Issue 105 Item 8 40% of Children with Type 1 Have Psychiatric Problems

Underinsurance, the presence of psychiatric disorders, and having an extreme glycosylated hemoglobin level are risk factors for acute complications in children with type 1 diabetes, according to results of a large prospective study. Authors of the study, which appears in the Journal of the American Medical Association for May 15, suggest that targeted interventions could prevent a large proportion of acute complications that occur among children with diabetes.

Between 1996 and 2000, Dr. Arleta Rewers and associates, of the University of Colorado School of Medicine in Denver, tracked diabetes-related outcomes among 1243 children. There were an average of eight episodes of diabetic ketoacidosis per 100 person-years and 19 episodes of severe hypoglycemia per 100 person-years.

Hemoglobin A1c levels and insulin levels were significant predictors of diabetic complications in the group of children younger than 13 years and in those 13 years and older, Dr. Rewers said at a media briefing at The National Press Club in Washington, DC. "A 1% increase in hemoglobin A1c increased the risk of ketoacidosis by 50%."

Among girls, the incidence of ketoacidosis increased significantly with age, while the incidence of severe hypoglycemia decreased with age. No such relationship with age was observed for boys. In both sexes, ketoacidosis incidence was associated with longer duration of diabetes.

The investigators used underinsurance as a proxy for low socioeconomic status and unstable living conditions, and defined it as a lack of insurance or enrollment in Medicaid or Child Health Plan Plus. In children age 13 years and older, underinsurance was associated with a relative risk of 2.18 for ketoacidosis. The presence of psychiatric disorders led to a relative risk of 1.59 for boys and of 3.22 for girls.

Severe hypoglycemia was independently predicted by non-Hispanic white ethnicity, longer duration of diabetes, and underinsurance. Among older children, the relative risk was 1.42 for those who were underinsured, and 1.56 for those with a psychiatric disorder.

"Children with type 1 diabetes, while managed by a state-of-the-art multidisciplinary team, still experienced significant numbers of severe, potentially preventable complications," the authors write. They note that adolescent girls were at the highest risk for ketoacidosis, presumably because they are more likely to omit insulin injections to lose weight.

Psychiatric disorders, they hypothesize, lead to severe hypoglycemic episodes because of "less frequent blood glucose testing, and more chaotic diet and sleep and wake patterns."

At the same time, having diabetes in childhood may lead to psychiatric illness. "With time, the amount of psychiatric disorders in children increases," said Dr. Rewers. By 20 years old, "40% of children with type 1 will have some kind of psychiatric problem."

She speculates that the burden of the disease, "where you can’t take a vacation from it, has a significant influence on those kids." JAMA 2002;287:2511-2518.