Context:
Children diagnosed with T1DM often encounter emotional and behavioral challenges such as anxiety and depression. These difficulties were magnified by COVID-19 restrictions, which restricted their access to healthcare services.
Purpose:
This research aimed to examine behavioral issues among T1DM children with different levels of metabolic control during the pandemic.
Methodology:
At General Hospital Dr. Soetomo Surabaya, a cross-sectional study was implemented. Children with T1DM were categorized into two groups based on their metabolic control: good (HbA1C ≤ 8) and poor (HbA1C > 8). The PSC-17 tool was utilized to evaluate internalizing, externalizing, and attention-related problems.
Findings:
A total of 27 participants were included in the study, with 33.3% exhibiting behavioral issues. While children with good metabolic control displayed fewer problems, there was no statistically significant difference between the two groups.
Summary:
Although no significant variances were noted, children with good control showed more externalizing concerns, while those with poor control demonstrated higher levels of internalizing problems.
Impact of COVID-19 Pandemic on Behavioral Problems in T1DM Children
Children diagnosed with T1DM commonly experience emotional and behavioral challenges. The restrictions imposed due to COVID-19 have had implications on healthcare accessibility and potentially on metabolic management.
Study Implementation
The research took place at General Hospital Dr. Soetomo in Surabaya. A total of 27 pediatric T1DM patients between the ages of 4 and 17 were examined using the PSC-17 questionnaire to assess their behavioral patterns.
Characteristics of T1DM Patients
The average age of the 27 participants was 12.63 ± 3.39 years, with an average HbA1C level of 10.29 ± 2.39%. The average duration of illness was 5.41 ± 3.61 years.
| Feature | Quantity (%) | Average ± Standard Deviation |
|---|---|---|
| Age Range | 27 years (100%) | Mean: 12.63 ± 3.39 |
| Children Below 8 Years | 3 (11.1) | |
| 8 – 13 | 8 (29.6) | |
| Suitable for ages 13 and above | 16 (59.3) | |
| Men | 17 (63) | |
| Woman | 10 out of 37 respondents are female. | |
| Length of Sickness (years) | 27 (100) | 5.41 ± 3.62 |
| HbA1C (%) | 27 (100) | Mean value of HbA1C was 10.29 ± 2.39 |
| Educating Caregivers | ||
| Basic Level | 0 | |
| Middle school | Grade 5 (18.5) | |
| Secondary education | 16 students (59.3%) | |
| Secondary education | 6 (22.2) | |
| Performance Score in PSC-17 | Achieved a score of 27 out of 100 | Mean score was 8.70 with a standard deviation of 4.75 |
| Age below 15 | 18 (66.7%) | |
| Age 15 and above | 9 (33.3) |
Analysis of Patients with T1DM: Demographic Profile
The data presented in Table 2 illustrates the correlation between behavior patterns and metabolic regulation. Out of the total participants, 14.8% exhibited internalizing challenges, while 18.5% displayed externalizing issues. Notably, no instances of attention-related difficulties were detected. When comparing the occurrence of behavior problems among subjects with varying levels of metabolic control, there were no statistically significant variations in the prevalence of internalizing or externalizing problems (P = 1.00 and P = 0.14, respectively).
| Challenges with Behavior (PSC-17 Score) | Blood Sugar Level (HbA1C) | Statistical Significance (P-Value) | |
|---|---|---|---|
| Less than or equal to 8 (n = 8) | Greater than 8 (n = 19) | ||
| Assimilation of information | 1.00 | ||
| 5 or more | 1.8 (12.5) | 3.19 (25.8) | |
| Children under 5 years old | 7.8% (87.5%) | 16.19% (84.2%) | |
| Expressing Outwardly | 0.14 | ||
| Equal to or more than 7 | 3.8 (37.5) | 2.19 (10.5) | |
| Children under 7 years old | 5.8 years old (62.5%) | 17.19 lbs (89.5%) | |
| Important Notice | – | ||
| 7 и более | 0.8 (0) | 0.19 (0) | |
| For children under 7 years old | 8.8 out of 10 (100%) | 19 out of 100 (100%) | |
Research Findings
Our study did not show a significant difference in behavioral problems between groups with good and poor metabolic control. During the COVID-19 pandemic, 33.3% of children with Type 1 Diabetes Mellitus (T1DM) experienced behavioral issues. This aligns with a previous study where 17-19 year olds with T1DM had a 33.3% rate of behavioral problems compared to a control group at 9.7%. Indonesian children with T1DM also had behavior problems, with a rate of 45.8% before the pandemic. Another study over three years found similar levels of psychosocial function in diabetic and healthy groups, with differences in social acceptance and eating behavior noted. The impact of behavioral issues in T1DM children during the pandemic is not fully understood.
Among our participants, externalizing (18.5%) and internalizing (14.8%) problems were most common. Those with good metabolic control had higher rates of externalizing problems. Previous research has linked unstable glucose levels to behavioral changes in children with T1DM. Externalizing problems may be influenced by child development, sociocultural factors, caregiving experiences, and peer interactions. The limited school and social opportunities during the pandemic may contribute to these issues.
Butwicka et al. found that children with T1DM had a higher risk of behavioral problems, especially in families with psychiatric disorders. These children also had more suicide attempts than those without behavioral issues. Bernstein et al. discovered high prevalence rates of anxiety, behavioral issues, and mood disorders in children with T1DM. Other studies have connected T1DM with various mental health conditions such as anxiety, eating disorders, behavioral problems, and depression, which can negatively impact disease management.
Our study did not establish a significant link between metabolic control and behavioral issues, illness duration, or age. A Danish study indicated that children with T1DM diagnosed between ages 10-14 had a higher risk of psychiatric conditions, particularly those with longer diabetes duration. Behavioral issues and stress have been shown to affect illness progression and metabolic control, although some studies have not found a clear association between metabolic control and behavioral problems.
The incidence of T1DM is increasing globally, with Indonesia experiencing a significant rise. Our study during the COVID-19 pandemic showed a decrease in metabolic control among children with T1DM, attributed to limited access to healthcare affecting glycemic control and leading to hyperglycemic episodes and diabetic ketoacidosis. Conversely, studies in Italy reported improved metabolic control during the pandemic.
A Swedish study found no change in metabolic control among children with T1DM in the years 2019 and 2020, likely due to active treatment measures during the pandemic. Unlike Sweden, our study did not utilize telemedicine as a routine alternative treatment during the pandemic, resulting in poorer metabolic control for T1DM patients.
Behavioral problems were not explored before the lockdown in our study. Despite its limitations, our findings during the COVID-19 pandemic have implications for future research and care for children with T1DM. The PSC-17 questionnaire may be valuable in assessing behavioral problems in these children.
In summary, no significant differences were found in the prevalence of behavioral issues between groups with good and poor metabolic control. Adolescents with diabetes exhibited more mental, behavioral, and developmental disorders than those without diabetes. Regular mental health screenings and support can benefit young individuals with diabetes. Addressing the emotional aspects of diabetes and providing adequate mental health care are crucial for managing both diabetes and behavioral problems in young patients.
Support and Advice
When a child resists managing their blood sugar levels, it is important to connect with them and understand the underlying issues. Diabetic children may feel neglected compared to their siblings, so it is essential to provide balanced attention and support.
Diabetic children may require extra care, which can make siblings feel excluded. Strive to maintain a balance in privileges and rewards among siblings to prevent feelings of unfairness.
Conversely, diabetic children may envy the freedom and opportunities their siblings have. Finding equilibrium in these situations can be challenging but is essential for family harmony.
If you are struggling to find this balance, seek advice from other parents on our online diabetes forum for parents and children.
Additionally, it is important to involve the entire family in the management of diabetes. Educate siblings about the condition and involve them in activities related to monitoring blood sugar levels and providing support to their diabetic sibling.
Remember to prioritize open communication within the family to address any concerns or feelings of jealousy that may arise. Encouraging a supportive and understanding environment will help the entire family navigate the challenges of living with diabetes.