Cognitive adaptation theory as a predictor of adjustment to emerging adulthood for youth with and without type 1 diabetes

Highlights

• We use cognitive adaptation theory to predict emerging adulthood outcomes.

• We examined these relations over 3 annual assessments.

• Cognitive adaptation predicted psychological, relational, and work outcomes.

• ]Findings were stronger for emerging adults with than without type 1 diabetes.

Abstract

Objective

The purpose of the study was to determine whether resilience, defined by cognitive adaptation theory, predicted emerging adulthood outcomes among youth with and without type 1 diabetes.

Methods

Youth with (n = 118) and without type 1 diabetes (n = 122), who were part of a previous longitudinal study during adolescence, completed on-line questionnaires during their senior year of high school and one and two years later. They were average age 18, 53% female, and 93% white. Questionnaires assessed cognitive adaptation theory (CAT) indicators (self-esteem, mastery, optimism) and psychological, relationship, behavioral, vocational, and, for those with diabetes, diabetes outcomes.

Results

The CAT index at baseline predicted reduced psychological distress, enhanced psychological well-being, increased friend support, reduced friend conflict, the presence of romantic relationships, reduced likelihood of romantic breakups, higher GPA, higher work satisfaction, and lower work stress during the transition to emerging adulthood. Among those with diabetes, the CAT index predicted better self-care behavior and revealed a marginal relation to better glycemic control. Analyses controlled for baseline levels when appropriate. Findings were stronger one year than two years post high school graduation, and findings were stronger for those with than without diabetes. Youth with diabetes also scored lower on the CAT index than youth without diabetes.

Conclusions

These findings suggest that the implications of CAT include not only psychological health but also relationship, vocational, and diabetes outcomes. Those who score lower on CAT indicators should be identified as children so that interventions designed to enhance resilience can be implemented.

Introduction

Early research in the field of health psychology focused on pathology and identifying risk factors for poor psychological and physical health. Over the past couple of decades, the field has experienced a paradigm shift as investigators have moved from a disease model that focuses on variables that place one at risk for poor health to a resilience model that identifies variables that predict adapting to and flourishing under adversity [1]. Research has shown that many people fare well after trauma, stressful life events, and threats to health. For example, as early as 1988, Wallender et al. [2] found that the majority of children with chronic physical problems did not experience significant psychological problems, although they were at increased risk for adjustment difficulties. More recently, a meta-analytic review of the literature showed that children with diabetes were more depressed than children without diabetes [3], but effect sizes were small and decreasing over time, suggesting that the majority of children with diabetes are not depressed and do not suffer from major psychological problems. In our research comparing youth with to those without diabetes, we found relatively few differences [4]. Because many people seem to fare well under conditions of adversity, researchers have begun to investigate the factors that predict these positive outcomes.

Resilience is one name that has been assigned to factors that protect one from the negative sequele that accompany major stressors and promote successful adaptation to adversity [1]. Resilient people are said to recover more quickly from stress and maintain a high level of functioning throughout adversity [1], [5]. In the area of life-span development, resilience is described in the context of maintaining and optimizing psychological health throughout an accumulation of life challenges [6]. Resilient people are not only able to maintain normal functioning but can experience growth as they confront the normative losses, threats, and opportunities that pervade the lifespan. This framework suggests that resilience might be an important construct to examine as people navigate developmental challenges, such as the transition to emerging adulthood.

Emerging adulthood is the period of development between the ages of 18 and 25—a period that is distinct from adolescence and young adulthood [7]. This stage of development is a relatively recent phenomenon, appearing over the last century when key events that formerly defined the onset of adulthood, such as employment, marriage, and parenthood, were postponed. It is during emerging adulthood that youth explore possibilities in the areas of work and love and make choices that will define themselves as adults [7]. From a vocational perspective, the majority of youth graduate from high school and go on to further their education or enter the labor force. From a relational perspective, young adults separate from their families of origin and form attachments to peers, including romantic partners. According to Arnett [7], “Emerging adulthood is a time of life when many different directions remain possible… when the scope of independent exploration of life's possibilities is greater for most people than it will be at any other period of the life course.” (p. 469).

Emerging adulthood also is the period of development that is associated with the highest rate of risk behaviors [7]—perhaps because of the increased freedom that this period brings. This age group has the highest rate of alcohol/drug usage, unprotected sex, and driving while intoxicated [8]. There is some evidence that depressive symptoms peak in young adulthood [9], and reports of stress are higher during emerging adulthood than any other point in the lifespan [10]. Emerging adulthood is also an important developmental period in which to examine disturbed eating behavior, as the age of onset for bulimia is late adolescence and early adulthood [11]. Thus, emerging adulthood is a period associated with increased risk as well as increased opportunities [12]. Despite the fact that emerging adults face numerous challenges, this group of people has only recently come to the forefront of researchers' agendas.

In the present paper, we examine resilience in the context of the transition to emerging adulthood, using cognitive adaptation theory [13] as a framework for conceptualizing resilience. According to cognitive adaptation theory, traumatic events threaten people's assumptions about the self and the world—specifically, assumptions that one has personal control over what happens to the self, that the self is good (i.e., esteem), and that positive events are more likely to occur than negative events [13]. One way that people successfully adjust—that is, cognitively adapt—is to find ways to regain a sense of control, esteem, and optimism. That is, cognitive adaptation theory argues that resilient people are those who can maintain high self-esteem, high personal control, and high optimism in the face of challenges and trauma [13]. Although cognitive adaptation theory has been widely applied to threats to health [14], [15], it is not a framework that has been used to understand adaptation to developmental challenges, such as the transition to emerging adulthood. Yet, cognitive adaptation theory may be particularly useful in predicting successful adjustment to this transition. Emerging adulthood is characterized as a period of instability [16]. The fluctuations that occur in roles, relationships, and living arrangements during emerging adulthood—even if positive—may be stressful. Because resilience generally and cognitive adaptation theory specifically is about adapting to change, emerging adulthood is an important context in which to study the implications of these personal characteristics. The stress associated with emerging adulthood could be effectively managed by high levels of self-esteem, mastery, and optimism. In the present paper, we ask whether these components of cognitive adaptation theory can promote successful adjustment to the transition to emerging adulthood. We are not only interested in psychological outcomes and risk behaviors, but also outcomes that are relevant to the changes that emerging adults experience in relationships and vocation.

Cognitive adaptation theory also is considered to be especially adaptive under conditions of high risk or severe threat. For example, Helgeson [17] showed that perceived control, a component of cognitive adaptation theory, predicted less distress among cardiac patients 3 months later only among those with a worse prognosis and those who had been rehospitalized. In another study of people with heart disease, a cognitive adaptation index composed of self-esteem, optimism, and control predicted better adjustment 6 months later, especially so for those who experienced a recurrent event in the intervening 6 months [18]. The more severe the threat or risk factor, the more important it may be to maintain high levels of optimism, self-esteem, and perceived control.

One group of “at-risk” emerging adults are those with type 1 diabetes. Type 1 diabetes is an autoimmune disorder characterized by an inability of the pancreas to produce insulin, an essential metabolic hormone. Taking care of type 1 diabetes requires monitoring food intake and blood glucose levels, injecting insulin on a regular basis, engaging in physical exercise, and adjusting insulin levels depending on the outcomes of the aforementioned activities. There is some evidence that cognitive adaptation indicators are related to positive outcomes among those with type 1 diabetes. In a study of adults with diabetes, a resilience index defined by optimism, self-esteem, and self-efficacy buffered the effects of stress on glycemic control one year later [19]. Luycks and Seiffge-Krenke [20] found that a positive self-concept which included a positive body image and mastery predicted better glycemic control over the transition from adolescence to emerging adulthood.

Because type 1 diabetes is a health threat, we predict that cognitive adaptation indicators will be more predictive of positive health outcomes among those with than those without type 1 diabetes. There are several reasons that emerging adulthood may be a particularly difficult transition for youth with type 1 diabetes to negotiate. Emerging adults with type 1 diabetes not only have to take on more of the responsibilities for the daily care of diabetes but also have to transition from the pediatric health care system to the adult health care system—a transition that is characterized by numerous difficulties [21]. Finally, the previously described challenges of emerging adulthood may be even more stressful for those with type 1 diabetes. Research has shown that adults with diabetes are more likely than those without diabetes to suffer from depressive symptoms [22]. Research also has shown that people with diabetes—especially females—are at increased risk for eating disorders compared to those without diabetes [23], and disturbed eating behavior is linked to diabetes-related complications [24]. Risk behaviors, especially alcohol use, can be more problematic for emerging adults with than without type 1 diabetes because alcohol increases blood sugar levels and impairs judgment that may be needed to enact appropriate self-care behavior.

Thus, cognitive adaptation indicators might be especially predictive of good adjustment to the transition to emerging adulthood for those with type 1 diabetes because these individuals face greater challenges than those without type 1 diabetes. This prediction would be consistent with research on cognitive adaptation theory that shows cognitive adaption indicators reveal stronger relations to good health outcomes under conditions of more severe threat.

The goal of the present study is to examine whether markers of cognitive adaptation theory during youths' senior year of high school predict emerging adulthood outcomes one year later and two years later, when the vast majority of youth leave home. A second goal is to test whether the relation of cognitive adaptation indicators to outcomes is stronger for those with than without type 1 diabetes, as youth with type 1 diabetes face additional strains during this transition. We also explored interactions with sex because sex differences in mental health are pervasive [25], but did not make specific predictions. We examined psychological, relational, behavioral, vocational, and, for youth with diabetes, disease-related outcomes. Because cognitive adaptation indicators are expected to predict lower levels of distress as well as higher levels of well-being, we examine both positive and negative outcomes within each of these domains.