type 1 diabetes ( t1d ) can cause significant stress in the affected children , due to its chronic nature and multipronged management ; involving multiple daily injections , blood glucose monitoring , dietary restrictions , and risk of complications . in developing countries , financial constraints , suboptimal health infrastructure , lack of universal health insurance ,
scarce school health facilities , poor health - seeking behavior in the community , and the social stigma attached to the disease are likely to further aggravate the psychosocial and cognitive profiles of children / adolescents with t1d , as compared to developed nations .
there is , however , a paucity of reports on these aspects from developing countries .
it is imperative to understand the extent of psychological comorbidity in children / adolescents with t1d , because this has a significant impact on the self - management of diabetes , and glycemic control in the patient .
the study was undertaken with the objective of assessing the quality of life ( qol ) , emotional well - being , and behavioral and cognitive profile of indian children and adolescents with t1d ; and to examine the influence of sociodemographic factors , glycemic control , age of onset , and duration of diabetes on these parameters .
we enrolled 49 children / adolescents aged 6 - 18 years with t1d under follow - up at the pediatric endocrinology clinic of our tertiary care institute , for at least 6 months , after obtaining voluntary informed consent from parents and assent from the subjects .
information regarding age of onset , duration of disease , socioeconomic status ( based on modified kuppuswamy scale ) , and mother 's education were recorded .
degree of glycemic control was assessed by last hba1c ( considered normal if american diabetes association ( ada ) cut - offs , i.e. , 8.5% for age < 6 years , 8% for age 6 - 12 years , and 7.5% for age > 12 years ) , and number of episodes of perceived or documented hypoglycemia ( blood glucose < 60 mg / dl or symptomatic ) in past 1 month .
the following instruments were used to assess qol , emotional adjustment , behavioral problems , and cognition in the subjects .
this is a 22-item validated questionnaire to assess possible problems in the following six domains : impact of symptoms related to diabetes , impact of the treatment , impact on activities , parents issues , worry about the future , and perception of one 's own health .
this was administered by the physician to subjects aged 10 - 18 years ( n = 34 )
. each question has five possible responses , ranging from  0 ( never ) to  4 ( all the time ) , and the responses are added up to get the total score for the subscale .
, we considered the adverse impact on qol in a domain to be significant , if the score for that domain was in the upper half of the possible range .
this was administered by the psychologist to subjects aged 10 - 18 years ( n = 34 ) .
it comprises of five positively worded items ; related to positive mood , vitality , and general interests ; which are rated on a 6-point likert scale from  0 ( not present ) to  5 ( constantly present ) .
it has been shown to be a reliable tool to assess emotional well - being over the preceding 2 weeks .
this was administered by the psychologist to parents of children aged 6 - 18 years ( n = 49 ) .
this is a standardized measure of parent - reported behavioral problems , comprising of 120 questions , with responses graded on a likert scale , as 0 - 2 .
the responses are then summated as directed by the instrument to yield scores for nine behavior syndromes .
the summation of the responses of some of the individual syndromes yields scores for internalizing behaviors ( is ) , externalizing behaviors ( es ) , and overall scores for total behavior problems ( ts ) .
internalizing behaviors include behaviors such as anxious / depressed , withdrawn / depressed , and somatic ; and externalizing behaviors include rule - breaking , aggression , and inattention .
the range for each of the scores ts , es , and is is 0 - 100 .
this intelligence quotient ( iq ) scale is the indian adaptation of wechsler intelligence scale for children and provides scores for verbal iq ( viq ) , performance iq ( piq ) , and full scale iq ( fsiq ) .
this was administered by the psychologist to children aged 6 - 16 years ( n = 41 ) .
statistical analysis was carried out using stata 9.0 ( college station , texas , usa ) .
bivariate analysis was carried out using student 's t - test ( for categorical variables ) and spearman 's rank correlation ( for continuous variables ) to assess the strength of association with potential predictors .
this is a 22-item validated questionnaire to assess possible problems in the following six domains : impact of symptoms related to diabetes , impact of the treatment , impact on activities , parents issues , worry about the future , and perception of one 's own health .
this was administered by the physician to subjects aged 10 - 18 years ( n = 34 )
. each question has five possible responses , ranging from  0 ( never ) to  4 ( all the time ) , and the responses are added up to get the total score for the subscale .
, we considered the adverse impact on qol in a domain to be significant , if the score for that domain was in the upper half of the possible range .
this was administered by the psychologist to subjects aged 10 - 18 years ( n = 34 ) .
it comprises of five positively worded items ; related to positive mood , vitality , and general interests ; which are rated on a 6-point likert scale from  0 ( not present ) to  5 ( constantly present ) .
it has been shown to be a reliable tool to assess emotional well - being over the preceding 2 weeks .
this was administered by the psychologist to parents of children aged 6 - 18 years ( n = 49 ) .
this is a standardized measure of parent - reported behavioral problems , comprising of 120 questions , with responses graded on a likert scale , as 0 - 2 .
the responses are then summated as directed by the instrument to yield scores for nine behavior syndromes .
the summation of the responses of some of the individual syndromes yields scores for internalizing behaviors ( is ) , externalizing behaviors ( es ) , and overall scores for total behavior problems ( ts ) .
internalizing behaviors include behaviors such as anxious / depressed , withdrawn / depressed , and somatic ; and externalizing behaviors include rule - breaking , aggression , and inattention .
the range for each of the scores ts , es , and is is 0 - 100 .
this intelligence quotient ( iq ) scale is the indian adaptation of wechsler intelligence scale for children and provides scores for verbal iq ( viq ) , performance iq ( piq ) , and full scale iq ( fsiq ) .
this was administered by the psychologist to children aged 6 - 16 years ( n = 41 ) .
statistical analysis was carried out using stata 9.0 ( college station , texas , usa ) .
bivariate analysis was carried out using student 's t - test ( for categorical variables ) and spearman 's rank correlation ( for continuous variables ) to assess the strength of association with potential predictors .
the clinicodemographic features of the enrolled subjects are summarized in table 1 . the mean age of subjects was 11.7  3.1 years
. forty - three percent of subjects belonged to lower socioeconomic class , and the glycemic control was inadequate in a majority .
the overall results of the qol , who-5 , cbcl , and misic administered to the patients are summarized in table 2 .
nearly a third of the subjects had a significant adverse impact on qol due to their diabetes . amongst the subdomains ,
the maximally reported adverse impact was related to symptoms of diabetes and perception of health , while the minimally reported was the impact on activities . who-5
demographic and clinical characteristics of patients ( n=49 ) results of tests for quality of life , emotional well - being , behavior , and cognition the results of bivariate analysis for the association of various potential predictors with the overall results are presented in table 3 .
early onset of t1d ( < 5 years of age ) was associated with significantly lower adverse impact on qol , and lower score on cbcl , suggestive of fewer behavioral problems . elevated hba1c level
duration of disease was inversely associated with cbcl score , suggesting that behavioral problems decrease as the duration of diabetes increases .
misic score was lower by 10.77 units in children from lower ses compared to children with higher ses .
no significant association of gender , current age , presence of comorbid condition , and frequency of hypoglycemia was observed with the scores for any of the tests employed in the study , and hence their data is not presented in table 3 .
association of potential predictors with outcomes ( qol , who-5 , cbcl and misic ) on bivariate regression analysis the association of the potential predictors with the subdomains of these tests is presented below .
worries ( p = 0.047 ) , lesser negative impact on  activities ( p = 0.023 ) , and better health perception ( p = 0.019 ) .
 worries were fewer ( p = 0.033 ) among children whose mothers were educated beyond high school . there was a trend towards significance for the association between elevated hba1c and ' symptoms of diabetes ( p = 0.092 ) , and  worries ( p = 0.077 )
. a significant inverse correlation was noted between the who and qol score ( r = 0.518 , p = 0.016 ) , indicating that emotionally well - adjusted children perceived a lower adverse impact of the disease on qol .
the duration of diabetes was inversely associated with es ( p = 0.016 ) , indicating that recently diagnosed children are more likely to have externalizing behaviors , and these become less common with increasing duration .
children from lower ses , and those whose mothers educational level was below high school , had more withdrawn / depressed behaviors ( p = 0.051 and 0.075 , respectively ) .
lower ses was associated with lower scores in information , arithmetic , analogies / similarities , general information , awareness , attention , concentration , and immediate memory and recall .
onset of t1d before 5 years of age was associated with significantly lesser  worries (
p = 0.047 ) , lesser negative impact on  activities ( p = 0.023 ) , and better health perception ( p = 0.019 ) . 
worries were fewer ( p = 0.033 ) among children whose mothers were educated beyond high school .
there was a trend towards significance for the association between elevated hba1c and ' symptoms of diabetes ( p = 0.092 ) , and 
a significant inverse correlation was noted between the who and qol score ( r = 0.518 , p = 0.016 ) , indicating that emotionally well - adjusted children perceived a lower adverse impact of the disease on qol .
the duration of diabetes was inversely associated with es ( p = 0.016 ) , indicating that recently diagnosed children are more likely to have externalizing behaviors , and these become less common with increasing duration .
children from lower ses , and those whose mothers educational level was below high school , had more withdrawn / depressed behaviors ( p = 0.051 and 0.075 , respectively ) .
lower ses was associated with lower scores in information , arithmetic , analogies / similarities , general information , awareness , attention , concentration , and immediate memory and recall .
being a life - long condition with significant burden of treatment , in terms of regular injections , monitoring blood sugar , restrictions on diet and lifestyle , planned and emergency hospital visits , and financial impact on the family ; compounded by the effect of fluctuating blood glucose on mood and cognition , t1d has a significant influence on the quality of life , emotional well - being , cognitive profile , and behavior of the affected children .
shorter duration since diagnosis , poor glycemic control , low ses , and female gender have been noted to be associated with greater negative impact on these parameters , in studies reported from developed countries .
the mean dawn qol score in our subjects was 29.3 ( with maximum ( worst ) possible score of 84 ) .
this is comparable to the qol score of 97.5 ( with maximum possible score of 255 , using the diabetes quality of life for youth ( dqoly ) questionnaire ) reported by matziou et al .
. amongst the possible predictors studied , early onset of diabetes ( before age 5 years ) was associated with significantly lesser negative impact on the overall qol score as well as in most of the subdomains . in comparison to children who were diagnosed after 5 years of age ,
those with early onset were more optimistic about their life with diabetes , were less worried about the limitations imposed by diabetes on their current activities and future achievements , and had a more positive perception of their health .
this may be related to the fact that being introduced to a way of life incorporating diabetes management at a tender age , they make fewer comparisons to their more carefree life before the diagnosis of diabetes , and hence adapt better .
in contrast to previous reports ( matziou et al . , 2011 , ingerski et al . , 2010 )
, we did not find an association of poorer glycemic control with either the overall qol score , or the  perception of one 's own health status subdomain .
this is indicative of a less robust understanding of the disease among our subjects , and suggests greater need for education and counseling of patients to help them prioritize their concerns .
the who-5 instrument is highly specific for depression , and a lower score indicates a greater prevalence of / predilection for depression .
the overall mean ( standard deviation ( sd ) ) who-5 score in our study population was 74.6 ( 19.4 ) , which is higher ( indicating better emotional adjustment ) than that reported by de wit et al .
the score was significantly lower among those with elevated hba1c compared to those with normal hba1c ( 71.1 ( 19.4 ) vs 90 ( 7.4 ) , p = 0.004 ) .
similar to other studies , we found that lower who-5 scores correlated well with greater adverse impact on qol . using this simple instrument
well - behaved and  well - adjusted. children with suboptimal disease control should undergo regular psychological review , and counseling . with the cbcl questionnaire , the percentage of borderline clinical and clinical scores , and the mean total scores found in our patients are comparable to those previously reported .
this is of special concern because the parents may not perceive such behaviors as abnormal and seek consultation .
we observed a better level of adjustment and fewer behavioral problems in our patients with onset of t1d before the age of 5 years .
also , the behavioral problems were inversely associated with the duration of disease , suggesting that there is greater adjustment to the diagnosis with time .
we did not find an association of cbcl scores with the degree of glycemic control as measured by the hba1c .
comparing with previous studies among diabetic children / adolescents , while studies by nardi et al . , and akbas et al .
, also did not observe association between cbcl scores and hba1c , ohmann et al .
, reported significantly higher prevalence of somatic complaints and internalizing behaviors in children with suboptimal glycemic control . similarly , whereas some of the previous studies also suggest fewer behavioral problems with increasing duration of disease as in our study .
, nardi et al . , reported higher prevalence of problems in the anxious / depressed , attention and hyperactivity and oppositional defiant scales as duration of disease increased .
we found an association of maternal educational level below high school with greater prevalence of clinical range internalizing behaviors . among the domains of qol also
, lower maternal education was associated with more  worries about the future. the mother is the central caregiver in most families . her lower education level may affect her understanding of the disease and its management , and the ability to cope with psychological stress associated with diagnosis .
this may translate into inadequate emotional support / care for the child , leading to more behavioral problems / stress in the child .
a similar association of lower maternal education with greater stress and more frequent behavior problems in the child was observed in an indian study among caregivers of children with cerebral palsy .
this finding also emphasizes the effect of the family on qol , and emotional adjustment of the diabetic child , and potential of the family unit as a target for psychological therapy and intervention . while we were limited by the lack of controls in our study ,
a full - scale iq of 105.1 ( 7.75 ) among controls in an indian study on children of alcoholic fathers has been reported .
thus , the mean iq in our diabetic subjects is possibly lower than the normal population average .
findings from studies from the west have variably suggested that children with early diabetes onset ( ferguson et al .
, 2005 , hannonen et al . , 2010 , naguib et al . , 2009 ) , poor glycemic control ( ohmann et al . , 2010 , hannonen et al . , 2010 , naguib et al . , 2009 ) , and episodes of severe hypoglycemia ( hannonen et al
however , in our patients , the above factors or the scores on the qol and who-5 questionnaires did not have any significant association with cognitive performance .
lower ses emerged as a consistently strong association with lower full scale iq score , as well as individual scores in specific components .
( usa ) have also reported that ses has a greater effect on academic performance in diabetic children than medical variables .
the implication of this finding is that diabetic children from lower ses are at higher risk of cognitive impairment , and should be prioritized for iq assessment .
we found a significant correlation between scores on the qol and the who questionnaires , and significantly poorer qol in patients with pathological who scores .
the who questionnaire is shorter and quicker to administer , and may be used as the initial screen in set - ups with a crunch of time - people resources , before moving on to administering the qol on a regular basis .
it is important to recognize psychological problems in children with t1d , as these may lead to poor motivation and inability to coordinate the multipronged therapeutic plan .
the consequent poor metabolic control may further impair the psychological status , thus propitiating a vicious cycle , with progressive worsening of clinical and psychological situation , and even lesser impetus to control disease .
psychological and behavioral interventions have been shown to have a beneficial effect on children and adolescents with diabetes evidenced in terms of better compliance to therapy , glycemic control as well as better relationships with family and peers and better coping capability .
however , such interventions require time - people resources that are often missing in the setting of a developing nation .
we hope that in resource - limited scenarios , where t1d is typically managed by a single physician , without the support of psychologists / social workers or diabetes counselors , our results will help in prioritizing children for behavioral monitoring and psychological evaluation .
based on our findings , children with recent diagnosis , older age at onset , lower maternal educational level , elevated hba1c , or belonging to lower ses are recommended for more frequent / detailed behavioral and cognitive evaluation .
 background and aims : the psychological stress associated with type 1 diabetes ( t1d ) may be higher in children from developing world due to limited health resources . 
 the aims of the study were to assess the quality of life ( qol ) , emotional well - being , behavioral , and cognitive profile of children / adolescents with t1d diagnosed at least 6 months prior.materials and methods : forty - nine children with t1d , aged 618 years were assessed using dawn youth qol questionnaire , who-5 well - being index , child behavior checklist ( cbcl ) , and malin 's intelligence scale for indian children ( misic ) . 
 the association of the scores was studied with age , gender , socioeconomic status ( ses ) , frequency of hypoglycemia , hba1c , and age of onset and duration of t1d.results:the mean ( standard deviation ( sd ) ) for dawn qol , who-5 , cbcl , and misic scores was 24.7 ( 16.7 ) , 74.6 ( 19.4 ) , 52.6 ( 8.8 ) , and 96.0 ( 11.2 ) , respectively . 
 the significant associations noted were : elevated hba1c with poorer emotional well - being ; higher negative impact on  symptoms of disease and  future prospects sub - areas of qol ; shorter duration of disease with more behavioral issues ; lower maternal education with more  withdrawn / depressed behaviors and  worry about future prospects ; and lower ses with lower misic scores . 
 earlier onset ( age < 5 years ) was associated with fewer behavioral problems and less negative impact on qol.conclusion:children with recent diagnosis , older age at onset , lower maternal educational level , elevated hba1c , or belonging to lower ses were identified to have higher prevalence of various psychological and cognitive problems . in resource - limited settings 
 , these children should be prioritized for behavioral and cognitive evaluation . 
I
M
Quality of life questionnaire (published by the DAWN youth project)
WHO-5 well-being Index (1998 version)
Child behavior check list (CBCL/6-18)
Malin's Intelligence Scale for Indian Children (MISIC)
R
QoL
CBCL
MISIC
D