Discussion
In this study, parental stress levels assessed using the PSI-SF questionnaire were low. Existing literature presents conflicting evidence regarding the relationship between parental stress and metabolic control in children and adolescents. Ferrito et al reported poor metabolic control as a significant source of parental stress,24 whereas another study reached the opposite conclusion.25 For the overall data of our study, no significant correlation was found between metabolic control in children and parental stress. However, despite the limited sample size (n=9), our findings suggest that parents of children aged <7 years who completed the PSI-SF questionnaire experienced higher stress levels than did parents of older children with T1D, and higher parental stress levels correlated with lower HbA1c and higher TIR in young children. This finding supports the results of a previous meta-analysis reporting that for younger children (aged 0–11 years), parenting stress was either unrelated or negatively associated with HbA1c levels.26 This may be because parents of older children often share responsibilities with their child, whereas parents of younger children bear full responsibility for managing their child’s T1D. Another explanation for the higher stress levels observed among parents of young children with T1D might be the fear of hypoglycemia, given that young children are at increased risk for hypoglycemic events.27 28 Also, according to ISPAD 2022 guidelines, younger age and low HbA1c were earlier indeed risk factors for severe hypoglycemia, but low HbA1c is no longer a strong predictor of severe hypoglycemia in pediatric T1D cohorts on contemporary therapy.28 Unfortunately, our data collection did not include information on time below range values, leaving the underlying causes of elevated stress levels among parents of young children partly unresolved.
Our study offers additional insights into paternal stress, with fathers reporting slightly higher stress levels than mothers. A recent meta-analysis found that over half of children with T1D had a parent showing signs of depression. The authors emphasized the need for further research, particularly regarding fathers for whom data were limited.10 Although our study did not specifically aim to investigate parental depression, stress is a well-established risk factor for depression.29
Living in a nuclear family appears to be associated with better glycemic control in children.5 30 In nuclear families, diabetes-related supervision by parents may be shared more equitably, and caregivers tend to report a better quality of life.30 In our study, the prevalence of children living in a nuclear family aligns with that of the general Finnish population (76.5%) in 2020.31 This finding may partially explain the moderate levels of perceived stress reported by the parents.
A higher TIR was positively related to children’s well-being, as measured using the WHO-5 questionnaire. This result aligns with previous research indicating that better glycemic control, as measured by HbA1c, can enhance the overall quality of life.32 33 It is possible that better mental health affects the child’s motivation for diabetes care and, thus, affects glycemic control. Although our study did not confirm this relationship when using HbA1c levels, TIR correlates better with glycemic variability than does HbA1c,34 suggesting that stable glucose levels are related to overall well-being.
The mean WHO-5 score of 70 in our study population was higher than that reported in both a previous diabetes study and the general child and adolescent population in Finland.23 35 However, 7.8% of the children had WHO-5 scores indicating depression. All of them were aged 10 years or older. The percentage is slightly lower than the international data on depression among children with T1D. Hood et al36 reported that the prevalence of depressive symptoms in children with T1D aged 10–18 years was 15.2%, with a higher prevalence observed among females. In healthy children under 10 years of age, the prevalence of depression was estimated to be 1.6%–7.1% depending on the severity of depression.37 Overall, in our study, T1D did not negatively affect the general well-being of the patients. However, the WHO-5 is a measure of well-being rather than a diagnostic tool for depression23; thus, the results should be interpreted with caution.
Children’s engagement in hobbies and higher parental education were related to better well-being in the WHO-5 questionnaire, consistent with findings from the BELLA (German: BEfragung zum seeLischen Wohlbefinden und Verhalten, i.e. Survey on Mental Health and Well-Being) study,38 which linked external social support and parental socioeconomic status to improved mental health in children. These results underscore the role of parental resources in supporting diabetes care and well-being, while hobbies may provide stress relief, social interactions, and self-esteem development.
Conversely, older age, due to puberty, increased responsibilities and self-management demands, as well as neuropsychiatric or neurological disorders and special school arrangements, was related to poorer well-being. Children with these conditions may face additional challenges in the management of T1D. Mental health also appears to influence treatment outcomes, as psychiatric comorbidities in pediatric T1D are linked to poor metabolic control.39
In this study, higher parental stress, measured by the PSI-TS score, was strongly related to poorer well-being in children. One possible explanation is that higher parental stress may also lead to increased risk of diabetes-related conflicts with their children, which in turn could negatively affect the children’s well-being. This relationship highlights the potential impact of family dynamics and parental mental health on children’s well-being, as suggested by the BELLA study group.38 Additionally, parental unemployment had a negative impact on children’s well-being in our study, indicating the influence of socioeconomic instability on children’s well-being as demonstrated previously.38
In the WHO-5 analyses, IPT was related to a near-statistically significant reduction in children’s well-being scores. IPT was also related to increased parental stress levels compared with IIT. Previous literature offers mixed findings regarding IPT and parental stress.40–42 However, recent articles suggest that the use of modern hybrid closed-loop insulin pumps is related to improved well-being and lower parental stress in families of children with T1D.33 43 During the data collection for our study, hybrid closed-loop pumps were yet to be used in our clinic. As the use of hybrid closed-loop pumps is rapidly increasing, it may positively affect the well-being of patients and their families.
This study had some limitations. Neither the PSI-SF nor the WHO-5 questionnaires are diabetes-specific instruments. However, they are easy to use, validated, widely used in diabetes research, and have been translated into Finnish. When examining the PSI-SF results, it must be noted that, based on the dropout analysis, information was more likely to be missing from the parents of children with poorer glycemic control and older age, which may bias the results. Additionally, due to the small sample size of parents with children aged under 7 years (n=9) in the PSI-TS analyses, these results are approximate and should be interpreted with caution. Finally, as our study relied on voluntary participation and had a relatively low participation rate (60%), it is possible that families facing more significant challenges chose not to participate, which could introduce bias in the results. The low participation rate may be attributable to the sensitive nature of the questions included in the questionnaire. The reasons for declining participation in the study were not asked or investigated, and glycemic control data for individuals who refused to participate were not collected. However, the participating cohort was broadly representative of the clinic’s entire patient population with respect to glycemic control. The Md HbA1c in the study group was approximately the same as the mean HbA1c of all patients treated at our clinic prior to the study period in April 2020 (HbA1c 59.4 mmol/mol). Although glycemic control among children from non-participating families did not markedly differ from the clinic’s overall average, the possibility remains that, for example, some familial psychosocial factors affected participation and may have introduced bias into the results. In the future, as the use of hybrid closed-loop insulin pumps becomes more widespread, it would be valuable to investigate their potential effects on parental stress levels and child well-being within the Finnish population. Some previous studies have not demonstrated statistically significant differences in quality of life between families using hybrid closed-loop systems and those using sensor-augmented pumps.44 However, de Beaufort et al reported significant improvements in parental quality of life and reduced fear of hypoglycemia among parents of very young children using hybrid closed-loop systems.45 Furthermore, given the increasing number of immigrants with T1D in Finland, future research should also explore the well-being of these families. To gain a more comprehensive understanding of the quality of life in families of children with T1D, incorporating annual assessments into routine follow-ups for patients and their parents would be beneficial.
In conclusion, although the average glycemic control in our study population was suboptimal, the children’s well-being was good, and parents’ stress levels were low. In particular, more stable glycemic control, as measured by TIR, appears to be related to the well-being of children and adolescents with T1D. Our findings highlight the important roles of family resources and dynamics, socioeconomic stability, and well-being in managing pediatric diabetes. Regular assessments, as an integral part of follow-up visits, are essential to identify patients and their parents whose well-being may be compromised.
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