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Post-traumatic Stress Disorder in Children Affected by Type 1 Diabetes and Their Parents

  • R. SchiaffiniEmail author
  • C. Carducci
  • S. Cianfarani
  • M. Mauti
  • G. Nicolais
Medicine
  • 13 Downloads
Part of the following topical collections:
  1. Topical Collection on Medicine

Abstract

Type 1 diabetes is a challenge for children, adolescents, and their families as it affects the quality of life and lifestyle of the whole family context. Diabetes onset and its chronic management could be therefore particularly related to post-traumatic stress disorder (PTSD), a group of persistent psychological and physiological symptoms due to a traumatic and severe event. The aim of this study was to assess the rate of PTSD in a group of pediatric patients with T1DM and to evaluate the relationship between parental trauma and quality of life. Forty-nine prepubertal children affected by T1DM and their families were consecutively enrolled in the study. Patients and parents were asked to complete two types of questionnaires: (1) The Impact of Event Scale (IES) questionnaire for the evaluation of PTSD. (2) The PedsQL™3.0 Diabetes Module questionnaire to measure diabetes-specific QOL in both children and their parents. Our data suggest that a clinical level of trauma is present in 66.7% of mothers and 65.5% of fathers of T1D children. Parents with medium or high IES Scores demonstrated lower levels of QoL. The results of this study show a high prevalence of acute post-traumatic stress symptoms in parents of prepubertal children with T1DM. This finding is consistent with data from adult diabetic patients. Our data demonstrated also a relation between parents’ level of traumatism and declared QoL scores. Indeed, our data confirm that the duration of diabetes negatively correlates with the QoL by both, parents and patients.

Keywords

Type 1 diabetes Post-traumatic stress disorder Quality of life Impact of Event Scale (IES) 

Introduction

Autoimmune type 1 diabetes mellitus (T1DM) is one of the most frequent chronic diseases during childhood and adolescence; it starts dramatically with acute hyperglycemia and is characterized by a deficit of insulin production, requiring lifelong, intensive, multi-injective, insulin therapy.

Type 1 diabetes is a challenge for children, adolescents, and their families as it affects the quality of life and lifestyle of the whole family context.

Diabetes onset and its chronic management could be particularly related to post-traumatic stress disorder (PTSD), a group of persistent psychological and physiological symptoms due to a traumatic, severe event.

Several authors [1] observed that children affected by severe and chronic diseases and their parents show significant symptoms related to PTSD; in particular, they frequently re-experience the trauma, develop a sort of excessive supervision on affected children, and especially present avoidance behaviors.

The chronic nature of type 1 diabetes persists as a continuous source of distress and concerns (Horsch A and collaborators [2]); some authors demonstrated that the link between type 1 diabetes in children and PTSD in their parents is related to several factors such as the acute criticisms resulting from the diagnosis, the pervasive nature of the disease itself, and the awareness of long-term needs and assistance directly related to the management of children affected by type 1 diabetes. Parents, mothers in particular, have reported both chronic and acute stressors related to disease. These stressors are especially pertinent for mothers of young children, where disease management is even more complex due to administration of frequent, small doses of insulin, variable eating patterns, and the inability of the child to recognize and communicate early symptoms of hypoglycemia [3].

Aim of the Study

The aim of this study was to assess the rate of PTSD in a group of pediatric patients with T1DM.

In particular, we aimed at evaluating (a) the presence of psychological trauma in parents of children affected by T1DM for at least 1 year; (b) the relationship between parental trauma and quality of life (QoL) of diabetic children and their parents; and (c) the impact of glucose control (HbA1c) on parental trauma and QoL and vice versa.

Patients and Methods

Forty-nine prepubertal children affected by T1DM and their families, followed at the Diabetes Unit of Bambino Gesù Children’s Hospital – Rome – Italy, were consecutively enrolled in the study. All patients were treated with a multi-injective insulin scheme (four or more insulin administrations per day).

Demographic and clinical features of patients are described in Table 1. The study was conducted according to the Declaration of Helsinki. Participants and their parents provided written informed consent.
Table 1

Demographic and clinical features of enrolled families

 

Mean age (years)

M/F

Mean diabetes duration (months)

Mean HbA1c (%)

Severe hypos

DKA episodes

High education level

Medium education level

Low education level

n = 49 T1D children

8.5

22 M

27 F

32.8

7.67

0

0

   

Mothers

30

48

    

8

28

3

Fathers

42

29

    

9

23

3

As part of routine clinical controls, patients underwent blood sampling for HbA1c evaluation.

Instruments

In order to evaluate the presence of traumatism and its hypothetic relationship with quality of life (QoL) patients and parents were asked to complete two types of questionnaires between January 2013 and December 2014:
  1. 1)

    The Impact of Event Scale (IES) questionnaire for the evaluation of PTSD. IES (Horowitz, Wilner, Alvarez, [4]—Italian version Pietrantonio, De Gennaro, Di Paolo, Solano, 2003 [5]) represents a self-report scale with a final score. According to the final score, patients and parents are allocated in a specific range that defines the presence and the severity (mild to very severe) of traumatism.

     
  2. 2)

    The PedsQL™3.0 Diabetes Module questionnaire was established to measure diabetes-specific QOL dimensions in both children and their parents:

     

The PedsQL™3.0 Diabetes Module includes 28 items distributed into 5 scales: (1) Diabetes symptoms; (2) Treatment barrier; (3) Treatment adherence; (4) Worry; (5) Communications. The Final Total Sore correlates with the degree of QoL.

Questionnaires were administered by the same psychologists of the Psychology Unit of Bambino Gesù Children’s Hospital and the Department of Dynamic and Clinical Psychology of University Sapienza of Rome. A total of 48 mothers completed the questionnaires, whereas only 29/49 fathers returned their complete questionnaires.

The main reasons why only 29 fathers returned their complete questionnaire are as follows: 10 fathers refused to participate the investigation, 4 IES questionnaires were incomplete and therefore not useful for data analysis, and finally, 6 fathers returned the questionnaires in late, and therefore, pairing with HbA1c sample and with mother’s questionnaire was not possible.

In addition, also one mother refused to participate in the investigation.

Statistical Evaluation

Student’s t test for independent variables and paired data was applied in order to evaluate the influence of trauma symptoms on QoL. Analysis of variance (ANOVA) was performed in order to compare the effects of PTSD on clinical aspects. A p value < 0.05 was considered statistically significant.

Results

  1. 1.

    Presence of psychological trauma in parents of children affected by 1TD

    Our data suggest that a clinical level of trauma is present in 66.7% of mothers and 65.5% of fathers of T1D children (Table 2).

     
  2. 2.

    Correlation between parental trauma levels and quality of life (QoL) of diabetic children and their parents

    Mothers with medium or high IES Scores demonstrated lower levels of QoL especially in Total Score, Diabetes symptoms scale, and Worry Scale, while fathers with medium or high IES scores demonstrated lower levels of QoL especially in Total Score and Diabetes symptoms scale (Tables 3 and 4).

    No relationship was found between the level of parents’ trauma and children QoL perception.

     
  3. 3.

    Impact of glucose control (HbA1c) on parental trauma parental trauma and QoL and vice versa

    HbA1c did not significantly impact on parental trauma and QoL and vice versa.

     
Table 2

Incidence of trauma in mothers and fathers of children with T1D

Subjects

Subclinical score N (%)

Clinical score N (%)

Total

Mothers

16 (33.3%)

32 (66.7%)

48 (100%)

Fathers

10 (34.5%)

(65.5%)

29 (100%)

Table 3

Relation between mothers’ IES scores and QoL

PedsQL™—Parents

N

Mean (SD)

T (42)

p

Total score

  

2.958

.005

 Subclinical

16

79.87 (8.00)

  

 Clinical

32

72.16 (8.08)

  

Diabetes symptoms

  

3.472

.001

 Subclinical

16

75.51 (13.37)

  

 Clinical

32

61.50 (12.04)

  

Treatment barriers

  

.409

n.s.

 Subclinical

16

79.39 (17.90)

  

 Clinical

32

77.06 (17.44)

  

Treat adherence

  

.358

n.s.

 Subclinical

16

84.79 (14.24)

  

 Clinical

32

83.32 (11.90)

  

Worry

  

2.248

.030

 Subclinical

16

83.90 (17.13)

  

 Clinical

32

68.57 (22.61)

  

Communication

  

.021

n.s.

 Subclinical

16

77.36 (24.77)

  

 Clinical

32

77.21 (22.00)

  
Table 4

Relation between fathers’ IES scores and QoL

PedsQL™—parents

N

Mean (SD)

T (24)

p

Total score

  

2.260

.033

 Subclinical

10

80.80 (10.57)

  

 Clinical

19

72.24 (8.41)

  

Diabetes symptoms

  

2.145

.042

 Subclinical

10

77.08 (14.99)

  

 Clinical

19

64.46 (13.89)

  

Treatment barriers

  

.571

n.s.

 Subclinical

10

79.16 (18.49)

  

 Clinical

19

75.30 (15.19)

  

Treat. adherence

  

1.803

n.s.

 Subclinical

10

88.86 (9.36)

  

 Clinical

17

79.72 (13.52)

  

Worry

  

1.808

n.s.

 Subclinical

10

86.09 (19.10)

  

 Clinical

19

70,55 (21.67)

  

Communication

  

− .366

n.s.

 Subclinical

10

68.50 (26.27)

  

 Clinical

19

72.52 (26.82)

  

Discussion

The present investigation refers to questionnaires administered between 2013 and 2014 and the principal referral in the description of PTSD was the Diagnostic Statistical Manual of Mental Disorders (DSM-IV); In 2014, in Italy, the DSM-5 where the evaluation of PTSD has been shifted from the chapter about anxiety disorders to a new chapter about disorders related to traumatic events has been published. Indeed, the description of PTSD is the same; as reported in the Diagnostic Statistical Manual of Mental Disorders (DSM-IV and DSM-5), a post-traumatic event is classified as a life-threatening event and it is perceived as a risk for physical and mental integrity. PTSD can occur in different ways but the main feature is the development of a series of anxiety-depressive symptoms following a traumatic event. In some patients, symptoms related to fear, avoidance, and anxiety prevail; in others, there is the depressed mood; others may show dissociative symptoms, although a combination of these symptoms is often observed in patients suffering from PTSD.

Usually, parents of children with diabetes report initially an acute stress, strictly related to diabetes diagnosis. This psychological status can be followed by a chronic, persistent stress, essentially related to traumatic aspects of medical treatment.

Given that T1DM is a life-threatening, chronic illness, it could be a precipitant of PTSD for patients and their family members.

The results of this study show a high prevalence of acute post-traumatic stress symptoms in parents of prepubertal children with T1DM. This finding is consistent with data from adult diabetic patients and with data from other similar studies. Psychological distress was most acute at the time of diagnosis and throughout the first year after diagnosis. In one study, within 6 weeks of diagnosis, about 51% of mothers met diagnostic criteria for partial PTSD and 24% of mothers met diagnostic criteria for full PTSD based on the Posttraumatic Stress Diagnostic Scale (PDS; [6]). In another study, 29.3% of mothers met full diagnostic criteria for PTSD based on PDS within 6 weeks of diagnosis, and mothers were significantly more vulnerable to PTSS than fathers [7].

In our study population, parents are more affected by psychosocial traumatic distress as a consequence of diabetes diagnosis than in previous reports (Stoppelbein and Greening, 2007 [8]).

Our data demonstrated also a relation between parents’ level of traumatism and declared QoL scores. In particular, we found that mothers with medium or high trauma symptoms had lower levels of QoL especially in Total Score, Diabetes symptoms scale, and Worry Scale, while fathers with medium or high trauma symptoms demonstrated lower levels of QoL especially in Total Score and Diabetes symptoms scale. It means that it is important for health care providers to conduct regular mental health screening in mothers of children with T1D. Regular assessment may help to ensure that mothers struggling with emotional distress are not missed. Such screening should become a part of regular T1D clinic visits, especially for mothers of very young children.

Another important consequence of parental stress could be children mental health. For example, some studies suggested that mothers with post-traumatic stress symptoms were more likely to have children with some difficulties to cope stress symptoms [7].

Streisand et al. [9] underline that maternal mental health has a deep impact on children’s psychological status, because of their poorer coping skills and their depressive symptoms.

Therefore, monitoring the possible appearance of risky behaviors in diabetic children with parents with PTSD is extremely important. Serafini et al. [10] show that adverse life events like maltreatment and violence, loss events, intra-familial problems, and school and interpersonal problems could lead to suicidal behaviors especially in young people. In conclusion, parents’ discomfort must be monitored, as depressed or stressed mothers can create negative experiences in their children. These negative experiences can influence the psychological well-being of the young and make them vulnerable to mental disorders [11, 12, 13].

Our data therefore confirm that parents of children with diabetes present a chronic distress strictly related to the obligation to chronically provide to medical treatment and psychosocial adaptation; these data need to be replicated in larger and more representative populations. Moreover, also different study designs are needed, especially in order to define right treatment strategies.

Indeed, our data confirm what previously described in chronic diseases by Miller 1999 [14]: the duration of diabetes negatively correlates with the QoL by both, parents and patients.

Unexpectedly, the level of parents’ trauma does not seem to affect the metabolic control of children or their quality of life. The trauma seems to induce an adaptive role, as reported by Stallwood et al., in which a higher level of perceived stress increased the adherence to treatment.

These preliminary data open several working hypotheses about the probable adaptive role of parental trauma in parents of children affected by T1DM.

Notes

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Diabetes UnitBambino Gesù Children’s HospitalRomeItaly
  2. 2.Psychology UnitBambino Gesù Children’s HospitalRomeItaly
  3. 3.Department of Dynamic and Clinical Psychology, Faculty of Medicine and PsychologySapienza UniversityRomeItaly

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