Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 3 - Jul/Sep - 2018

Review Article Imprimir 

Páginas 111 a 118

Psychology and adolescents with diabetes mellitus type 1: a systematic review

Psicología y adolescentes con diabetes mellitus tipo 1: una revisión sistemática

Psicologia e adolescentes com diabetes mellitus tipo 1: uma revisão sistemática

Autores: Laís Claudino Moreira Ribeiro1; Renata Lira dos Santos Aléssio2; Brena Souza Almeida3

1. Master student in Psychology by the Postgraduate Program in Psychology of the Federal University of Pernambuco (UFPE). Specialist in Hospital Health from the Federal University of Paraíba (UFPB). Recife, PE, Brazil
2. PhD in Psychology from the University of Provence Aix-Marseille I, Aix-Marseille I, France. Adjunct Professor by the Department of Psychology of the Federal University of Pernambuco (UFPE). Recife, PE, Brazil
3. Graduating in Psychology from the Federal University of Pernambuco (UFPE). Recife, PE, Brazil

Laís Claudino Moreira Ribeiro
Rua Deputado José Mariz, nº 690, Tambauzinho
João Pessoa, PB, Brasil. CEP: 58042-020

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Keywords: Diabetes Mellitus, adolescent, chronic disease, psychology.
Palabra Clave: Diabetes Mellitus, adolescente, enfermedad crónica, psicología.
Descritores: Diabetes Mellitus, adolescente, doença crônica, psicologia.

OBJECTIVE: This article presents a systematic review with the objective of understanding how adolescents with Diabetes mellitus type 1 (DM1) have been studied from the field of psychology.
DATA SOURCE: The review took place through the search of electronic articles in indexed databases (Scielo, Pepsic and BVS). The research was carried out using the descriptors: "adolescents" in any field of production and "diabetes" in the title.
DATA SYNTHESIS: The bibliographic survey resulted in 134 articles, where 14 were selected considering the inclusion and exclusion criteria. The articles were analyzed according to the concepts used for the fundaments, objective, besides the methodological outline and main results observed. Throughout the readings, it is noticed that the articles express as relevant the biopsychosocial aspects that involves ill people. In addition, the characterization of adolescence is a pertinent fact, where this phase is perceived as being responsible for tensions that may hinder the treatment of diabetes.
CONCLUSION: Based on concepts such as resilience, quality of life, self-esteem, coping with the disease, among others, the analyzed articles are focused on the experience of adolescents with DM1. The greatest difficulties of the adolescents are related to the feeding and application of insulin. The social support, affective bonding and self-esteem were pointed out as aspects that facilitate the adolescent to overcome the illness situation.

OBJETIVO: Este artículo presenta una revisión bibliográfica con el objetivo de comprender cómo los adolescentes con Diabetes mellitus tipo 1 (DM1) vienen siendo estudiados a partir del campo de saber de la psicología.
FUENTES DE DATOS: La revisión ocurrió por medio de la búsqueda de artículos electrónicos en bases de datos indexadas (Scielo, Pepsic y BVS). La investigación fue realizada utilizando los descriptores: "adolescentes", en cualquier campo de la producción y "diabetes" en el título.
SÍNTESIS DE LOS DATOS: El levantamiento bibliográfico resultó en 134 artículos, donde 14 fueron seleccionados considerando los criterios de inclusión y exclusión. Los trabajos fueron analizados en función de los conceptos utilizados para la fundamentación, el objetivo, además del delineamiento metodológico y principales resultados observados. A lo largo de las lecturas, se nota que los artículos expresan como relevante los aspectos biopsicosociales que involucran a la persona en enfermedad. Además, la caracterización de la adolescencia es un dato pertinente, donde esa fase es percibida como responsable por tensiones que pueden dificultar el tratamiento de la diabetes.
CONCLUSIÓN: A partir de conceptos como resiliencia, calidad de vida, autoestima, enfrentamiento de la enfermedad, entre otros, los trabajos analizados se centran en la vivencia de los adolescentes con DM1. Las mayores dificultades de los adolescentes están relacionadas con la alimentación y la aplicación de insulina. El apoyo social, vinculación afectiva y autoestima fueron apuntados como aspectos que facilitan al adolescente sobrepujar la situación de enfermedad.

OBJETIVO: Este artigo apresenta uma revisão bibliográfica com o objetivo de compreender como os adolescentes com Diabetes mellitus tipo 1 (DM1) vem sendo estudados a partir do campo de saber da psicologia.
FONTES DE DADOS: A revisão ocorreu por meio da busca de artigos eletrônicos em bases de dados indexadas (Scielo, Pepsic e BVS). A pesquisa foi realizada utilizando-se os descritores: "adolescentes", em qualquer campo da produção e "diabetes" no título.
SÍNTESE DOS DADOS: O levantamento bibliográfico resultou em 134 artigos, onde 14 foram selecionados considerando os critérios de inclusão e exclusão. Os trabalhos foram analisados em função dos conceitos utilizados para a fundamentação, o objetivo, além do delineamento metodológico e principais resultados observados. Ao longo das leituras, nota-se que os artigos expressam como relevante os aspectos biopsicossociais que envolvem a pessoa em adoecimento. Além disso, a caracterização da adolescência é um dado pertinente, onde essa fase é percebida como sendo responsável por tensões que podem dificultar o tratamento da diabetes.
CONCLUSÃO: A partir de conceitos como resiliência, qualidade de vida, autoestima, enfrentamento da doença, entre outros, os trabalhos analisados debruçam-se sobre a vivência dos adolescentes com DM1. As maiores dificuldades dos adolescentes estão relacionadas à alimentação e aplicação de insulina. O suporte social, vinculação afetiva e autoestima foram apontados como aspectos que facilitam ao adolescente sobrepujar a situação de adoecimento.


Chronic non-communicable diseases (CNCDs) attack a greater number of people each year. According to the World Health1 Organization, it is estimated that in 2014, 422 million people, including children, adolescents, adults and the elderly, lived with diabetes mellitus (DM) in the world. The prospect is for that number to increase to 642 million by 2040. Within this context, Brazil is the third country in number of children and adolescents diagnosed with diabetes mellitus type 1 (DM1)2.

DM1 is characterized by deficiency in the production of insulin by the pancreas as a consequence of the destruction of beta cells, making the individual insulin dependent, being more common the emergence in childhood and adolescence. In addition, this type of DM, in general, occurs abruptly and with a tendency to accentuated hyperglycemia, which can easily trigger a picture of ketoacidosis in the presence of another type of stress3.

Diagnosis of DM1 demands changes in habits of the subject in order to perform glycemic control, thereby initiating the measurement of glycemia and application of insulin, as well as changes related to eating and the practice of physical activities. According to Vieira and Lima4, the daily routine of children and adolescents with a chronic disease is modified, requiring a readjustment to the situation, so this process occurs to the detriment of the complexity of the disease and the child's or adolescent's ability to manage.

Adolescents with DM1 are studied from different disciplines, and in the case of psychology, research uses concepts such as resilience, anxiety, social support, confrontation of the disease, quality of life, among others. In a systematic review carried out by Pérez, Alves and Dell'Aglio5, it was identified that social support is an important protection factor in the confrontation of DM1 in adolescents. Thus, it can reverberate in the management of the disease, in metabolic control and adherence to treatment. In addition, social support can also be positively related to quality of life, self-esteem, self-efficacy, self-image and well-being.

Considering the social category to which this study was directed, chronic addiction penetrates the reality of adolescents through their development as a non-normative influence. The lifespan paradigm includes development as a process of continuous, multidimensional and multidirectional change that undergoes influences of biological and historical cultural order, which may be normative or non-normative in nature, considering the gains and losses in the course of the process and the interaction of the subject process with the culture6. Normative influences are related both to biological events that occur predictably in a certain age group, in terms of events regulated by history, so that a historical generation has its behaviors implied by the event. The non-normative influence refers to unpredictable events that may occur in the life of the individual, whether biological or social. These events can be configured as challenges or uncertainties and the impact of this on the subject will depend on the meaning attributed by him7.

According to Papalia and Feldman7, the segmentation of the life cycle in periods, such as childhood and adolescence, is a social construction that is circumscribed within a specific historical and cultural context of a society. This is because, effectively, there is no consensus on how to define the moment of passage from one period to another. In this way, it can be said that the notion of adolescence emerges as a phenomenon of contemporary western society, being the product of economic and social transformations caused by the Industrial Revolution8.

Adolescence is recognized as a transition phase from childhood to adult life, having been explained by different perspectives, whether from a biological, psychological, social or historical-cultural emphasis. The network of senses that involves this period of human development has been constructed throughout history, extrapolating the chronological delimitations. In addition, culture and social relations go beyond the way in which this transition process occurs, there being no pattern for such8.

The objective of this study was to understand how adolescents with DM1 are being studied from the field of knowledge of psychology. Psychology has contributed in the last decades to the field of health, favoring a holistic view of the subject. Considering the population scope of the DM1 over time, it is necessary to understand how psychology has produced knowledge in order to subsidize improvements for that group, and to group that information in order to analyze them critically.


This study sought to answer the following question: how have adolescents with type 1 diabetes mellitus been studied from the field of knowledge of psychology?

The systematic review occurred in the month of June of 2017, through the search of electronic articles in indexed databases (Scielo, Pepsic and VHL). The research was carried out using the descriptors: "adolescents", in any field of production and "diabetes" in the title, there was no filter corresponding to the year of publication. The selection of the articles occurred through three stages, first by reading the titles, after the summaries and finally by reading the material completely. For the selection of articles, inclusion and exclusion criteria were developed.

Compose the inclusion criteria: to be a research developed with adolescents with diabetes mellitus type I, to propose to investigate psychological aspects in adolescence with diabetes mellitus type I, having been carried out in Brazil. The exclusion criteria were: articles that reviewing the duplicate literature, studies that flee the subject of the review and that do not have Portuguese text.

The articles were analyzed based on the concepts used to support the research, main objectives, methodological delineation and main results observed.


The search resulted in 134 articles. After reading the titles and abstracts, considering the inclusion and exclusion criteria, 14 works were part of this review, the first one published in 2003 and the last one in 2016. Figure 1 organizes the articles in chronological order of publication.

Figure 1. Selection of productions for systematic review

Seven studies were published in journals in the area of psychology9,10,11,12,13,14,15 and seven in the nursing area16,17,18,19,20,21,22.The articles were published in five journals in the area of psychology conqualis A19,15, B211,12,14, B313 and one was not identified, 10 and in five in the area of nursing, with the qualis A121,22, A216,17,19,20, and B118. The information on the subject of the journals refers to the last triennial evaluation of Capes for the area of Psychology.

The period of adolescence was approached in 12 studies as a transition phase permeated by conflicts and immaturity10,11,12,13,14,15,16,17,19,20,21,22. Six articles13,16,17,18,19,22proposed to understand how adolescents with DM1 live and/or experience the disease; For this purpose, they sought theoretical support in the symbolic interaction17,22and the concept of identity13. In eight papers9,10,11,12,14,15,20,21 the authors focused on the way in which adolescents deal with DM1, using the concepts of: resilience9, anxiety14, confronting the disease15, quality of life and self-esteem20, psychoanalysis11, psychosocial aspects12 and therapeutic itinerary21.

In the articles analyzed, qualitative research9,12,13,16,17,18,19,21,22 predominated, while only two studies were quantitative14,20 and three quantitative-qualitative10,11,15. The participants of the analyzed studies were of both sexes and with ages varying between 9 and 21 years. Three of the works16,18,20 justified the election of the age group considering the provisions of the World Health Organization16 and the Statute of the Child and Adolescent18,20, the others did not present a justification. One article presented criteria, but did not identify whether they were inclusion or exclusion2,1doce had only the inclusion criteria9,10,11,12,13,14,15,16,17,18,20,22 and one pointed out the criteria of inclusion and exclusion19. The criteria forwarded by the papers were: participants should present cognitive conditions to respond to the investigation9,10,20, be in treatment at least a year ago13,17,18,22, not present chronic complications11, present difficulty in following the treatment21and agree to participate in the research15,16. Only one of the articles does not mention the ethical aspects that should be followed in research with human beings13.

Regarding the data collection, the qualitative research used a semi-structured interview9,12,13,16,17,18,19,22, an in-depth interview21, field observation21 and a map of the five fields9. Quantitative research applied the Quality of Life Instrument for Young People with Diabetes and an instrument of self-esteem of Rosemberg20e Trace-state Anxiety Inventory14. The quantitative-qualitative investigations used an interview for clinical characterization, 10 application of a questionnaire on difficulties for the supervision of therapeutic behaviors10 and Design of the Human Figure and the Person with Diabetes11, mapping of daily activities15 and a semi-structured interview15.

Nine investigations were developed with adolescents with DM1 in health services9,10,15,16,18,19,20,21,22, three with adolescents in health services and associations of people with diabetes11,14,17, one with adolescents in the holiday camp12 and one work did not specify a place for data collection13. The three comparative studies between adolescents with and without DM1 looked for adolescents without DM1 in schools, care institutions and through indications11,14,15. Eight articles contained information on the period and the city where the data were collected10,15,16,17,18,19,22, three of which consisted only of the city12,20,21 and in three of them the information was not described9,13,14.

The qualitative works analyzed the data through categorization, 13,17,22 content analysis9,12,16,18,19,21. The quantitative articles were used for descriptive statistics, 14,20test parametric14,20 and non-parametric tests.14 Quantitative-qualitative studies used the graph of growth and development10, categorization10, descriptive statistics10, nonparametric tests11,15 and content analysis15.

Regarding the main results presented by the articles selected for this review, Pires10, Alencar16 and Fragoso18, identified that the difficulties faced by adolescents with DM1 were related to face the diagnosis, the application of insulin, to maintain a healthy diet and the need to change the lifestyle. Alencar et al.16andAlmino, Queiroz and Jorge19 emphasize that these difficulties can trigger negative attitudes, feelings of fear, insecurity and discomfort. In contrast, social support was highlighted as an important factor in the confrontation of the disease by Heleno et al.12, Almino, Queirozy Jorge19 and Cassarino-Perez and Dell-Aglio9. These authors observed that social support, as well as affective bonding, self-esteem, optimism and altruism act as a protective factor contributing to resilience processes in adolescents with DM1.

To deal with the changes coming from the treatment of DM1, Fragoso et al.18 pointed out confrontational strategies used by the adolescents studied, these included facing the routine, learning to deal with contingencies and follow the treatment correctly. Alencar et al.16 observed that over time, adolescents incorporate the changes imposed by the treatment of DM1 and begin to deal with the disease naturally. In that way, Imoniana13 identified that some adolescents considered that routine was not affected due to DM1. Quality of life and self-esteem were evaluated positively by the adolescents in the Novato, Grossi and Kimura study20.

The studies presented by Ballas, Alves and Duarte11, Santos and Enumo15 and Ballas, Alves and Duarte14 carried out comparative analyzes between groups of adolescents with and without DM1. The results found by these studies indicated that there were no statistically significant differences in terms of anxiety traits, daily activities, design of the human figure and person with diabetes.


A similar number of publications were observed in journals in the area of nursing and psychology, which shows the interest of health professionals in understanding the adolescent in sick considering the biopsychosocial aspects that surround it.

The articles present the importance of social support and of the affective bond in the confrontation of the disease, also functioning as protective factors. In review of the scientific production on resilience, social support was associated with all the research found. Regarding the concept of resilience addressed in the works, only one was in the field of psychological processes, others in the field of nursing. The articles pointed out that the period of transition of parental care for self-care was characterized as a factor that can be decisive in subsequent resilience processes. It was identified that the increase in autonomy was directly associated with worsening metabolic control, putting in projection a tenuous relationship between protective factors such as social support and autonomy and risk factors such as low adherence to treatment and increased blood glucose23 .

Adolescence emerges in studies as a "problematic" stage, permeated by tensions that can hinder the treatment of diabetes. For example, Pires10 stated that the emotional conflicts characteristic of this period can lead to poor adherence to treatment, since the diagnosis of DM1 aggravates the feeling of non-belonging and exclusion experienced by adolescents. Second Leal and Facci24, adolescence little by little consolidated itself as a phase of life, a universal phenomenon, being studied from an individual perspective associated with biological maturity.

It was then identified a crystallized conception of adolescence in twelve of these publications, a negative view of this stage of life that seems to be anchored in adult life as a referential of stability. Berni and Roso25 affirmed that adolescence has particularities in relation to the contexts of life and cultural and temporal aspects, so studies should be cautious in the definitions that are proposed universal and static. In the case of adolescents with DM1, the chronic patient emerges as a non-normative influence, considering that it is not part of the natural biological development of the individual, and thus demands a reorganization of the subject so that it adapts to this new condition.

The works analyzed in this review, in a general way, brought aspects of that phase of human development, but they did not work with the conceptualization and representations of it by the different fields of knowledge. From the conception according to which adolescence is a polysemic field, it was considered important to deconstruct the crystallized perspective on it and the problematization of its conceptualization, due to its particularities at a biological, psychological, social and historical level. By bringing this critical view, professionals can attack the networks of meaning that cross each individual and not reduce the problems faced throughout the treatment as exclusive to the period of adolescence.

It was perceived in the selected articles that responsibility for oppositional behaviors, conflicts or non-acceptance of the disease that arise is attributed to the period of adolescence. It is not taken into account that human development is marked by a continuous process of changes, including gains and losses, as well as by the interaction of the subject with culture6. In addition, one must consider the chronic illness that suddenly surpasses the life of the subject being necessary to attribute new meanings to their experiences. In this way, the stigmatizing view of the adolescent is also a decontextualized view of the individual.

The articles that were proposed to analyze the experiences and experiences of adolescents with DM1 found similar results, these were: difficulties in relation to following the diet and making the measurement and application of insulin, fear of complications derived from the disease, issues related to acceptance and non-acceptance, importance of family support, friends, health professionals and adaptation to changes. Damião, Diasy Fabri17 stressed that the way in which the subject deals with the disease is not linear, as well as the intensity can vary, that is, along the way the adolescent can experience the patient in different ways. It is understood then that if a teenager has adhered to the treatment at a given time, this does not mean that the adolescent remains in the treatment. Given this, professional accompaniment is necessary in order to strengthen the protective factors that surround the adolescent.

Considering the studies gathered here, twelve were conducted with adolescents assisted by health services of the public network, which indicates that the investigated public may be circumscribed in a specific socioeconomic class. Despite not being a fact discussed in all articles, it is possible that the context in which these adolescents are inserted has implications for the patient's experience, in the treatment management, even differentiating them from adolescents from other social classes. Thus, it is a variable that can be weighted in order to produce knowledge sensitive to the social dynamics that crosses the individual issues of the subject. In addition, it is a fact that should be considered when comparing these results with other studies.

It was possible to observe in the works the absence of conceptualization about the constructs analyzed in what refers to the theoretical contribution used by the studies that were proposed to analyze the experiences and experiences of adolescents with DM1. In this way, the discussions carried out based on the results outline fragile contours in relation to the proposed objectives.

The articles selected for this review lacked information in the section of the method, such as the absence of information regarding the justification for determining the age group of the study participants, the period and city in which the data were collected, the ethical aspects of research with human beings, in addition to lack of clarity regarding the naming of the inclusion and exclusion criteria used. The field of data analysis was fragile, while there were not very specific descriptions and absence of reference in the exposed information.

In general, the gaps presented in the methodology of the works bring some implications such as, difficulty of understanding the context in which the results were found and analyzed, in this way, the absence of information affects the reliability of the data and consequently in the knowledge that has occurred in the area. As well as, for quantitative studies they are not transformed from replication, considering that for this a detailed and complete description of each methodological step is necessary. From that, the need for greater scientific rigor in the production of knowledge on the subject was perceived.


Financial Support: CAPES Master's.


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