Children and adolescents with type 1 diabetes and psychiatric disorders have educational underachievement

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Children and adolescents with both type 1 diabetes (T1D) and psychiatric disorders, compared to children with just T1D, had universal long-term educational underachievement, according to a recent study in Jama Network Open.

With onset during childhood, T1D is one of the most common chronic diseases, and children and adolescents with T1D are at risk of depression, anxiety, neurodevelopmental disorders (NDDs), and other psychiatric disorders.

Prior research shows that children and adolescents with T1D, compared to those without T1D, have a greater risk of psychiatric disorders. However, examination whether having psychiatric disorders is associated with educational outcomes is lacking, authors wrote.

The primary aim of the study was to examine educational outcomes in children and adolescents with T1D both with and without psychiatric disorders, while the secondary aim was to assess whether the associations differ across multiple psychiatric disorders. 

This population-based cohort study included Sweden-born individuals between January 1, 1973, and December 31, 1997. Data was pulled from multiple Swedish registers and follow-up was conducted from birth through December 31, 2013, with data collected from March 1 to June 30, 2022. The initial cohort study included 2,607,319 individuals born in Sweden. Individuals diagnosed with chromosomal abnormalities, organic brain disorders, or intellectual disability were excluded. The final cohort consisted of 2,454,862 individuals (51.3% male).

Exposures included T1D and psychiatric disorders including depression, anxiety disorders, eating disorders, bipolar disorder, psychotic disorder, and substance misuse diagnosed before 16 years.

Educational outcomes were achieving educational milestones and compulsory school performances. All children in Sweden during the study period were required to begin compulsory school at approximately 6 years of age. This schooling generally lasted for 9 years and comprised primary and lower secondary education. By year 9 of compulsory school, students were assessed for upper secondary school eligibility, which lasted for 3 years. After this period, students could apply to university to continue tertiary education, according to study authors. Educational milestones that were examined included completing compulsory school, eligibility for upper secondary school, finishing upper secondary school, starting university, and finishing university. 

To develop the statistical analysis, authors wrote, “for each outcome, we initially modeled T1D and any psychiatric disorder while accounting for their interactions. This approach allowed us to compare individuals with T1D with or without any psychiatric disorder to their healthy peers (ie, without T1D and psychiatric disorder). We then simultaneously modeled T1D and the 3 categories (NDDs, depression or anxiety, and other psychiatric disorders) as independent exposures while accounting for interactions between T1D and the 3 categories. This approach allowed us to compare individuals with T1D with or without each category to their healthy peers while adjusting for the influence of the other categories.”

Of the 2,454,862 individuals in the study, 13,294 (0.5% [53.9% male]) were diagnosed with T1D. The median (IQR [interquartile range]) age at diagnosis was 9.5 (6.0 to 12.5) years. Of these students, 1,012 (7.6%) also had at least 1 psychiatric disorder. Individuals with T1D alone had similar odds of completing compulsory education to healthy peers (without T1D and psychiatric disorders) (OR 1.09; 95% CI, 0.93 to 1.28), but statistically significantly slightly lower odds of achieving postcompulsory milestones (ORs, 0.82 to 0.89).

Authors noted individuals with T1D and any psychiatric disorder had much lower odds of achieving any of the educational milestones including completing compulsory school (OR, 0.17; 95% CI, 0.13 to 0.21), eligibility for upper secondary school (OR, 0.25; 95% CI, 0.21 to 0.30), finishing upper secondary school (OR, 0.19; 95& CI, 0.14 to 0.26), starting university (OR, 0.36; 95% CI, 0.29 to 0.46), or finishing university (OR, 0.30; 95% CI, 0.20 to 0.47). All 3 psychiatric disorder categories ( NDDs, depression or anxiety, and other psychiatric disorders) were associated with lower odds of achieving milestones in individuals with T1D, and those with NDDs had the most profound disadvantages with “considerably lower odds of completing compulsory school (OR, 0.09; 95% CI, 0.06-0.13), being eligible for (OR, 0.19; 95% CI, 0.14-0.25) and finishing (OR, 0.26; 95% CI, 0.20-0.34) upper secondary school, and starting university (OR, 0.26; 95% CI, 0.14-0.47), and only 3 of them has ever finished university,” authors wrote.

Compulsory school performances were reflected by the GPAs (20 points total) of school subjects on graduation. Those with T1D alone had a slightly lowered GPA compared with healthy peers for all subjects (β = −0.13; 95% CI, −0.20 to −0.06) and core (Swedish, English, and mathematics) subjects (β = −0.26; 95% CI, −0.33 to −0.18). Those with T1D and psychiatric disorders had lower GPAs for all subjects (β = −1.73; 95% CI, −2.00 to −1.46) and for core subjects (β = −2.72; 95% CI, −3.02 to −2.42).

Based on the demonstrated results, authors concluded students with T1D and psychiatric disorders had, “universal long-term educational underachievement. These findings highlight the importance of identifying psychiatric disorders in pediatric patients with T1D and the need for targeted educational intervention and support to minimize the education gap between the affected children and their peers.”

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. doi:10.1001/jamanetworkopen.2023.8135