Emotional and Behavioral Problems among Diabetic Children
Authors: Al‐Khurinej Anwar 
Published: March 2010

AbstractPurposeDiabetic children experience many psychological disorders as well as behavioral problems as suggested by previous research. This study has a three‐fold goal: 1) to determine the prevalence of emotional and behavioral problems among diabetic children; 2) to examine the relationship between emotional‐behavioral problems and demographic variables; and 3) to determine the best predictors of emotional‐behavioral problems among diabetic children. Methods: To carry out this study a convenient sample consisting of 302 subjects was drawn from different pediatric clinics in Kuwait. In order to accomplish the goals of the study, the Arabic version of the Strengths and Difficulties Questionnaire (SDQ) was utilized. Results: The results suggest that although diabetic children experience some emotional‐behavioral problem, they have fine pro‐social behaviors and positive characteristics.Literature review:Diabetic children are at great risk of being inflicted with psychological dysfunction. There is a body of research revealing that diabetic children show high levels of psychiatric disorders and behavioral problems. For example, Dantzer, Swendsen, Maurice‐Tison, & Salamon (2003) report that depression is the most common psychiatric disturbance among diabetic children, following anxiety. A large body of research revealed that children with diabetes, like children with chronic illnesses, show considerable depressive symptomatology and some behavior problems, as well (Close, Davies, Price, & Goodyer, 1986; Worchel, Rae, Olson, & Crowley, 1992; Yousef, 1993). These psychological problems have a major effect on BG control—that is diabetic children with emotional problems have more difficulties in disease management than children with better psychological adjustment (Close et al, 1986; Chisholm, 2003). As for adolescents, Dantzer (2003) states that youths with a chronic illness such as diabetes are generally at high risk of depression, anxiety, and low self‐esteem. These psychosocial problems have significant impact on the process of physical, psychological, and social maturation of adolescents and their transition into adulthood (Dantzer et al, 2003). Also, Kovacs, Goldston, Obrosky, & Bonar (1997) state that their longitudinal study on 92 youths shows that after 10 years, 47.6% of the sample experience some kind of psychiatric disorder, such as major depression and generalized anxiety, with the highest rate for major depression. Concomitantly, Schiffrin (2001) notes that most psychiatric problems, such as depression and anxiety, and somatic complaints are temporary and usually resolve within six to nine months after diagnosis, however, depressive symptoms increase with duration of illness in some patients. With respect to gender, Lavigne, Traisman, Marr, & Chasnoff, (1982) note that in terms of psychological adjustment, boys had higher obsessive compulsive symptoms, hyperactivity, and aggression than non‐diabetics and that behavioral symptoms tended to increase for male diabetic patients with length of illness.In terms of intelligence, a review of the literature shows that children with diabetes often score lower than their counterparts in IQ tests (Rovet, Ehrlich, Czuchta, & Akler, 1993). In fact, children who develop diabetes early in their lives are more likely to score significantly below children with later onset and other non‐diabetic children. Moreover, the review shows that diabetic children with a duration of at least seven years usually have low IQs.In their study on 91 adolescents, Goldstone et al (1997) found that the rate of suicidal thoughts was higher than expected among them. However, the rate of suicidal attempts was equivalent to general population. They also found that suicidal thoughts were strongly associated with serious noncompliance with medical regimen.As for school performance, a study by McCarthy, Lindgren, Mengeling, Tsalikian, and Engvall (2002) shows that children with low diabetic control have lower school performance than others. They also note that diabetic children have more school absences and more behavioral problems than their siblings. Also, children with diabetes usually have poorer performance than other students especially in reading and spelling and in arithmetic (Rovet, Ehrlich, Czuchta, & Akler, 1993). Moreover, diabetic children with early‐onset are more likely to be in special education classes than other diabetic and non‐diabetic children (Rovet et al., 1993).In her study, Chisholm (2003) states that children with diabetes usually have great concerns about their illness and its effect on peer relations. Children with diabetes “find management of the regimen and disease‐related problems in the presence of non‐diabetic peers embarrassing” (Chisholm, 2003, p.347). Also, they are more likely to feel different because of their condition (Chisholm, 2003) and have the feeling of inadequacy which leads to withdrawal (Yousef, 1993).The purpose of this study is to determine the prevalence of emotional and behavioral problems among diabetic children and the relationship between those problems and the demographic variables. Therefore, it was hypothesized that 1) children with diabetes would experience a number of psychiatric disorders; 2) children with diabetes would show a number of behavioral problems; and 3) there is relationship between emotional‐behavioral problems and demographic variables.Method:A total of 302 children, age 7‐ 13, with diabetes and their parents were recruited from different diabetes centers in Kuwait. Parents were asked to participate in this study by responding to a questionnaire concerning any emotional and/or behavioral problems their children might have. Descriptive statistics were conducted to describe the sample and find the means, standard deviations, and range of scores. Also, univariate, bivariate and multivariate analysis were employed to find relationships among variables.Instrument:The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioral screening questionnaire that can be completed in 5 minutes by the parents or teachers of children aged 4 to 16; there is a self‐report version for 11–16 year olds.SDQ is a three‐point scale; Not True, Somewhat True, and Certainly True. It asks about 25 attributes, some positive and others negative. These 25 items comprise 5 subscales:

Emotional symptoms (5 items such as: worried, unhappy child, easily scared)
Conduct problems (5 items such as: fights with others, lies and cheats, steals from home or school)
Hyperactivity/inattention (5 items such as: moves his body, easily distracted, cannot stay still for long)
Peer relationship problems (5 items such as: loneliness, liked by other children, has at least one good friend)
Pro‐social behavior (5 items such as: considerate of other people's feelings, helpful, kind to younger children).

A total difficulty score is calculated by summing the first four subscales and exclude the pro‐social behavior subscale. Usually, the scores range from 0–40. Scores are classified in three categories: normal (0–13), borderline (14–16), and abnormal (17–40). For the prosocial behavior subscale, the scores can be interpreted according to: normal (6–10), borderline (5), and abnormal (0–4).Validity and reliability of the scale:In one study, the Strengths and Difficulties Questionnaire (SDQ), was administered, along with Rutter questionnaires, to parents and teachers of 403 children drawn from dental and psychiatric clinics (Goodman, 1997). It was found that scores derived from the SDQ and Rutter questionnaires were highly correlated; parent‐teacher correlations for the two sets of measures were comparable or favored the SDQ. Also, the two sets of measures did not differ in their ability to discriminate between psychiatric and dental clinic attendees. In another study by Goodman & Scott (1999), scores from the SDQ and CBCL were highly correlated and equally able to discriminate psychiatric from dental cases. As judged against a semi‐structured interview, the SDQ was significantly better than the CBCL at detecting inattention and hyperactivity, and at least as good at detecting internalising and externalising problems.As for reliability, Goodman (2001) conducted a study on a nationwide epidemiological sample of 10,438 British 5–15 year olds. It was found that reliability was generally satisfactory, whether judged by internal consistency (mean Cronbach's alpha: 0.73), cross‐informant correlation (mean: 0.34), or retest stability after 4–6 months (mean: 0.62).In another study, Muris, Meesters, & Berg (2003) conducted a study on a large sample of normal Dutch children and adolescents (N = 562) and their parents who completed the SDQ along with a number of other psychopathology measures. Factor analysis of the SDQ yielded five factors that were in keeping with the hypothesized subscales of hyperactivity‐inattention, emotional symptoms, peer problems, conduct problems, and pro‐social behavior. Moreover, internal consistency, test‐retest stability, and parent‐youth agreement of the various SDQ scales were acceptable.Using a large community sample (n=1359) of young Australian children (4–9 years), Hawes & Dadds (2004) assessed the internal consistency, stability and external validity of the parent‐report SDQ. Their study showed moderate to strong internal reliability across all SDQ subscales. Support was also found for the original five‐factor structure of the measure.In this study, the Arabic version of the SDQ was utilized. A validation study by Almaqrami and Shuwail (2004) suggest that the Arabic version of the SRQ of SDQ is valid in Yemen; and it can be a useful tool for investigating childhood behavioral and emotional disorders at clinical settings. Also, a reliability test of the Arabic version of the SDQ was conducted for this study and showed a Chronbach's alpha of 0.72.In conclusion, the reliability and validity of the SDQ make it a useful brief measure of the adjustment and psychopathology of children and youth.Demographic information included: Nationality, Respondent gender, Child gender, Respondent age, Child age, Respondent education, Child education, family income, years of having diabetes, Does any of parents have diabetes?, Number of siblings who have diabetes, Number of times the child entered the hospital, Hemoglobin, and type of diabetes.