key: cord-0755172-act6pcnq
authors: Wang, Christine H.; Hilliard, Marisa E.; Carreon, Samantha A.; Jones, Jasmine; Rooney, KellyAnn; Barber, John R.; Tully, Carrie; Monaghan, Maureen; Streisand, Randi
title: Predictors of mood, diabetes‐specific and COVID‐19‐specific experiences among parents of early school‐age children with type 1 diabetes during initial months of the COVID‐19 pandemic
date: 2021-08-30
journal: Pediatr Diabetes
DOI: 10.1111/pedi.13255
sha: 0391a11adf6b051d5815243d5bdf151c1a64866b
doc_id: 755172
cord_uid: act6pcnq

OBJECTIVE: The current study explored pre‐pandemic sociodemographics, medical characteristics, social/family support, and mood symptoms, and current COVID‐19 experiences as predictors of mood, positive/negative diabetes‐specific experiences, and COVID‐19‐specific distress among parents of children with type 1 diabetes during the COVID‐19 pandemic. We hypothesized that parents from marginalized backgrounds, youth with higher pre‐pandemic A1c and no CGM use, parents with lower pre‐pandemic social/family support and more pre‐pandemic mood/anxiety symptoms, and those with more negative COVID‐19 experiences would have more depressive symptoms, fewer positive and more negative diabetes‐specific experiences, and more COVID‐19‐specific distress during the initial months of the pandemic. RESEARCH DESIGN AND METHODS: Participants were parents of early school‐age children with type 1 diabetes (n = 100; 65% non‐Hispanic, white, 92% mothers, 75% married; M (child age) = 6.74 ± 1.59 years) who had completed a behavioral intervention trial ≥6 months ago and were re‐contacted in June/July 2020 to report on their COVID‐19 pandemic experiences and parent psychosocial outcomes. Pre‐pandemic parent mood/anxiety symptoms, family/social support, and children's medical characteristics (CGM use; M (A1C) = 8.17% ± 1.40%) were assessed M = 1.45 ± 0.59 years prior. RESULTS: More pre‐pandemic social support predicted fewer depressive symptoms, more positive diabetes‐specific experiences, and less COVID‐19‐specific distress during the pandemic. More pre‐pandemic depressive symptoms predicted more depressive symptoms during the pandemic. More life disruptions due to the pandemic were associated with more negative diabetes‐specific experiences and more COVID‐19‐specific distress. Parents of color had more negative diabetes‐specific experiences. CONCLUSIONS: Social support may be particularly important to assess and address through intervention. Pediatric diabetes care providers should monitor parent experiences in relation to children's diabetes management. ClinicalTrials.gov identifier: NCT02527525.

Type 1 diabetes management in early-school age children is particularly challenging due to developmental factors, such as unpredictable diet and physical activity, behavioral challenges, frequent illness, glycemic variability, high insulin sensitivity, and a potentially shortened honeymoon period. 1, 2 Parents bear the burden of diabetes management, as early school-age children are often unable to sense glucose variations or reliably conduct diabetes self-management activities, resulting in more parenting stress. 1, 3 Relatedly, managing diabetes in early school-age children may be even more demanding on parents during the global COVID-19 pandemic, given additional stressors including balancing work and childcare/school, concerns about contracting COVID-19, and risk of financial instability. 4 Emerging research has identified parental stress as one of the most commonly endorsed psychological problems during the COVID-19 pandemic. 4, 5, 6 Regarding diabetes-specific experiences, a study of 34 families in Greece found that children with type 1 diabetes on insulin pumps and continuous glucose monitors (CGM) experienced increased glycemic variability and behavioral changes related to mealtime routines/ schedules during pandemic lockdowns; however, no differences were found in blood glucose (BG) time in range between the COVID-19-related lockdown and pre-pandemic levels. 7 On the other hand, a study of 22 families from Italy showed that parents were more involved in daily diabetes management in early school-age children due to the "stay at home" order, and more involvement was associated with more BG time in range based on CGM data. 8 This early research on diabetes-specific experiences of parents of youth with diabetes during the pandemic is illuminating; yet it is in its infancy, has been limited by small sample sizes, and has minimal focus on the unique psychosocial issues related to parenting early school-age children with type 1 diabetes.

Different characteristics of parents of youth with type 1 diabetes may also be associated with varying psychosocial outcomes during the COVID-19 pandemic. Pre-existing anxiety and depression have been identified as risk factors for greater psychological distress in adults, broadly, and parents, specifically. 9,10 Social support is a wellknown buffer against stress, and recent data also show that social support protects against adverse psychological outcomes during the COVID-19 pandemic in parents. 11 Sociodemographic factors may also be important. For example, initial research has reported that non-Hispanic white individuals, women, and single individuals have reported more distress during the COVID-19 pandemic, whereas older individuals and those with higher income have not experienced more distress. 12 Parents from communities of color are also more likely to experience social and economic inequities, unemployment due to the pandemic, and exposure to the virus, 10, 13 which have all been linked to more distress. Considering the growing body of literature related to predictors of psychosocial functioning during the COVID-19 pandemic among adults generally and parents specifically, similar patterns may apply for parents of children with type 1 diabetes, yet their experiences during the COVID-19 pandemic remain unexplored in the current literature.

To fill this gap, the current study sought to prospectively examine pre-pandemic sociodemographics/medical factors, pre-pandemic parent mood/anxiety and social/family support, and current COVID-19 experiences as predictors of parent mood, diabetes-specific and COVID-19-specific experiences among parents of early school-age children with type 1 diabetes during the initial months of the COVID-19 pandemic.

We hypothesized that parents from marginalized backgrounds, youth with higher pre-pandemic A1c and no CGM use, parents with more pre-pandemic anxiety and depressive symptoms and lower social/family support, and those experiencing more significant impacts of the pandemic (e.g., increased family/school disruption, COVID-19 exposure, illness or death in the family, stricter quarantine) would experience (1) more depressive symptoms, (2) more negative diabetes-specific experiences, (3) fewer positive diabetes-specific experiences, and (4) more COVID-19-specific distress during the initial months of the COVID-19 pandemic. We refer to these four outcomes collectively as parent psychosocial outcomes.

Between 2015 and 2019, a cohort of 157 parents of children who were initially ages 1-6 diagnosed with type 1 diabetes for ≤8 weeks enrolled in a two-site randomized clinical trial, where they were randomly assigned to either a stepped care behavioral intervention (n = 115) or usual care (n = 42). Original study inclusion/exclusion criteria and study procedures, including intervention specifics, are described elsewhere. 14, 15 As part of the original trial, all participants completed assessments throughout the trial, including a "final assessment" at 15-month post-randomization.

During the initial months of the COVID-19 pandemic (June and July, 2020), we re-contacted this original cohort for further data collection to examine their functioning during the pandemic. Participants were eligible for this additional follow up if they had completed their "final assessment" for the original trial ≥6 months prior. The Institutional Review Board at two pediatric academic medical centers in the mid-Atlantic and Southwest regions of the United States gave approval to email eligible participants from the original cohort to complete this additional survey without requiring additional documentation of informed consent. Text/email reminders were sent to those who did not reply within 2 weeks. Participants received $50 in appreciation of their time.

In total, 121 participants from the original cohort were eligible to complete the current COVID-19 survey (collected in June/July 2020), and 100 completed it (83% response rate). The "pre-pandemic" timepoint in the current study represents data collected from the "final assessment" of the original trial, which occurred about 1.45 ± 59 years prior (range 0.52-2.61 years; November 2017 to December 2019) (see Figure 1 for full study timeline).

The current sample of 100 participants was 65% non-Hispanic, white, 92% mothers, and 75% married; M child age = 6.74 (SD = 1.59; range 3-10 years).

As part of the original trial, parents self-reported on sociodemographics at study entry, such as parent race/ethnicity, marital status, education, family income, child age/sex, and insurance type (Table 1 and Figure 1 ).

A1C values were collected at the pre-pandemic timepoint as part of routine diabetes care and obtained from medical charts (M A1c = 8.17% ± 1.40%). CGM use at the pre-pandemic timepoint was based on parent report to a one-item, yes/no question, which was corroborated by medical record review and whether the study team had collected CGM data as part of the original trial.

Pre-pandemic depressive symptoms were assessed using the 20-item Center for Epidemiological Studies-Depression Scale (CES-D ≥ 16 = elevated). 16 Pre-pandemic anxiety symptoms were assessed using the

Anxiety-Short Form (PROMIS-A). 17 Reliability was adequate for both Existing COVID-19 psychosocial measures were also reviewed, and biostatisticians were consulted regarding item measurement. For each item, participants were prompted to report on their experiences "Since the COVID-19 pandemic, I…" (see relevant PP-T1D items in Appendix A).

Based on parent responses to the PP-T1D survey regarding COVID-19 experiences, we generated the following domains: "Life disruptions due to COVID-19 pandemic" was defined as the total number of disruptions reported (range 0-6), including change in school, loss of job/hours, loss of child care, change in health insurance, moving, and other changes ( Table 2) . "COVID-19 exposure (immediate family)" and "COVID-19 exposure (non-immediate family)" were defined as whether immediate or non-immediate family members, respectively, had experienced any "COVID-19 severity" was defined as whether any family members (immediate or non-immediate) experienced severe outcomes due to contracting COVID-19, such as treatments, hospitalizations or death (as opposed to only symptoms/diagnoses). "Strict COVID-19 social distancing" describes whether parents reported strictly adhering to selfquarantining (Appendix A).

In June/July 2020, parents again self-reported on their current depressive symptoms using the CES-D. They also completed items on the PP-T1D about three domains of experiences during the initial months of the COVID-19 pandemic: COVID-19-specific distress and positive and negative diabetes-specific experiences during the COVID-19 pandemic.

T A B L E 1 Descriptive data on sociodemographics, pre-pandemic medical characteristics, and psychosocial functioning "COVID-19-specific distress" was the total score of 12 items measuring parents' own levels of anxiety, stress, depressive symptoms, eating, sleep, and activity specifically during the COVID-19 pandemic (e.g., "have been more anxious than usual"; α = 0.84). "Positive diabetes-specific experiences during the COVID-19 pandemic"

included parent ratings of three items: "found it easier to manage my child's diabetes," "more time to monitor/manage my child's diabetes,"

and "more time to make/eat healthy meals" (α = 0.79). "Negative diabetes-specific experiences during COVID-19 pandemic" included parent ratings of four items: "struggled to properly manage my child's diabetes," "worried about having adequate access to my child's T1D supplies," "noticed more fluctuations/variability in my child's blood glucose levels," and "less access to my child's diabetes team"

(α = 0.68). The latter two domains are referred to as "positive diabetes-specific experiences" and "negative diabetes-specific experiences," respectively. Both were calculated by summing parents'

perceptions of positive (three items) and negative (four items) aspects of their child's diabetes management during the COVID-19 pandemic, respectively. For the PP-T1D domains, higher scores represent more positive experiences, more negative experiences, and more COVID-19-specific distress (see Table 2 and Appendix A for additional information). Regarding COVID-19 experiences, 83.84% reported at least one COVID-19 disruption, with change in school being the most common (48.48%). Moreover, 57.57% reported adhering to "strict" social distancing guidelines, and the majority had no COVID-19 exposure during the initial months of the pandemic (see Table 2 ).

Rates of elevated CES-D scores were similar pre-pandemic (24.30%) and during the COVID-19 pandemic (22.20%), and 9.10% of the whole sample were elevated at both points (see Tables 1 and 2 ).

Results of all Pearson's and point-biserial correlations among predictors and parent psychosocial outcome variables are presented in Table 3 .

Parents of color experienced significantly more negative diabetesspecific experiences and marginally more COVID-19-specific distress than non-Hispanic, white parents. Parents with college education experienced significantly more COVID-19-specific distress than those without college education. Participants from the southwest site experienced marginally fewer depressive symptoms and fewer positive diabetesspecific experiences than thoe from the mid-Atlantic site. Parents whose children used CGM experienced marginally more parent depressive symptoms and significantly more COVID-19-specific distress.

More pre-pandemic depressive symptoms were significantly correlated with more current depressive symptoms and marginally correlated with fewer positive diabetes-specific experiences and more COVID-19-specific distress. Both lower pre-pandemic social support and more pre-pandemic anxiety were significantly correlated with more depressive symptoms, fewer positive diabetes-specific experiences, and more COVID-19-specific distress. More pre-pandemic family support was significantly correlated with more positive diabetes-specific experiences.

More life disruptions due to the COVID-19 pandemic and strict social distancing practices were each significantly correlated with more negative diabetes-specific experiences and more COVID-19-specific distress. COVID-19 exposure in non-immediate family members was significantly correlated with fewer current depressive symptoms.

See Table 4 for results of multiple regression analyses. For the model predicting depressive symptoms during the pandemic, fewer pre-pandemic depressive symptoms and more pre-pandemic social support predicted fewer depressive symptoms during the pandemic. For the model predicting positive diabetes-specific experiences during the pandemic, more social support and being from the mid-Atlantic (vs. southwest) site predicted more positive diabetes-specific experiences.

For the model predicting negative diabetes-specific experiences during the pandemic, more COVID-19 life disruptions and being a parent of color (compared to a parent of non-Hispanic, white background) predicted more negative diabetes-specific experiences. For the model predicting COVID-19-specific distress, more pre-pandemic social support and fewer life disruptions due to the COVID-19 pandemic were associated with less COVID-19-specific distress.

This is one of the first prospective studies to examine predictors of parent psychosocial outcomes among parents of early school-age children with type 1 diabetes in the initial months of the COVID-19 pandemic. Results support emerging data showing that social support buffers against psychological distress specifically during the COVID-19 pandemic, 20 which adds to the well-documented stress-buffering effects of social support. 21 Recently, social support has also been proposed as a salient predictor of psychological thriving, defined as growth (as opposed to just the absence of maladaptive outcomes) despite adversity. 21 Though improved health outcomes, such as increased BG time in range, have been reported during the COVID-19 pandemic, 7 our study is the first to report positive diabetes-specific psychosocial experiences during the COVID-19 pandemic. Positive diabetes experiences were uniquely predicted by more pre-pandemic social support, even when controlling for pre-pandemic anxiety and depressive symptoms, pointing to a likely source of resilience for parents.

What might have accounted for these patterns? During turbulent times, social supports provide functions such as safety, protection, and relief; clarification of values/strengths; and reframing adversity. 21 Similarly, during neutral times, social supports provide different functions like growth opportunities, positive appraisals, life engagement.

These functions lead to positive emotions/coping, positive appraisals of the event, as well as improvements at the biological (e.g., less brain activation in threat areas) and health behaviors (e.g., sleep, diet) level, which all support thriving . 21 Thus, pre-pandemic social supports that helped parents thrive pre-pandemic may have continued to help them manage the turbulence and stressors of the pandemic. Given that diabetes-related challenges are common even pre-pandemic, further research into the mechanisms specific to the type 1 diabetes population are needed.

Although social support predicted positive diabetes-specific experiences, it was unrelated to negative diabetes-specific experiences, even in bivariate analyses. Our definition of negative diabetes-specific experiences emphasized challenges with access to diabetes supplies/ medical team, given that this was a major concern during the initial 26 other studies found the opposite. 27 Thus, identifying sociodemographic correlates of mental health outcomes during the COVID-19 pandemic is complex, and perhaps requires more data variability in order to detect effects. Regarding medical characteristics, we found bivariate correlations between CGM use and more parent depressive symptoms and more COVID-19-specific distress (but associations were attenuated in multivariate analyses). Given that COVID-19 stay-at-home-orders are associated with limited physical activity and increased rates of unhealthy eating patterns, 28 it is possible that ongoing CGM feedback about BG levels may increase parent stress.

Further, the benefits of CGM use (i.e., remote monitoring) for parent psychosocial outcomes may also be reduced while adhering to stay at home orders. 29 Overall, the current study had several strengths. It included prospective data of pre-pandemic sociodemographics/medical information and parent social/family support and depression/anxiety; a more diverse sample than is typical for a type 1 diabetes sample; data collection that occurred 3-4 months into the COVID-19 pandemic; and examination of multiple parent psychosocial outcomes.

However, the study is not without limitations, including the use of the newly developed PP-T1D measure, which has not been validated and does not have established clinical cut-offs. We developed this measure based on established literature in diabetes and current research about experiences of people during the early months of the pandemic. 22 The negative diabetes-specific experiences domain had a focus on difficulty with access to supplies/medical team to reflect the concern of families during the initial months of the COVID-19 pandemic 22 ; however, negative diabetes-specific experiences likely changed as the pandemic progressed, so these items may not be as relevant later in the pandemic. As the original trial enrolled the "primary caregiver" of the child, and most primary caregivers of young children and/or children with type 1 diabetes are women/mothers, 30,1 the current study included only 6% fathers, which may limit our understanding of fathers' experiences during the pandemic. Though mothers continued to carry the majority of childcare during the pandemic, some data suggest an increase in father's contribution toward childcare during the COVID-19 pandemic. 31 Thus, examining changes in paternal involvement specifically in children's T1D tasks during stay-at-home-orders is an area for further inquiry. Additionally, our A1c variable was measured at the pre-pandemic timepoint, as opposed to the pandemic timepoint, due to the lack of in-person A1c data collection during the pandemic (resulting in $75% missing A1c data), which was a common issue during the pandemic. 32 Lastly, the study was conducted based on knowledge of COVID-19 during the initial months, and knowledge of the pandemic is continuously changing. 

The authors declare no conflict of interest.

Christine H. Wang contributed to the conceptualization of the current study and wrote the methods, results and discussion. Samantha 

The peer review history for this article is available at https://publons. com/publon/10.1111/pedi.13255.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Predictors of mood, diabetes-specific and COVID-19-specific experiences among parents of early school-age children with type 1 diabetes during initial months of the COVID-19 pandemic

For the next few items, please consider your experience during the Coronavirus (COVID-19) pandemic

Using a scale of 1-5, please respond to the questions below

= extremely/almost all of the time

Have found it easier to manage my child's diabetes

Have had more time to monitor/manage my child's diabetes

Have noticed more fluctuations/variability in my child's blood glucose levels

Have less access to my child's diabetes team

Since the COVID-19 pandemic

Did any of the following life events occur as a result of COVID

Have you, your family member or any significant person experienced any of the following as a result of COVID-19: Had symptoms (but never tested), diagnosed, treated, hospitalized or passed away? If so, please check all that apply: [COVID-19 social distancing] 3. Which of these is most true for you? a. I have gone about my normal routines since learning about the novel coronavirus

I tried to follow guidelines related to social distancing since learning about the novel coronavirus

I strictly limited my interactions with others (self-quarantined) since learning about the novel coronavirus

Had symptoms of COVID-19