Shock to the System: Pediatric Type 1 Diabetes Patients and Trauma

A new study seems to suggest that while trauma and post-traumatic stress syndrome are common in kids with type 1 diabetes, they have little to no impact on their diabetes self-management. However surprising this finding may be to researchers, it further stresses the need for multidisciplinary teams to care for these patients.

Children suffering traumatic experiences is already disheartening enough, but when that trauma is compounded by a diagnosis of type 1 diabetes (or when that diagnosis causes the trauma), that can put up a lot of obstacles that need to be navigated, walls that need to be scaled or demolished.

Endocrinologists who treat children with type 1 diabetes who may not be hitting their glycemic targets should be aware that there may be more than meets the eye to these patients, something bubbling underneath the surface that can potentially cause a cycle that’s difficult to break.

Last November, a paper appeared in Diabetes Spectrum that looked at how traumatic experiences and post-traumatic stress disorder (PTSD) impacts how pediatric patients manage their type 1 diabetes, born out of clinical observations and discussions among authors at the University of Kentucky and the UK HealthCare Barnstable Brown Diabetes Center in Lexington, Ky. The authors – from a variety of disciplines – observed that psychiatric symptoms seemed to play a role in diabetes self-management in children, adolescents, and emerging adults with type 1 diabetes.

Indeed, psychiatric factors like depression and anxiety are known to negatively affect glycemic control, but little is known about how trauma exposure and PTSD may impact type 1 diabetes, so the researchers at UK decided to look for how common these factors are in children with type 1 diabetes, and the relationship between trauma exposure, PTSD, anxiety, depression, and diabetes self-management.

“Emotional factors and experiences play an important role for children and teenagers who are learning to manage type 1 diabetes; psychological trauma exposure is very common, but we are still working to understand more about how it may affect diabetes self-management,” says Amy Lynn Meadows, MD, MHS, FAAP, FAPA, DFAACAP, associate professor of Psychiatry and Pediatrics at the University of Kentucky College of Medicine, who led the study.

Trauma’s Negligible Impact  

For this study, the researchers recruited 99 children and young adults between the ages of seven and 21 with type 1 diabetes over almost two years. They conducted screening questionnaires to identify underlying psychiatric disorders such as trauma exposure, PTSD, depression, anxiety disorder, and suicidal ideation, then looked at the rates of various psychiatric disorders and their correlation to diabetes management, including glycemic control and self-management.

“Careful screening and management of underlying psychiatric disorders may help in improving diabetes-related outcomes in pediatric patients with Type 1 diabetes. Use of standardized screening questionnaires such as Child and Adolescent Trauma Screen (CATS) may help identify children with traumatic life experiences and PTSD.”

Rishi Raj, MD, director, Division of Endocrinology, Diabetes and Metabolism, Pikeville Medical Center, Pikeville, Kentucky

The study found that 66% of participants had traumatic exposure; 39% of those also had PTSD symptoms. Researchers found the most common trauma exposure was accidental injury and traumatic medical stress. They also found that when comparing to the goal of treatment as defined by American Diabetes Association guidelines, only 11% of children with type 1 diabetes achieved glycemic targets and only 40% of participants were checking blood glucose four times a day.

The study ultimately concluded that while trauma was common among youth with type 1 diabetes, neither trauma nor PTSD was associated with changes to self-management. However, they do believe certain forms of anxiety and suicidal ideation were associated with poor self-management and higher HbA1c.

“Our study replicated findings from prior work and found a correlation between some forms of anxiety disorder and suicidal ideation to impact glycemic control and self-management,” says Rishi Raj, MD, who is currently the director of Division of Endocrinology, Diabetes and Metabolism at Pikeville Medical Center, Pikeville, Ky., helped lead the study during his fellowship at the University of Kentucky, and is the first author of the paper. “However, we were surprised to see that despite high rates of trauma exposure and PTSD, there was not any statistically significant association of trauma exposure/PTSD with glycemic control or diabetes self-management.”

The project was supported by a Research Starter Grant from the Kentucky Children’s Hospital – Children’s Miracle Network Research Fund and the NIH National Center for Advancing Translational Sciences through grant number UL1TR001998.

Difficult Discussions with Pediatric Patients

These results were surprising, but both Meadows and Raj say that for future work, it could be valuable to examine more in depth which specific psychological trauma exposures are the most important, who may be most vulnerable, and how timing of traumatic experiences may affect self-management. “Our work could serve as a ground for future research to look at more specific questions such as type of trauma exposure, the timing of trauma exposure, and so on,” Raj says.

And those specific questions may be needed sooner than later. The researchers say that they observed during their work that rates of trauma and PTSD in these patients were “alarmingly high” – again, the rates of exposure to traumatic events were seen in approximately two-thirds of the participants, while more than a third of the children had PTSD. “One important factor is that many children with diabetes may experience their diagnosis itself or hospitalizations as potentially traumatizing,” Meadows says.

And while this study was a snapshot of participants at that particular moment in time, alarmingly high rates like these may point to the fact that providers need to start assembling teams of people who know how to carefully broach some upsetting topics for a more multidisciplinary approach.

Avoiding Avoidance

Raj says psychiatric disorders are often underdiagnosed and even less frequently addressed. He says certain psychiatric symptoms, including some symptoms of anxiety, were found to be associated with less frequent blood glucose checking. “Careful screening and management of underlying psychiatric disorders may help in improving diabetes-related outcomes in pediatric patients with type 1 diabetes,” he says. “Use of standardized screening questionnaires such as Child and Adolescent Trauma Screen (CATS) may help identify children with traumatic life experiences and PTSD.”

Meadows says that one of the core factors of PTSD is avoidance – these patients may be hesitant to talk about traumatic experiences. A lot of times, traumatic experiences are related to medical issues, which could throw up another barrier to optimal care, but a barrier that can be broken through. “Providers may not recognize trauma unless they are directly asking about it,” she says. “Asking specifically about stressors and potentially traumatic life experiences may open up important conversations.”

“Emotional factors and experiences play an important role for children and teenagers who are learning to manage type 1 diabetes; psychological trauma exposure is very common, but we are still working to understand more about how it may affect diabetes self-management.” –

Amy Lynn Meadows, MD, MHS, FAAP, FAPA, DFAACAP, associate professor of Psychiatry and Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky

For Meadows and Raj, the study itself was encouraging. Both tell Endocrine News that the participants and their families were enthusiastic and eager to help their team learn more about the factors affecting diabetes control. And this study once again provides additional support for pediatric diabetes management to include a multidisciplinary team of social workers, psychologists, or psychiatrists for routine screening, managing underlying psychiatric conditions, and coordinating care with endocrinologists and other diabetes specialists, Raj says.

“What we see again and again is that we can have the best treatments and technology in the world, but they do not work if patients will not do them,” Meadows and Raj say. “Understanding more about the psychological factors that impact self-management can help us to better support our patients and their families, identify barriers to treatment, and treat underlying psychosocial vulnerabilities. Multidisciplinary teams and expertise enable us to all be more effective at managing all aspects of diabetes care.”

Bagley is the senior editor of Endocrine News. In the February issue, he wrote about advances in pediatric growth hormone deficiency treatment.