In our study, we found that diabetic children had significantly higher prevalence of psychological, behavioral, and social problems than control children (92.37% vs. 20.2%, P 0.001). All subscales of SDQ except prosocial subscale were significantly affected in children with type 1 diabetes mellitus than control children. The higher prevalence of emotional and behavioral problems in diabetic children may be explained by the stress of chronic illness diagnosis and stress of treatment as painful injections and diet and life style restrictions as well as stigma and social stressors from peers and the society as a whole.
Certain factors were significantly associated with impaired subscales of SDQ scale. We found a positive correlation between age and emotional, hyperactivity, and conduct problems as these problems were more frequent in older children. Female children had more hyperactivity and conduct problems than male children (68.6%, 71.7% vs. 58.0%, 62.0%, P 0.002 and 0.003, respectively), while male children were more affected by emotional problems than female children (68% vs. 57.4%, P 0.003).). Peer problems were more prevalent in children of parents with higher educational level. Children with positive family history of diabetes were less affected by emotional problems than children with negative family history (50% vs.64.3%, P 0.04). Longer duration of disease was associated with increased prevalence of peer and emotional problems. Poor control of diabetes increased the prevalence of conduct and emotional problems (P 0.007 and 0.022, respectively).
Relation to other studies
Previous studies which were done to determine the psychological and behavioral complications of diabetes in children and adolescents found that diabetic children had higher prevalence of these problems. Different studies focused on certain psychological problems such as depression, eating problems, and suicide. Most of these studies included small numbers of patients. In our study, we tried to add to the previous work done in this area and tried to include a large representative sample and tried to avoid confounding factors that might affect the accuracy of the results. Also, we tried to find factors correlated with different psychological and behavioral problems like age at diagnosis of diabetes mellitus, duration of the disease, glycemic control, and family history of diabetes. Our results confirm the results in previous studies. Most of these studies were small and investigated specific disorders [5,6,7]. Three recent large studies showed similar results Denmark, Sweden, and Australia [15,16,17].
A large Danish study compared 5084 child and adolescent patients diagnosed with type 1 diabetes mellitus with age- and sex-matched controls regarding diagnosis with one or more psychiatric disorders. The researchers found significant higher incidence of anxiety disorders, depression, eating disorders, somatization disorders, and dissociations in diabetic group .
A second large Swedish study followed 17,122 child and adolescent diagnosed with diabetes mellitus type 1 for 5 years. The control subjects (n = 18,847) were the healthy siblings of the patients (this was a strength point in this study as patients and controls are to large extent similar in genetics and social factors). The researchers found that the incidence of different psychiatric disorders was twice more common in patients than controls. The main psychiatric disorders diagnosed in patients group were depression, anxiety, eating disorders, inattention, hyperactivity, conduct disorder, and abuse of addictive substances .
A third large study from Australia, compared between 1303 patients with type 1 diabetes and 6422 healthy individuals matched with the patients group for age and sex. The researchers found that 14.3% of patients groups were diagnosed with ant psychiatric disorder, while in control subjects, only 6.2% were diagnosed with a psychiatric disorder. The main psychological problems diagnosed in patients group were depression, anxiety, eating disorders, and conduct disorders. Poor control of diabetes was significantly associated with diagnosis of different psychiatric disorders .
Factors associated with different psychiatric problems
In our study, we tried to address certain factors that may be associated with different psychological and behavioral problems. We selected certain factors which were significant in previous studies and added other risk factors that we speculated may be associated with psychological problems.
Age at diagnosis of type 1 diabetes mellitus
In our study, we found a positive correlation between age and emotional, hyperactivity, and conduct problems as these problems were more frequent in older children. The Danish study found that the highest risk for diagnosis with any psychiatric disorder occurred when diabetes was first diagnosed between 10 and 14 years of age . This finding was also noticed in the Swedish study as the researchers found an increasing incidence of psychological problems when diabetes was first diagnosed in older children . A suggested, explanation of these findings is that pre-adolescence and adolescence are naturally sensitive periods of development, combined with the stress of diagnosis of diabetes mellitus and the possible social and emotional strains commonly occurring in this age group . Our explanation to this relation may be that as the child is older his perception of the disease and social stressors is increased and also the duration of the illness and suffering from it is mostly longer as the child is older.
Sex of the patients
In our study, we found that female children had more hyperactivity and conduct problems than male children (68.6%, 71.7% vs. 58.0%, 62.0%) while male children were more affected by emotional problems than female children (68% vs.57.4%). The Danish study found that abuse of psychoactive substances was significantly higher in male patients, while personality changes were higher among female patients. The Australian and Swedish studies did not stratify patients based on sex [15,16,17]. We did not find an explanation to this finding, as what is well known is that conduct problems and hyperactivity problems are higher in males than in females, while emotional problems are more frequent among females. Our results were opposite to that.
Other factors associated with psychological and behavioral problems
Some other factors are found to be associated with certain problems in diabetic children. Peer problems were more frequent in children of parents with higher educational level. Children with positive family history of diabetes were less affected by emotional problems than children with negative family history (50% vs. 64.3%, P 0.04); this may be explained by the experience of the family about the disease and its management. Longer duration of disease was associated with increased prevalence of peer and emotional problems. Poor control of diabetes increased the prevalence of conduct and emotional problems, and this may be explained by the biological effects of hyperglycemia on mood and behavior and also the stress of management of the complications of poor glycemic control which add to the stress of management of the disease itself.
Limitations of the study
We recommend the use of more accurate and specific questionnaires for screening and diagnosis of different psychiatric disorders in the following studies.