What Mom and Dad Don't Know CAN Hurt You: Adolescent Disclosure to and Secrecy From Parents About Type 1 Diabetes

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What Mom and Dad Don’t Know CAN Hurt You: AdolescentDisclosure to and Secrecy From Parents About Type 1 Diabetes

Peter Osborn,1 MS, MA, Cynthia A. Berg,1 PHD, Amy E. Hughes,1 MS, Phung Pham,1 MS, and

Deborah J. Wiebe,2 PHD, MPH1Department of Psychology, University of Utah, and 2Division of Psychology, Department of Psychiatry,

University of Texas Southwestern Medical Center

All correspondence concerning this article should be addressed to Peter Osborn, MS, MA, Department of

Psychology, University of Utah, 380 S. 1530 E., Salt Lake City, UT 84112, USA. E-mail:

[email protected]

Received January 24, 2012; revisions received June 20, 2012; accepted August 6, 2012

Objective To examine how adolescent disclosure to and secrecy from parents were related to parental

knowledge of diabetes management behaviors, and to adolescent adherence, metabolic control, and depres-

sive symptoms. Methods A total of 183 adolescents with type 1 diabetes reported on disclosure to and se-

crecy from parents regarding diabetes management, adherence behaviors, depressive symptoms, and

perceptions of parental knowledge. Mothers and fathers reported on their own knowledge.

Results Adolescent disclosure was associated with all reporters’ perceptions of knowledge. Secrecy from

both parents moderated the relationship between disclosure and adherence, and secrecy from fathers

moderated the relationship between disclosure to fathers and glycosylated hemoglobin level. In all cases, dis-

closure was associated with better diabetes management only when secrecy was low. Finally, higher secrecy

related to greater adolescent depressive symptoms. Conclusions Disclosure to parents appears to be an im-

portant component of how parents get their knowledge about adolescents’ diabetes management, but may be

most beneficial for diabetes management when it occurs together with low secrecy.

Key words adherence; disclosure; parental knowledge; parental monitoring; secrecy; type 1 diabetes.

The management of type 1 diabetes during adolescence is

challenging, as adolescents expect and are granted more

autonomy (Tilton-Weaver & Marshall, 2008) and illness-

related responsibilities (Helgeson, Reynolds, Siminerio,

Escobar, & Becker, 2008). Diabetes management is

better when parents remain involved in diabetes care

through parental monitoring, a construct frequently

measured as parents’ overall knowledge of their adoles-

cents’ illness management (Ellis et al., 2007b, Berg et al.,

2008). Parents gain knowledge about management behav-

iors through their own attempts (direct observation,

questioning their adolescents, structuring their activities,

and relying on others for information, see Crouter,

Bumpus, Davis, & McHale, 2005; Ellis et al., 2012), as

well as through information adolescents actively disclose

to them (Stattin & Kerr, 2000). Adolescent disclosure ap-

pears crucial for understanding the benefits of parental

knowledge on a range of adolescent outcomes, as teens

spend increasing time away from their parents’ presence

(e.g., Darling, Cumsille, Caldwell, & Dowdy, 2006; Kerr,

Stattin, & Burk, 2010; Smetana, 2008; Tilton-Weaver

et al., 2010).

Although adolescent disclosure is key to understand-

ing links between high parental knowledge and positive

adolescent adjustment, Frijns, Keijsers, Branje, & Meeus

(2010) noted that commonly used measures of adolescent

disclosure (e.g., Stattin & Kerr, 2000) confound adoles-

cents’ voluntary disclosure to parents with keeping secrets

from parents. These two constructs are not simply oppos-

ites along a single continuum, as youth can disclose while

Journal of Pediatric Psychology 38(2) pp. 141–150, 2013

doi:10.1093/jpepsy/jss102

Advance Access publication September 26, 2012

Journal of Pediatric Psychology vol. 38 no. 2 � The Author 2012. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.All rights reserved. For permissions, please e-mail: [email protected]

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also keeping secrets about their lives. Furthermore, secrecy

is associated with adolescent problems such as depression

beyond the effects of disclosure (Finkenauer, Engels, &

Meeus, 2002; Frijns, Finkenauer, Vermulst, & Engels,

2005; Frijns et al., 2010), presumably because of the dif-

ferent benefits of disclosures versus the costs of secrecy

(e.g., Lane & Wegner, 1995; Wismeijer, 2011). For

youth with diabetes, disclosing to parents may be beneficial

by increasing parental knowledge and eliciting their in-

volvement when adolescents need help. However, adoles-

cents most often keep information secret from parents to

avoid punishment or disapproval for negative behaviors

(e.g., Smetana, 2008). Keeping secrets about instances of

poor diabetes management may skew parents’ knowledge

of problems with their adolescent’s illness management

behaviors. Secrecy about problems with diabetes manage-

ment could also be psychologically taxing on adolescents,

as it involves self-monitoring to avoid the truth from being

known (Pennebaker, 1997). The primary aim of the pre-

sent study was to examine whether disclosure and secrecy

among adolescents with type 1 diabetes were uniquely

associated with parental knowledge of diabetes, and

whether these constructs were related to adolescents’

health (adherence, metabolic control) as well as psycho-

logical (depression) outcomes. Depression is an important

outcome because youth with diabetes experience

heightened risk for depression, and depressive symptoms

may undermine diabetes management (e.g., Korbel, Wiebe,

Berg, & Palmer, 2007).

Although secrecy is uniquely associated with negative

outcomes in the general developmental literature (Finken-

auer, Frijns, Engels, & Kerkhof, 2005; Frijns et al., 2010;

Laird & Marrero, 2010), it remains unclear whether se-

crecy and disclosure operate independently or whether

they interact to predict outcomes such as adherence, gly-

cemic control, or depression. Disclosure and secrecy may

be uniquely (i.e., independently) associated with how well

adolescents manage their illness. Alternatively, secrecy and

disclosure may interact such that disclosure to parents is

most beneficial when adolescents simultaneously keep few

secrets from their parents. For example, if adolescents tell

parents a great deal about their diabetes care, but also keep

important information regarding diabetes problems from

them, parents may be unable to offer adequate support.

Given the complex demands of type 1 diabetes, the com-

bination of disclosure and secrecy will likely be important

for understanding diabetes care behaviors.

Adolescent disclosure and secrecy may be differentially

associated with measures of parental knowledge depending

on whether adolescents or parents are the reporters, as

parents are not privy to information adolescents keep

secret from them. Adolescent reports of parental know-

ledge may be informed by what they keep secret from par-

ents—information that they alone have access to—whereas

parent reports may rely more heavily on disclosed informa-

tion. An important aspect of the present study was to ex-

plore whether adolescents’ reports of disclosure and

secrecy may relate to both adolescents’ and parents’ re-

ports of parental knowledge.

Disclosure and secrecy may also be differentially

related to adolescent outcomes when they occur with

mothers versus fathers (Bumpus, Crouter, & McHale,

2001; Smetana, Metzger, Gettman, & Campione-Barr,

2006), given that mothers are often more responsible for

and involved in their adolescent’s diabetes (Seiffge-Krenke,

2002). Adolescents tend to confide more in mothers than

fathers about schoolwork and personal issues (Smetana

et al., 2006). Given mothers’ more prominent role in

managing and monitoring diabetes care, it is possible

that keeping secrets from mother may be associated with

poorer health outcomes than keeping secrets from father.

The present study examined how disclosure and se-

crecy related to both adolescent and parent reports of

knowledge, and to measures of adolescent adherence,

metabolic control, and depressive symptoms. Adolescents

reported separately on their perceptions of maternal and

paternal diabetes knowledge; mothers and fathers reported

on their own knowledge. Furthermore, adolescents as-

sessed the amount they disclosed to each parent, as well

as the amount they kept secret, regarding their diabetes.

Consistent with the broader developmental literature

(Smetana et al., 2006; Stattin & Kerr, 2000), we expected

that adolescent disclosure and secrecy would be uniquely

associated with adolescents’ own reports of parental dia-

betes knowledge, and that disclosure, but not secrecy,

would be uniquely associated with parents’ reports of

knowledge. In line with research on adolescent depression,

delinquency, and other negative behavioral outcomes, we

predicted that secrecy regarding diabetes management

would be uniquely associated with negative health out-

comes above the effects of disclosure, and that disclosure

would be more beneficial when secrecy was low. Finally,

we explored whether disclosure to and secrecy from

mother showed a different pattern of associations with ado-

lescent outcomes than did disclosure to and secrecy from

father.

MethodsParticipants

The Institutional Review Board approved the study. Parents

gave written informed consent, and adolescents gave

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written assent. The present cross-sectional data were drawn

from the fourth wave of data collected as part of a larger

longitudinal study that examined 252 families every

6 months for 3 years. Participants in the larger study

were recruited during routine outpatient visits to a univer-

sity diabetes clinic (76%) or a community-based private

practice (24%) that followed similar treatment regimens.

Eligibility criteria at enrollment included 10 - to 14-year-

olds with type 1 diabetes for at least 1 year, living with

mother (because the larger study targeted the mother–ado-

lescent dyad), and able to read and write English or

Spanish. Of the qualifying patients approached, 66%

agreed to participate; refusals primarily involved distance

and time constraints and lack of interest in being studied.

Eligible adolescents who did versus did not participate

were older (12.5 vs. 11.6 years, t(367)¼ 6.20, p < .01),

but did not differ on gender, pump status, glycosylated

hemoglobin (HbA1c), or illness duration (ps > .20).

Participants were primarily Caucasian (94%) and middle

class, with 73% of families earning >$50,000 a year.

Measures of disclosure and secrecy were added to the lon-

gitudinal protocol at time 4 (i.e., 2 years after enrollment).

Although 194 adolescents completed measures at this time

point, 10 were missing data on fathers’ knowledge because

no biological or stepfather was in the home, and one

was missing data on mothers’ knowledge. Thus, 183

adolescents were included in the present analyses

(M age¼ 14.1 years, standard deviation [SD]¼ 1.51,

53.8% females). More than half (64.4%) of adolescents

were on an insulin pump, with the remainder prescribed

multiple daily injections. These 183 participants did not

differ from those in the longitudinal cohort who did not

complete time 4 measures on age or illness duration,

but they did have better metabolic control at enrollment

as indexed by lower HbA1c (M [SD] = 8.24 [1.53] vs.

8.68 [1.67], t(249) = �2.05, p = .04). In all, 178 mothers

and 134 fathers also reported on their own knowledge

of their adolescent’s diabetes management and on their

perception of their adolescent’s adherence to diabetes

care regimens.

Procedure

Participants individually completed measures either at

home (i.e., adherence) or during a scheduled laboratory

visit (i.e., parental knowledge, disclosure and secrecy, de-

pression). For all questionnaires, participants received oral

and written instructions to complete them individually and

to direct questions to the investigators rather than family

members.

Measures

Parental Knowledge

Adolescents completed a scale consisting of six items to

capture parents’ knowledge of adolescents’ daily activities

concerning diabetes management (Berg et al., 2008),

modeled after Barber’s (1996) parental monitoring scale.

Adolescents reported how much mothers and fathers really

know about their diabetes management (e.g., blood sugar

readings, insulin taken) using a 1 (doesn’t know) to 5

(knows everything) scale; mothers and fathers reported

on their own knowledge (�� .87 for all reporters).

Diabetes Disclosure and Secrecy

Adolescents completed five items from Stattin and Kerr’s

(2000) disclosure measure (�¼ .81; 2-month test–retest

reliabilities¼ .87), modified to capture how much informa-

tion adolescents disclose to or keep secret from their

mother and father about diabetes care. Adolescents rated

on a 1 (strongly disagree) to 5 (strongly agree) scale their

agreement with statements separately about their mother

and father. The disclosure subscale contained three items

(‘‘I spontaneously tell my [mother/father] about what is

going on with my diabetes management,’’ ‘‘I often want

to tell my [mother/father] what is going on with my dia-

betes management,’’ ‘‘I like to tell my [mother/father]

about my diabetes management’’), and the secrecy

subscale contained two items (‘‘I keep a lot of secrets

from my [mother/father] about my diabetes management,’’

‘‘I hide a lot from my [mother/father] about my diabetes

management during nights and weekends when I am away

from [her/him]’’). This measure has no previous use in a

population of adolescents with type 1 diabetes, but the

original scale has been validated in an adolescent popula-

tion (Stattin & Kerr, 2000). The disclosure (mother

�¼ .83, father �¼ .90) and secrecy (mother �¼ .86,

father �¼ .93) subscales had excellent reliability in the

present study.

Adolescent Depressive Symptoms

Adolescents completed the Children’s Depression Inven-

tory (CDI; Kovacs, 1985), a 27-item self-report scale that

indicates depressive symptoms (e.g., disturbances in

mood, self-evaluation). This scale has high internal consist-

ency (�¼ .85 in our sample) and is associated with

difficulties in managing diabetes (e.g., Grey, Davidson,

Boland, & Tamborlane, 2001; Kovacs, Goldston, Obrosky,

& Bonar, 1997).

Adherence

Adolescents and parents completed a Self Care Inventory

(adapted from La Greca, Follansbee, & Skyler, 1990) to

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assess adherence to 16 different aspects of the diabetes

regimen over the preceding month (1¼ never did this to

5¼ always did this as recommended without fail). La

Greca’s scale was adapted by updating items and adding

two items with the assistance of a certified diabetes educa-

tor to reflect the current focus on carbohydrate counting

and adjusting insulin. Average scores across all 16 items

were computed. This scale has excellent reliability (�� .85

across reporters) and correlates well with more

time-intensive measures of adherence (Lewin et al., 2009).

Metabolic Control

Adolescents’ metabolic control was indexed by HbA1c re-

corded in medical records. HbA1c was obtained using the

Bayer DCA2000 by clinic staff. Participant authorization

provided access to medical records to obtain other illness

information (e.g., pump status, illness duration).

Analysis Plan

A mean substitution strategy was used to replace missing

data for individual items on scales when <20% of the

items were missing. We first conducted two mixed-

design analyses of variance to determine whether female

and male individuals significantly differed in their ratings of

mothers’ and fathers’ knowledge, disclosure, and secrecy.

Multiple regression analyses were then performed to exam-

ine the unique associations of secrecy and disclosure and

their interaction with adolescent and parent reports of par-

ental diabetes knowledge. Similar analyses were then con-

ducted to understand the unique and interactive

associations of disclosure and secrecy with adolescent

and parent reports of adherence, HbA1c, and adolescent

report of depressive symptoms. Significant interactions

were further explored through simple slopes analyses.

ResultsPreliminary Analyses

Means and correlations among variables are reported in

Table I. Disclosure to parents was associated with higher

parental knowledge and lower secrecy, as well as with

better adherence and lower depressive symptoms. Secrecy

from parents was associated with lower parental know-

ledge, with lower adherence, and with higher depressive

symptoms. Secrecy from mothers was correlated with

poorer (higher) HbA1c. Not surprisingly, older adolescents

reported lower parental knowledge and disclosure, and

higher secrecy from mothers. Three 2� 2 mixed-design

(adolescent sex as between-subjects variable, report of

mother/father as within-subjects variable) analyses of

variance were conducted to assess whether female and

male individuals differed in their ratings of mothers’ and

fathers’ diabetes knowledge, disclosure, and secrecy. The

interaction between sex and mother versus father revealed

that boys rated their fathers as knowing more about their

diabetes (M¼ 3.07, SD¼ .12) than did girls (M¼ 2.61,

SD¼ .13) (F (1, 171)¼ 5.35, p¼ .02). No differences

were found between girls’ and boys’ ratings of mothers’

knowledge. Similarly, the interaction between sex and dis-

closure to mother versus father revealed that boys disclosed

more about their diabetes to fathers (M¼ 3.02, SD¼ .14)

than did girls (M¼ 2.55, SD¼ .12) (F (1, 166)¼ 9.8,

p¼ .00). No differences were found between boys’ and

girls’ disclosure to mother. No sex differences were

found between teen reports of secrecy from mother and

father.

Preliminary analyses were also conducted to determine

whether the age and sex of teens significantly moderated

the associations of teen disclosure and secrecy with reports

of knowledge, adherence, HbA1c, or depressive symptoms.

Because no interactions were found (ps > .05), we did not

include age or sex as additional moderating variables in the

primary analyses reported later in the text. That is, neither

sex nor age moderated the associations of disclosure and

secrecy with parental knowledge or any outcome variable.

Associations of Disclosure and Secrecy WithParental Knowledge of Diabetes

We ran four multiple regressions with adolescent, mother,

and father reports of parental diabetes knowledge serving

as outcome variables. In each model, we included as

predictors adolescent reports of disclosure and secrecy

and their interaction (calculated after centering each inde-

pendent variable, Aiken & West, 1991). Age, pump status,

and illness duration were included as covariates, given their

relationship to diabetes management outcomes (Wiebe

et al., 2010). Because the primary aims were to examine

associations of disclosure and secrecy with parental know-

ledge and outcomes, we do not report the significant ef-

fects of covariates in these analyses. Across all reporters,

greater adolescent disclosure was associated with more par-

ental knowledge: adolescents’ report of mother (B¼ .37,

t(166)¼ 5.70, p¼ .00, 95% confidence interval [CI]

.24, 49), adolescents’ report of father (B¼ .65,

t(155)¼ 10.96, p¼ .00, 95% CI .53, 76), mother’s report

(B¼ .21, t(155)¼ 3.40, p¼ .00, 95% CI .09, 33), and

father’s report (B¼ .16, t(121)¼ 2.62, p¼ .01, 95% CI

.04, 28). Across all reporters, neither secrecy (ps > .09)

nor the secrecy by disclosure interaction (ps > .07) was

associated with parental knowledge. These models pre-

dicted significant proportions of the variance in parental

diabetes knowledge: for adolescents’ reports of mothers’

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knowledge (R2¼ .26, F(5, 166)¼ 10.70, p < .01), adoles-

cents’ reports of fathers’ knowledge (R2¼ .23,

F(5, 155)¼ 32.01, p < .01), mothers’ reports (R2¼ .13,

F(5, 163)¼ 4.61, p < .01), and fathers’ reports (R2¼ .17,

F(5, 121)¼ 4.52, p < .01). Thus, across all reporters, dis-

closure to parents, but not secrecy, was a significant

unique predictor of parental knowledge.

Associations of Disclosure and Secrecy WithAdolescent Outcome Variables

Two multiple regression models were conducted predicting

teens’ reports of adherence from their reports of disclosure

and secrecy with mother and father (see Table II).

Disclosure, secrecy, and their interaction were significantly

associated with adherence in both models. Greater disclos-

ure was associated with better adherence, whereas greater

secrecy was associated with poorer adherence. The inter-

action between secrecy and disclosure with mothers is

graphed in Figure 1, plotting adherence at 1 SD above

and below the mean of teen secrecy; the shape of this inter-

action was identical for disclosure to and secrecy from

fathers. Simple slopes testing (Preacher, Curran, & Bauer,

2006) indicated that the slope was significantly different

from zero for adolescents with low secrecy from

mothers and from fathers, respectively, (slope¼ .29,

t(166)¼ 5.61, p < .001; slope¼ .24, t(155)¼ 5.63,

p < .001, respectively), but not for adolescents with high

secrecy from mothers and from fathers (slope¼ .04,

t(166)¼ .61, p¼ .54; slope¼ .02, t(155)¼ .30, p¼ .77,

respectively). Thus, at lower levels of secrecy, adolescents

with higher disclosure reported better adherence; however,

higher levels of secrecy diminished the positive relationship

between disclosure and adherence. Similar regressions were

conducted using parents’ reports of adolescent adherence.

In the analysis using mothers’ reports of adherence as the

outcome, more adolescent disclosure was associated with

higher mother reports of adherence (B¼ .10, t(161)¼ 2.16,

p¼ .03, 95% CI .01, 19). No associations were found be-

tween disclosure, secrecy, and fathers’ reports of adherence.

Similar multiple regression models were conducted for

HbA1c. Adolescents’ reports of secrecy from mother (but

not disclosure) were uniquely associated with HbA1c, such

that higher secrecy was associated with higher (worse)

HbA1c levels (B¼ .32, t(156)¼ 1.98, p¼ .05, 95% CI

.65, 00). The interaction between secrecy and disclosure

to mother was not significant. The main effect for adoles-

cents’ reports of secrecy from father was qualified by an

interaction with disclosure to father (B¼ .34,

t(147)¼ 2.94, p¼ .00, 95% CI .11, 57). The plot of this

interaction (see Figure 2) indicated that disclosure to

fathers was associated with better HbA1c only whenTab

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Diabetes Disclosure and Secrecy 145

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Figure 1. Interaction of teen disclosure to mother and secrecy from mother associated with teen report of adherence.

Figure 2. Interaction of teen disclosure to father and secrecy from father associated with HbA1c.

Table II. Regression Analyses for Adolescent Disclosure and Secrecy Associations With Self-Reported Adherence

Disclosure to/Secrecy from mother Disclosure to/Secrecy from father

B(SE B) 95% CI t p B(SE B) 95% CI t p

Pump status .14 (.09) �.03, 31 1.65 .10 .15 (.09) �.02,.31 1.70 .09

Age �.01 (.03) �.07, 04 �.47 .64 �.03 (.03) �.08,.02 �1.10 .27

Illness duration .00 (.00) �.00, 00 �.21 .84 .00 (.00) �.00,.00 �.11 .91

Disclosure .15 (.05) .06, 25 3.26 .00 .18 (.04) .04,.19 3.08 .00

Secrecy �.22 (.05) �.33,�.11 �4.03 .00 �.23 (.05) �.34, �.13 �4.39 .00

Disclosure � secrecy �.15 (.05) �.25,�.05 �2.83 .01 �.12 (.04) �.20, �.05 �3.25 .00

R2¼ .29, F(6, 154)¼ 12.51** R2

¼ .29, F(6, 145)¼ 11.70**

Note. **p < .01.

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adolescents reported keeping fewer secrets from fathers.

Simple slopes testing revealed that each slope was sig-

nificantly different from zero, but in opposite directions,

for adolescents with low and high secrecy from fathers,

respectively (slope¼�.308, t(147)¼�2.22, p¼ .03;

slope¼ .380, t(147)¼ 2.01, p¼ .05, respectively). Dis-

closure to fathers was associated with better HbA1c only

when adolescents reported low secrecy. These models pre-

dicted significant proportions of the variance in HbA1c

levels: for adolescents’ reports of disclosure to and secrecy

from mothers (R2¼ .12, F(6, 154)¼ 3.55, p < .01), and

adolescents’ reports of disclosure to and secrecy from

fathers (R2¼ .16, F(6, 145)¼ 4.52, p < .01).

Multiple regression models for adolescent reports of

depressive symptoms revealed secrecy from parents was

the only significant predictor of adolescent reports of

symptoms of depression. Adolescents’ reports of secrecy

from mothers (B¼ 2.63, t(166)¼ 4.95, p¼ .00, 95% CI

1.58, 3.68, R2¼ .18, F(5, 166)¼ 7.12, p < .01) and from

fathers (B¼ 2.08, t¼ 4.18, df¼ 155, p¼ .00, 95% CI 1.10,

3.07, R2¼ .18, F(5, 155)¼ 6.26, p < .01) were uniquely

associated with higher depressive symptoms. All other ef-

fects were not significant (ps > .05).

Discussion

Our results add to the literature on the importance of par-

ental monitoring and knowledge for adolescent diabetes

management by suggesting that parents gain knowledge

about their adolescent’s illness management through the

information adolescents are willing to disclose. Our

findings also suggest that keeping secrets about diabetes

from parents is associated with poorer health and psycho-

logical outcomes in youth with diabetes. Secrecy from par-

ents was related to diabetes health outcomes by

moderating the relationship between disclosure to parents

and teen reports of adherence, but only disclosure was

associated with mother’s (not father’s) report of adherence.

Furthermore, secrecy especially from mother was related to

poorer HbA1c above and beyond the effect of disclosure.

Similar to recent findings in the general developmental and

clinical literature, keeping diabetes-related secrets from

either parent was associated with higher depressive symp-

toms (e.g., Finkenauer et al., 2005; Frijns et al., 2010).

These results support a growing literature (e.g., Stattin

& Kerr, 2000) indicating that parental monitoring ques-

tionnaires that contain items of parental knowledge (Ellis

et al., 2007b; Berg et al., 2008) may be especially influenced

by adolescent disclosure. When adolescents report about

parental knowledge, they appear to consider how much

they are disclosing to their parents, rather than what they

keep secret. That is, disclosure was associated with adoles-

cent reports of parent knowledge above and beyond their

reports of secrecy from parents. These findings were pre-

dicted for parent reports of knowledge, as parents likely do

not have access to information adolescents keep secret

from them. However, these results were contrary to our

expectations for adolescent reports, as we had predicted

both disclosure and secrecy would be associated with ado-

lescents’ reports of parental knowledge. One explanation

for this result could be that the phrasing of questions com-

monly used to assess parental knowledge (‘‘How much

does your parent really know’’) may prime youth to call

to mind what they tell parents. Distinguishing between

disclosures and secrecy about illness management is im-

portant for future research linking parental knowledge with

health outcomes, given that disclosure and secrecy are

associated differently with health outcomes.

As hypothesized, our results demonstrate that the

secrets that adolescents keep may be important in under-

standing when adolescent disclosure about illness manage-

ment is beneficial to their physical as well as psychological

health. When teens reported high levels of secrecy about

diabetes management, disclosure was not associated with

better diabetes management. In addition, keeping secrets

from parents was associated with higher depressive symp-

toms and appeared to undermine the benefits of disclos-

ure. These results provide additional support for recent

conceptualizations of the importance of secrecy for under-

standing maladjustment in the larger developmental litera-

ture (e.g., Frijns et al., 2010). The fact that disclosure alone

was associated with mother (not father) reports of adher-

ence suggests that mothers in particular rely on youth dis-

closure in making judgments about their child’s illness

management. Such disclosure provides mothers with

information about how well adherence is going and may

facilitate their ability to provide necessary support and

assistance. One explanation for the moderating effects of

secrecy on the benefits of disclosure for diabetes manage-

ment may lie in the reasons why youth choose to with-

hold information from parents. Smetana, Villalobos,

Tasopoulos-Chan, Gettman, and Campione-Barr (2009)

found youth disclose less to parents about issues pertain-

ing to health and safety primarily because they are afraid of

parental disapproval or punishment. Youth who are not

adhering well to the diabetes regimen (e.g., forgetting to

check blood glucose, miscounting carbohydrates, not ad-

justing insulin) may attempt to avoid getting in trouble for

mismanagement by keeping these ‘‘slips’’ secret from par-

ents. If adolescents keep their parents in the dark about

their poor management decisions, they may not avail

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themselves of the possible guidance and assistance that

their parents would otherwise be in a position to provide.

In addition, maintaining secrecy is an effortful and psycho-

logically taxing behavior (Frijns & Finkenauer, 2009),

potentially making coping with their illness even more

stressful.

Adolescent disclosure to and secrecy from mothers

about diabetes were found to be associated with adolescent

mental/physical health in different ways than disclosure/

secrecy from fathers. For fathers, secrecy again moderated

the relationship between disclosure and metabolic control,

such that disclosure was associated with better HbA1c only

when adolescents kept fewer secrets from their fathers. For

mothers, secrecy was associated with worse HbA1c; neither

disclosure to mothers nor the interaction between secrecy

and disclosure was significantly associated with HbA1c.

Because mothers are most often the parent involved in

helping to manage and solve diabetes problems, keeping

secrets about certain aspects of management (e.g.,

choosing not to bolus at mealtime) from mothers may be

especially detrimental to metabolic control irrespective of

information disclosure. The significant moderating effect of

secrecy from both parents on the relationship between dis-

closure and adherence highlights that although disclosure

alone uniquely related to adherence, having clear and open

communication (i.e., high disclosure and low secrecy) with

parents may boost adolescent adherence.

The study should be interpreted in the context of

several limitations. The cross-sectional data limit our ability

to make temporally based conclusions or to rule-out third-

variable explanations of associations between disclosure

and diabetes management. Longitudinal research is

needed to understand how high disclosure to and low se-

crecy from parents may develop out of high-quality parent–

child relationships and facilitate diabetes adherence.

Further research is also needed to understand how secrecy

from parents may reflect other long-standing risk factors

such as externalizing behaviors that have been linked to

poor diabetes outcomes (Horton, Berg, Butner, & Wiebe,

2009). It is likely that adolescents who keep secrets from

their parents about diabetes management similarly keep

secrets about other risky behaviors. Research is also

needed to understand what aspects of diabetes manage-

ment adolescents keep secret and whether particular

types of secrets (e.g., high or low blood glucose) are

more problematic than others (e.g., forgetting supplies).

In addition, studies have indicated that telling lies, as

opposed to not disclosing or purposefully keeping

secrets, is a strong indicator of problematic behaviors in

children and adolescents (e.g., Gervais, Tremblay,

Desmarais-Gervais, & Vitaro, 2000). Future research

should examine whether lying to parents about diabetes

management is uniquely associated with mental and phys-

ical outcomes when compared with disclosure and secrecy.

Finally, our results are restricted in generalizability, as our

sample included participants who had been motivated to

remain in a longitudinal study for 2 years, and who were in

predominantly intact, white, English-speaking,

middle-class families. Although similar patterns of disclos-

ure and secrecy about adolescents’ general lives have been

found across ethnicities and cultures (e.g., Bakken &

Brown, 2010; Hunter, Barber, Olsen, McNeely, & Bose,

2011), replicating the present findings in a more ethnically

diverse sample would be beneficial.

The finding that diabetes health outcomes are

associated with adolescent disclosure only when secret-

keeping is low may hold implications for promoting

better illness management. Psychosocial interventions for

adolescents with diabetes have often included family-based

behavioral programs such as setting short- and long-term

goals, developing and implementing reinforcement contin-

gencies, creating behavioral contracts, and appropriately

sharing responsibility for illness management (Anderson

& Collier, 1999; Satin, La Greca, Zigo, & Skyler, 1989).

By reducing negativity and increasing problem-solving

knowledge and skills, interventions that promote family

communication and parental support and involvement

(Ellis, Naar-King, Templin, Frey, & Cunningham, 2007a)

may work partially by increasing the likelihood that youth

disclose to parents. Such interventions may be enhanced if

they are able to not only increase disclosure but also

reduce keeping secrets from parents. If family conditions

fostering secret-keeping are too strongly entrenched and/or

are unchanged by treatment interventions, health-related

gains may be reduced. Family-based interventions that

explore adolescents’ understanding of potential parental

reactions to disclosures (e.g., anger) may assist in reducing

adolescent secrecy to instances of poor management

decisions. Future interventions, however, must be in-

formed by developmental trends that suggest that keeping

more things ‘‘private’’ from parents is a normal and

even adaptive part of adolescent autonomy development

(e.g., Finkenauer et al., 2002).

Acknowledgments

The authors thank members of the ADAPT research group

for their valuable input and assistance during the develop-

ment and execution of this project. They also thank the

physicians and staff at the Utah Diabetes Center and

Mountain Vista Medicine, as well as the adolescents and

their families who participated in this study.

148 Osborn, Berg, Hughes, Pham, and Wiebe

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Funding

This research was supported by grant number R01

DK-063044 from the National Institute of Diabetes and

Digestive and Kidney Diseases, awarded to Dr. Deborah

J. Wiebe (PI) and Dr. Cynthia A. Berg (co-PI).

Conflicts of interest: None declared.

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