathy in daily T1D care are more rele-
vant to indicators of diabetes resilience in this context
than general attachment. The attachment subscale
also had lower reliability than the other subscales
(a ¼ .64), suggesting that the items may not have been
as relevant for the current sample.
Using regression analyses, child protective factors
were associated with a significant proportion of the
variance in parent-reported depressive symptoms.
Given that prior research has found that approxi-
mately 20% of parents of young children with T1D re-
port elevated depressive symptoms (Hilliard et al.,
2011; Jaser et al., 2009), this enhanced understanding
of potentially modifiable factors associated with par-
ent emotional functioning above and beyond demo-
graphic characteristics is valuable. Although parents
complete most T1D management tasks for young chil-
dren, the diabetes experience is a transactional pro-
cess. Hilliard and colleagues found that higher levels
of parent anxiety and stress were associated with more
frequent child misbehavior (a negative outcome) in
young children with T1D (Hilliard et al., 2011). A re-
cent systematic review also noted that parent psycho-
logical distress was associated with higher child-
reported stress and lower quality of life (Whittemore,
Jaser, Chao, Myoungock, & Grey, 2012). However,
to date there has not been evidence to support that the
protective pathway also holds for young children with
T1D—that greater protective factors are associated
with better quality of life and lower distress. Current
findings complement prior research and highlight the
potential contributions of young children’s positive
characteristics and behaviors to resilient indicators.
Few significant relations were found between child
protective factors and glycemic control. It is possible
that effects may be more evident over time or that pro-
tective factors have a more immediate impact on
884
family T1D management behaviors, which in turn im-
pact later glycemic control. Surprisingly, a child
strength in self-control was associated with poorer gly-
cemic control. Non-Caucasian race and lower family
income were also associated with higher ratings of
self-control. The association between self-control and
A1c was largely accounted for by race and household
income. Other studies have found that urban youth
are rated higher in self-control compared with norms,
suggesting that community factors contribute to per-
ceived self-control (Bender, Fedor, & Carlson, 2011).
In population-based studies of youth with T1D,
Hispanic and African American youth are at increased
risk for poor glycemic control, and lower socioeco-
nomic status predicts poor glycemic control regardless
of race (Gallegos-Macias, Macias, Kaufman,
Skipper, & Kalishman, 2003; Petitti et al., 2009).
Items on the self-control scale assess a child’s ability to
do things for independently, make decisions, engage in
new activities, and manage emotions. Thus, it is also
possible that children rated higher in self-control
may be given premature responsibility for T1D care,
as cooperating with diabetes-related tasks or manag-
ing frustration well could lead parents to entrust more
diabetes tasks to a child before they were developmen-
tally ready to manage such responsibilities. However,
this was not evaluated in the current study. Given this
study’s sample size and demographics, future research
should evaluate associations among child protective
factors, responsibility for diabetes care, and glycemic
outcomes over time in a larger, more diverse sample to
draw conclusions about the relations and their
mechanisms.
Protective processes are modifiable and could be a
target of intervention; teaching positive parenting and
reducing parenting stress may lead to increased resil-
ient outcomes in young children. There are several em-
pirically supported programs targeting protective
social-emotional skills in young children in the class-
room and home settings, largely composed of differen-
tial attention to positive behaviors and cognitive-
behavioral strategies (McCabe & Altamura, 2011).
For example, the Triple P Parenting Program and
Parent Child Interaction Therapy are two examples of
successful interventions in promoting healthy parent–-
child interactions and reducing behavioral concerns,
and both may also enhance self-control and attach-
ment (Thomas & Zimmer-Gembeck, 2007). The
DECA is part of a social–emotional preschool pro-
gram that aims to bolster strengths and has been asso-
ciated with an increase in child protective factors
(Garbacz, Zychinski, Feuer, Carter, & Budd, 2014;
Lamb-Parker, LeBuffe, Powell, & Halpern, 2008;
LeBuffe et al., 2013). As part of this strengths-promo-
tion program, the categorical classifications are used
to guide individual classroom interventions to build
on or maintain each child’s areas of relative strength
Monaghan, Clary, Stern, Hilliard, and Streisand
(LeBuffe et al., 2013). Such intervention approaches
could be adapted to focus on protective behaviors re-
lated to T1D. For example, parents can be coached to
identify and praise children’s positive behaviors or
strengths, and to recognize efforts related to initiative
or self-control as related to diabetes care, instead of
praising the outcome (e.g., specific glucose value).
DECA scores were moderately associated with par-
ents’ self-reported depressive symptoms and stress re-
ported in this sample, similar to previous findings
linking parental stress with problem behaviors in
young children with T1D (Hilliard et al., 2011). It is
possible that parents with elevated stress or depressive
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symptoms perceived their child’s behavior as more
negative, independent of their child’s actual level of
current functioning, which may skew findings (Hood,
2009). Scores falling in the concern range in self-con-
trol scale or total protective factors may suggest the
need to assess and possibly provide support related to
parents’ own emotional well-being (e.g., Monaghan
et al., 2011).
This study is exploratory and has a number of limi-
tations, including a cross-sectional design and a rela-
tively well-resourced and high functioning sample.
Parents participating in baseline data collection had
agreed to participate in a rigorous RCT, and the sam-
ple may reflect parents with the time and emotional
resources to commit to participation in such research.
Parents completed all questionnaire data, reflecting
both on their own experiences and those of their
young children. Obtaining additional informant re-
ports, such as a second caregiver or a teacher, may po-
tentially decrease the risk for biased responding. It is
challenging to get self-report data from young chil-
dren, yet multimethod assessment approaches are rec-
ommended (Carter, Briggs-Gowan, & Davis, 2004). A
more objective evaluation of positive qualities, such as
behaviorally coding a scripted parent–child interaction
task or observation of a diabetes routine such as a
family meal (Patton et al., 2004), may provide more
insight into both parent and child positive qualities
and behaviors. Parents also represented predominantly
Caucasian mothers with relatively high reported fam-
ily income. Although this sample is consistent with
other samples of young children with T1D and may be
even slightly more diverse (Jaser et al., 2009; Patton
et al., 2004), the influence and role of protective pro-
cesses may be more apparent in families faced with
multiple adversities in addition to T1D, and this con-
struct should be evaluated in a more at-risk sample.
Questionnaires assessed general protective factors;
evaluation of diabetes-specific protective factors may
demonstrate a stronger association with indicators of
resilience. Even when significant, protective factors
were associated with a relatively small percentage of
variance in psychosocial indicators. However, while
protective processes may not fully account for
Protective Factors in Young Children With Type 1 Diabetes
differences among key diabetes outcomes, they should
be considered in combination with risk factors and
other relevant variables to obtain a more balanced pic-
ture of both negative and positive factors that impact
the lives of young children and their families.
Results suggest that assessment of child strengths can
contribute to the overall conceptualization of family ad-
aptation to T1D and promote health and well-being.
Identification of protective factors indicated in the dis-
ease process may inform targets for intervention in fam-
ilies struggling with adjustment to T1D at a young age.
Longitudinal research can examine how protective fac-
tors present in early childhood map on to later protec-
tive processes in youth with T1D to better understand
the cascading effects of risk and protection on resilient
outcomes in across development (Masten & Cicchetti,
2010). Training caregivers, including family members,
teachers, and health-care providers, to recognize and
build on young children’s unique strengths may lay the
foundation for confident, effective family and self-man-
agement throughout childhood and beyond.
Funding
This work was supported by the National Institute of
Diabetes and Digestive and Kidney Diseases (grant number
R01DK080102) to R.S. M.M. is currently supported by the
National Institute of Diabetes and Digestive and Kidney
Diseases (grant number K23DK099250). M.H. is currently
supported by the National Institute of Diabetes and
Digestive and Kidney Diseases (grant number
K12DK097696; PI: B.J. Anderson).
Conflicts of interest: None declared.
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