high levels of family integration and coordination were more likely to die earlier than their counterparts in families that were less cohesive. A moderate level of cohesion in communities would lead to the most optimal match between community characteristics and adolescents with diabetes.
In keeping with an ecosystemic perspective, communities do not simply impact adolescents directly. Instead, community characteristics influence families, and families in turn influence adolescents. In highly stressed communities, families may bolster efforts to protect adolescents from proximal dangers. This healthy wish to protect a child from danger, however, may be exacerbated in families that already engage in protective strategies surrounding the management and care of diabetes. Although increased protection may help adolescents' physical well-being to some extent, it may have the unfortunate consequence of undermining adolescents' attempts at individuation and attainment of other developmentally appropriate goals.
Previous research shows that in neighborhoods with low levels of social organization and control, adolescents' risk of engaging in deviant activity is increased (Furstenberg, 1993). The greater the prevalence of adolescents who engage in delinquent activity, the more opportunity for other adolescents to become associated with delinquent activity. It is suggested that such a situation presents a particularly risky situation for diabetic adolescents. Diabetic adolescents may be more susceptible to trying to “fit in” with peers (Thomas & Hauser, 1997), a situation that exposes them to the negative influence of peer pressure. If this is the case, then adolescents with diabetes who live in neighborhoods with low levels of social organization may be most vulnerable to engaging in delinquent activity. In other words, the relation between socially disorganized neighborhoods and delinquent adolescents may be intensified by diabetic adolescents' increased vulnerability to peer pressure.
Clearly, individual differences among diabetic adolescents exist, creating a mosaic of complex and diverse patterns within this special group. Individual differences occur at multiple layers. First of all, not all youth in the same community are exposed to the same level of community characteristics. Second, among those who are exposed to the same level of a community characteristic, not all will respond in the same way (Cicchetti & Aber, 1998). One line of inquiry relevant to researchers, health practitioners, and policymakers is to identify which community characteristics are associated with better or worse adherence to management of the disease. Within such identified high risk communities, what protects adolescents with diabetes from experiencing negative outcomes? How does gender figure into these models? Are girls or boys more sensitive to community characteristics in terms of their disease management? How would disease management interact with community characteristics to contribute to other outcomes (e.g., pregnancy status, school achievement, drug use)? Currently, psychosocial predictors of diabetic youths' health status include a patients' adherence and stress (Johnson, 1995). This work suggests that in addition to these individual level predictors, medical health professionals consider the context in which diabetes will be managed. The full gamut of highly organized to highly chaotic and dangerous neighborhoods has implications for how adolescents manage their disease, as well as for how their families will cope with maintenance. Consideration of the neighborhood context with respect to diabetic adolescents should occur at multiple levels, including the medical level (e.g., pediatricians taking into account the contextual barriers to compliance), research level (e.g., social scientists exploring the potential role of community characteristics on diabetic adolescents' adherence, general well-being, and family processes), and the policy level (e.g., implementing social policy that moves toward creating optimal environments for all youth, with particular attention to those who are chronically ill).
The focus here has been primarily on the broader context of neighborhoods; other contexts, such as schools, also play a significant role in shaping diabetic adolescents' experiences (Delamater, Bubb, Warren-Boulton, & Fisher, 1984). A valuable line of future research is to consider these interlocking contexts in their contribution to diabetic adolescents' development.
Although the aim of this chapter has been to describe communities and adolescents with diabetes, the information presented may be used as a template to better understand those youth who are HIV-positive, have asthma, lupus, cystic fibrosis, hemophilia, or other chronic illness. Discovering convergent themes running through studies of various discrete chronic illnesses and community connections will help researchers ultimately to arrive at a place where new factors, in a new context, can be identified that can enhance adaptation of these special groups of adolescents.
We gratefully acknowledge the scholarly help of Barbara Anderson and Timothy Davis in the preparation of this work.
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