T1D Plus Psychiatric Disorders May Influence Educational Outcomes

Children and adolescents who have both type 1 diabetes (T1D) and psychiatric disorders are more likely to experience long-term educational underachievement than their peers with T1D alone, who may only experience minor difficulties with their educational outcomes.

These study findings were published in JAMA Network Open.

“These findings suggest that target educational supports and adjustments, as well as clinical vigilance, are needed to promote educational outcomes in children and adolescents with T1D and psychiatric disorders,” the authors said.

Their cohort study used data from multiple registries in Sweden and included nearly 2.5 million children born in the country between January 1973 and December 1997. The researchers followed the participants from birth until December 2013, and data analyses were conducted from March 1 to June 30, 2022.

Of 2,454,862 individuals, 13,294 (0.5%) received a T1D diagnosis, with a median (IQR) age at diagnosis of 9.5 (6.0-12.5) years. Of this subgroup, 1012 (7.6%) also had at least 1 psychiatric disorder that was diagnosed before the age of 16, which was a higher percentage than their peers without T1D (3.4%).

The study included a general category of any psychiatric disorder, as well as 3 categories based on prevalence in pediatric patients with T1D and feature symptoms:

• Neurodevelopmental disorders (NDDs)
• Depression or anxiety
• Other psychiatric disorders

Compared with those without T1D, children with T1D were also proportionally more likely to have asthma (6.0% vs 3.9%), other autoimmune disorders (9.7% vs 1.3%), and epilepsy (1.4% vs 0.6%).

Educational outcomes in this study included educational milestone achievement and compulsory school performance. During the study period, all children in Sweden were mandated to begin compulsory school at about 6 years of age, which then spans 9 years and includes primary and lower secondary education. After this, student eligibility for upper secondary school, which spans 3 years, was determined. Thereafter, students could enroll in university to pursue tertiary education.

Compared with children without T1D or a psychiatric disorder, children with T1D alone had slightly lower odds of achieving the examined educational milestones. However, children and adolescents with comorbid T1D and any psychiatric disorder had significantly lower odds of achieving any of the educational milestones assessed in this study. These reduced odds applied to:

• Completing compulsory school (odds ratio [OR], 0.17; 95% CI, 0.13-0.21)
• Being eligible for upper secondary school (OR, 0.25; 95% CI, 0.21-0.30)
• Completing upper secondary school (OR, 0.19; 95% CI, 0.14-0.26)
• Starting university (OR, 0.36; 95% CI, 0.29-0.46)
• Completing university (OR, 0.30; 95% CI, 0.20-0.47)

Additionally, all 3 categories of psychiatric disorders—NDDs, depression or anxiety, and other—were associated with lower odds of achieving educational milestones in individuals with T1D. The most profound disadvantages were observed in those with NDDs, who had considerably lower odds of completing compulsory school (OR, 0.09; 95% CI, 0.06-0.13), being eligible for upper secondary school (OR, 0.19; 95% CI, 0.14-0.25), completing upper secondary school (OR, 0.26; 95% CI, 0.20-0.34), and starting university (OR, 0.26; 95% CI, 0.14-0.47). Only 3 of 361 individuals with T1D and NDDs in the study graduated from university.

Although individuals with depression, anxiety, or other psychiatric disorders had no statistically significant difference in completing compulsory school (ORs, 0.52-0.78), they had statistically significantly lower odds of achieving educational milestones after compulsory school (ORs, 0.19-0.47).

"Overall, the estimated ORs of individuals with T1D and psychiatric disorders were comparable to those with psychiatric disorders alone," the study authors wrote.

Children with comorbid T1D and any psychiatric disorder also had lower grade point averages for compulsory school subjects. The authors said these findings remained similar in sibling comparison analyses, suggesting independence from familial confounding. There were some instances where the associations were weakened, such as for individuals with other psychiatric disorders who were eligible for upper secondary school (OR, 1.08; 95% CI, 0.52-2.28), which could be attributed to low statistical power as indicated by the wide 95% CI.

This study had multiple limitations, including that it did not examine every psychiatric disorder or different psychiatric comorbidities, and the data did not capture recent changes in pediatric diabetes care. Additionally, Sweden provides free pediatric health care and tuition-free education, so these findings may not be directly applicable to other countries with different access to school and health care, which could affect the gaps in educational outcomes in other countries.

In line with current diabetes guidelines, the authors said it is important to closely monitor for psychiatric disorders in children with T1D and diabetes in general. Detecting and addressing these issues early on can help mitigate the negative impact of psychiatric disorders not only on diabetes management but also on academic achievement, which can in turn affect future outcomes.

“Moreover, schools are a unique opportunity to identify mental health needs in pupils with T1D and to provide targeted education adjustments and supports, which help promote school-life balance in pupils with T1D,” the authors added. “Furthermore, joint efforts from researchers, pupils and parents, schools, and policy makers are warranted to better understand the needs of these pupils and ways to improve their school life and academic progression.”

Reference

Liu S, Ludvigsson JF, Lichtenstein P, et al. Educational outcomes in children and adolescents with type 1 diabetes and psychiatric disorders. JAMA Netw Open. 2023;6(4):e238135. Published online April 3, 2023. doi:10.1001/jamanetworkopen.2023.8135