La compleja relación entre la jurisprudencia del TEDH y la del TC español

The presence of a chronic disease such as diabetes may have serious consequences for the maintenance of supportive family relationships.

The "dramatic impact" of the diagnosis of diabetes upon the entire family, "precipitating a state of shock in all concerned", has been clearly described by Laron (1984). However, there is some evidence

to suggest that the siblings of chronically ill children are not at a greater risk of psychosocial impairment compared with siblings of

healthy children (Ferrari 1984). There may be much confusion with regard to how parents and others, such as peers, should behave towards the child with diabetes, both in terms of relationships and also concerning medical management (Laron 1984). M o k and co-authors (1984) stated that few other diseases placed as much medical responsibility upon the family, and that the added stresses of management could expose flaws in family life and relationships. Others have noted increased stress levels in families with a diabetic member (Hauenstein 1989). Parents may be more aware of the dangers of the complications of diabetes than their children and this could be a further source of tension within the family (Gil et al 1977).

Skyler (1980) has suggested that the two interrelated factors of

parental emotions and family organisation can be identified as influencing patients' outcome with regard to diabetes management. Parental attitudes may also have an important effect on the child's adjustment to diabetes (Pond 1979).

Parents may be guilt-ridden or anxious, they may be over-protective, or may 'o v e r - m a n a g e ' the illness, to the detriment of the child. Pond (1979) suggested these attitudes could also influence the development of a positive relationship with health-care providers.

Family functioning has been considered to be a major mediating variable in terms of the patient's overall adaptation (Wertleib et al 1986). Family characteristics such as size, structure, functioning and ways of coping with diabetes may influence the impact of this illness upon all family members (Pless 1973). Grey et al (1980) used a 'family functioning index', and have linked this to the psychosocial adjustment of the young person with diabetes. The authors pointed to the importance of parental self-esteem and family communication, closeness and cohesiveness in the adjustment of children to their illness, however numbers in the study were small

and no control group was used.

In a study where 63 families who had a pre-adolescent or adolescent child with IDDM were compared with a group of 69 control families who had a child with a recently experienced acute illness, Wertleib (1986) concluded, "any assumption of behaviour pathology as a necessary component of IDDM is unwarranted, at least at the early stage of the illness". In the same study it was shown that, although

families who had a child with diabetes showed a high degree of "normalness" compared to the comparison group, the children with

diabetes perceived a more intense emphasis on organisation and

Different family structures may be more conducive to the attainment of metabolic stability. Good diabetic control may be achieved by those who belong to families with a rigid organisation, although this type of family structure could also lead to less independence and autonomy on the part of the adolescent, which could lead to serious difficulties later on (Evans et al 1987). Kaye (1976) and Baker et al (1975) have described how different patterns of family organisation can affect the level of diabetic control; for example, in "enmeshed" families there were inadequate boundaries between

members, with individuals involved in each other's business, and without resolution of conflicts. Baker called this type of family the "psychosomatic family" and reported good results with family therapy in terms of improvements in level of diabetic control.

Koski and Kumento (1977), in a study of 10 - 21 year olds with diabetes, showed that families defined as "helpless" by the authors were more likely to have had a diabetic member in poorer metabolic control compared with families who were not rated as helpless. Helpless families were those who were unable to recognise the child's need for counselling, and were characterised by

omnipotence regarding the care of the child w ith diabetes. The authors suggested that special care and guidance is required by patients with diabetes whose families are disturbed or seen as h e l p l e s s .

Disturbance and conflict within families may influence the degree of glycaemic control attained (Anderson et al 1981, Delbridge 1975, Koski 1969). Encouragement from parents to behave independently has also been associated with improved diabetic control (Anderson et al 1981). A study of 5-16 year olds has demonstrated that those with better glycaemic control had more cohesive families, without conflict, with emotional expressiveness and with mothers who were

satisfied with their marriage (Marteau 1987). Socio-economic factors such as social class, employment status and income, did not influence level of diabetic control. The author suggested that these family factors may be related to metabolic control via either a behavioural or a physiological pathway. Management of the child's diabetes may be affected, which in turn could influence diabetic control, or alternatively, family functioning could directly affect the physiological status of the child.

The family is not only a source of stress itself, the members may encounter stress outside the family which they may then introduce into that family domain (Pearlin and Turner 1986). The family may also act as the source of resources to deal with stress and can provide an arena for the support and cohesion required by people with diabetes in order to adjust to their disease. In a study of patients aged over 16 years, with either insulin-dependent or non­

insulin-dependent diabetes, Jenny (1984) demonstrated that the youngest group of patients (mean age, 20 years) reported the most social supports.

This group described their parents and other relatives as the most supportive people around them. McAnarney (1985) has also concluded that the family is an important support system for the adolescent whilst attempting to achieve independence.

A study of 4-16 year olds with various chronic diseases including diabetes, rheumatoid arthritis and cerebral palsy, has shown that these children were at risk for developing adjustment problems because they reported greater family difficulties compared to those

recorded in normative data (Wallander et al 1 9 8 9 a ) . This study demonstrated that both family and peer support were associated with improved adjustment.

In an investigation which compared a group of 'diabetic families' with families containing a child who had recently had a serious acute illness, Hauser et al (1986) demonstrated how chronic illness influenced interaction patterns within the family. The authors reported that the children with diabetes and their parents expressed more "enabling" (eg/ focussing, problem solving, active understanding) speeches than their 'acute' controls. However there were also indications of particular constraining interactions (de­ valuing) occurring between fathers and diabetic children. Hauser argued that these findings reflected the influence of the child's diabetes on family life, augmenting or amplifying important affective currents within the family.

The diagnosis of a chronic illness in the family ma y produce both

reactions of solidarity and cohesion, and also support for the member who has just been diagnosed. At the same time it may lead to more suppressed feelings of anger, guilt and discomfort. There may be significant effects of family functioning on degree of metabolic

control.

Perceived parental support may be associated with adolescents' adherence to their treatment regimen (Hanson et al 1987). In this last study, the younger adolescents received more support than the older adolescents. Adherence was significantly related to metabolic control as might be expected, and it was concluded that parental support was a crucial factor in the adaptation of chronically ill children.

There is much evidence to suggest that the family is an important source of support for the child with diabetes, and this may also apply to older patients. A more holistic approach towards understanding and assisting those with diabetes and their families may be required, taking into account both the physical and emotional impact of diabetes on both the patient and the family (Popkess- Vawter 1983). Certain types of family functioning may be related to adjustment to and control of diabetes, although some instruments designed to measure supportive attitudes within the family may not be appropriate for this age-group (Schafer 1986). The provision of ongoing support and counselling could assist those families with the

There has been to date, little research which considers the issues most pertinent to young adults (Ahlfield et al 1985). A special emphasis should be placed post-adolescence, in terms of both marital and peer relationships, and decisions on whether or not to have children. Young adults may still be living with their families and their specific concerns may differ in important ways from those

of younger age groups.

For those still living at home, family relations m a y influence glycaemic control, for example in times of stress or conflict. The support of the family may still be important once the young adult has left the family home. The opportunity to discuss their feelings or worries about their diabetes may or may not be available and it may be important to be able to feel that other family members are understanding and supportive. These concerns have yet to be addressed in research and one of the aims of the present investigation was to do so.