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Nylander, C., Lindstrom, K., Khalifa, N. & Fernell, E. (2018). Previously undiagnosed attention-deficit/hyperactivity disorder associated with poor metabolic control in adolescents with type 1 diabetes. Pediatric Diabetes, 19(4), 816-822
Open this publication in new window or tab >>Previously undiagnosed attention-deficit/hyperactivity disorder associated with poor metabolic control in adolescents with type 1 diabetes
2018 (English)In: Pediatric Diabetes, ISSN 1399-543X, E-ISSN 1399-5448, Vol. 19, no 4, p. 816-822Article in journal (Refereed) Published
Abstract [en]

Background: Managing modern diabetes treatment requires efficient executive functions. Patients with attention-deficit/hyperactivity disorder (ADHD) and type 1 diabetes have poor metabolic control and present with ketoacidosis more often than patients without ADHD. Objective: To assess whether patients with type 1 diabetes and with indications of executive problems met criteria for ADHD, and to investigate whether these patients had difficulties achieving metabolic control. Methods: In a hospital-based study, including 3 pediatric departments at hospitals in Stockholm and Uppsala, Sweden, questionnaires regarding executive problems had been filled out by 12- to 18-year-old patients with type 1 diabetes and their parents. Out of 166 patients with completed questionnaires, 49 were selected for a clinical study due to reported executive problems/ADHD symptoms. However, 7 already had a diagnosis of ADHD, 21 denied follow-up, 8 did not respond, leaving 13 adolescents for the clinical assessment. Results: Of the clinically assessed adolescents, 9 (6 girls) met criteria for ADHD. Patients who did not respond to the follow-up and patients who were diagnosed with ADHD within the study, showed to a larger extent than the other study groups high HbA1c levels (>70 mmol/mol, 8,6%). HbA1c >70 mmol/mol (8.6%) was associated with diagnosed ADHD (prior to or within the study), odds ratio 2.96 (95% confidence interval 1.02-8.60). Conclusion: Patients with type 1 diabetes and poor metabolic control should be assessed with regard to ADHD. There is a need for paying special attention to girls with poor metabolic control.

Keywords
ADHD, adolescents, HbA1c, metabolic control, type 1 diabetes mellitus
National Category
Pediatrics Psychiatry Endocrinology and Diabetes
Identifiers
urn:nbn:se:uu:diva-356857 (URN)10.1111/pedi.12651 (DOI)000432027100033 ()29575401 (PubMedID)
Funder
Swedish Child Diabetes Foundation
Available from: 2018-08-15 Created: 2018-08-15 Last updated: 2018-08-15Bibliographically approved
Nylander, C., Tindberg, Y., Haas, J., Swenne, I., Torbjörnsdotter, T., Åkesson, K., . . . Fernell, E. (2018). Self- and parent-reported executive problems in adolescents with type 1 diabetes are associated with poor metabolic control and low physical activity.. Pediatric Diabetes, 19(1), 98-105
Open this publication in new window or tab >>Self- and parent-reported executive problems in adolescents with type 1 diabetes are associated with poor metabolic control and low physical activity.
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2018 (English)In: Pediatric Diabetes, ISSN 1399-543X, E-ISSN 1399-5448, Vol. 19, no 1, p. 98-105Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Management of diabetes is demanding and requires efficient cognitive skills, especially in the domain of executive functioning. However, the impact of impaired executive functions on diabetes control has been studied to a limited extent. The aim of the study is to investigate the association between executive problems and diabetes control in adolescents with type 1 diabetes.

MATERIALS AND METHODS: Two hundred and forty-one of 477 (51%) of 12- to 18-year-old adolescents, with a diabetes duration of >2 years in Stockholm, Uppsala, and Jönköping participated. Parents and adolescents completed questionnaires, including Behavioral Rating Inventory of Executive Function (BRIEF), Attention-Deficit/Hyperactivity Disorder (ADHD)-Rating Scale (ADHD-RS) and demographic background factors. Diabetes-related data were collected from the Swedish Childhood Diabetes Registry, SWEDIABKIDS. Self-rated and parent-rated executive problems were analyzed with regard to gender, glycosylated hemoglobin (HbA1c), frequency of outpatient visits, and physical activity, using chi-square tests or Fisher's test, where P-values <.05 were considered significant. Furthermore, adjusted logistic regressions were performed with executive problems as independent variable.

RESULTS: Executive problems, according to BRIEF and/or ADHD-RS were for both genders associated with mean HbA1c >70 mmol/mol (patient rating P = .000, parent rating P = .017), a large number of outpatient visits (parent rating P = .015), and low physical activity (patient rating P = .000, parent rating P = .025). Self-rated executive problems were more prevalent in girls (P = .032), while parents reported these problems to a larger extent in boys (P = .028).

CONCLUSION: Executive problems are related to poor metabolic control in adolescents with type 1 diabetes. Patients with executive problems need to be recognized by the diabetes team and the diabetes care should be organized to provide adequate support for these patients.

Keywords
HbA1c, adolescents, neurodevelopmental problems, type 1 diabetes mellitus
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:uu:diva-332701 (URN)10.1111/pedi.12520 (DOI)000423397600014 ()28318073 (PubMedID)
Funder
Swedish Child Diabetes Foundation
Available from: 2017-10-31 Created: 2017-10-31 Last updated: 2018-03-07Bibliographically approved
Lindblad, I., Engström, A.-C., Nylander, C. & Fernell, E. (2017). Adolescents with type 1 diabetes mellitus and attention-deficit/hyperactivity disorder require specific support from healthcare professionals. Acta Paediatrica, 106(12), 1994-1997
Open this publication in new window or tab >>Adolescents with type 1 diabetes mellitus and attention-deficit/hyperactivity disorder require specific support from healthcare professionals
2017 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 12, p. 1994-1997Article in journal (Refereed) Published
Abstract [en]

AIM: Managing type 1 diabetes mellitus requires efficient cognitive and executive skills, and adolescents who have attention-deficit/hyperactivity disorder (ADHD) may face specific challenges. This study explored young people's experiences of diabetes treatment and care.

METHOD: In a population-based study, comprising 175 patients aged 5-16 years with type 1 diabetes mellitus in two Swedish counties, we found that eight also met criteria for ADHD. Six of these, aged 14.5-16 years, participated 2013-2014 in interviews that targeted aspects of their diabetes treatment. Conducted by two psychologists, these used the inductive qualitative, semi-structured interview format.

RESULTS: The two boys and four girls all reported difficulties in creating routines for their diabetes treatment and that problems were aggravated during stress. They had been criticised by their parents and the diabetes team when their blood levels indicated inadequate diabetes control. They requested ongoing information, involvement of their friends, group meetings and easy access to the healthcare system during difficult times.

CONCLUSION: Patients with type 1 diabetes mellitus and concomitant ADHD faced problems with their diabetes management, especially during stressful situations. Diabetes care provision should pay particular attention to patients with co-existing neuropsychiatric and neurodevelopmental disorders such as ADHD.

Keywords
Adolescent, Attention-deficit/hyperactivity disorder, Diabetes care, Executive dysfunction, Type 1 diabetes mellitus
National Category
Pediatrics Psychiatry Neurology Endocrinology and Diabetes
Identifiers
urn:nbn:se:uu:diva-332699 (URN)10.1111/apa.13989 (DOI)000414913500019 ()28708247 (PubMedID)
Funder
Swedish Child Diabetes Foundation
Available from: 2017-10-31 Created: 2017-10-31 Last updated: 2018-02-19Bibliographically approved
Nylander, C. (2016). Protective factors, health-risk behaviours and the impact of coexisting ADHD among adolescents with diabetes and other chronic conditions. (Doctoral dissertation). Uppsala: Acta Universitatis Upsaliensis
Open this publication in new window or tab >>Protective factors, health-risk behaviours and the impact of coexisting ADHD among adolescents with diabetes and other chronic conditions
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Mental health problems are increasing in Swedish adolescents and mortality rates are higher in this age group than among younger. 10-20% of all adolescents suffer from a chronic medical condition (CC). Few protective factors (PF) and clustering of health-risk behaviours (HRB) are frequent among adolescents with CCs.

One of the most common CC in Swedish adolescents is type 1 diabetes mellitus (T1DM). Metabolic control often deteriorates during adolescence, especially in girls. Poor metabolic control is associated with increased risk for long-term complications, of which cognitive problems are common. However, the implication of cognitive/executive problems in patients with T1DM has not been sufficiently studied. Neither has the impact of neurodevelopmental problems (NDP), such as ADHD, on HRB in adolescents with CCs been analysed.

Methods: In paper I and II the questionnaire ”Life and Health in Youth” was distributed to all students in year nine and year two of the upper secondary school in the county of Sörmland, 2008 (n=5771) and 2011 (n=5550). Adolescents with CCs were compared to healthy peers with regard to PFs and HRBs. In paper III, the ”Five to Fifteen” questionnaire was used in 175 paediatric patients with T1DM. Patients with indications of NDPs were compared with patients without such problems with regard to metabolic control. In paper IV, the BRIEF questionnaire and the ADHD Rating Scale as well as data from the Swedish Childhood Diabetes Registry was used in 241 adolescents with T1DM. Patients with indications of executive problems were compared with patients without such problems with regard to diabetes control.

Results: CCs were associated with few PFs and clustered HRBs. The combination of CCs and low numbers of PFs was found to be associated with an increased risk of clustered HRBs. In the presence of coexisting ADHD the pattern of few PFs and clustering of HRBs was aggravated. ADHD was more common among adolescents with other CCs.

Definite memory and learning problems as well as mild executive problems were associated with poor metabolic control, especially among adolescents. Executive problems were also associated with many outpatient visits and low physical activity. Girls with T1DM tended to self-report executive problems to a larger extent than boys, while parents more often reported these problems in boys.

Conclusion: Knowledge about factors influencing treatment adherence and life in general is essential in the work with chronically ill adolescents. Focus must be put on enhancing PFs in order to avoid HRBs. Identification of coexisting NDPs, such as ADHD, is crucial, since such problems can adversely influence treatment adherence, HRBs and school achievements

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. p. 75
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1213
Keywords
Adolescent development, adolescent medicine, health behaviour, protective factors, risk-taking, type 1 diabetes, HbA1c, neurodevelopmental problems and ADHD
National Category
Pediatrics
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-282964 (URN)978-91-554-9553-4 (ISBN)
Public defence
2016-06-03, Rosénsalen, Ingång 95/96 nbv, Uppsala Akademiska Sjukhus, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-05-13 Created: 2016-04-08 Last updated: 2016-06-01
Nylander, C., Fernell, E. & Tindberg, Y. (2015). Chronic conditions and coexisting ADHD-a complicated combination in adolescents. European Journal of Pediatrics, 174(9), 1209-1215
Open this publication in new window or tab >>Chronic conditions and coexisting ADHD-a complicated combination in adolescents
2015 (English)In: European Journal of Pediatrics, ISSN 0340-6199, E-ISSN 1432-1076, Vol. 174, no 9, p. 1209-1215Article in journal (Refereed) Published
Abstract [en]

Adolescents with chronic conditions (CCs) take more health risks than peers. However, coexisting ADHD has not sufficiently been considered. The aim of the present study was to investigate the impact of different CCs on protective factors and health-risk behaviors, taking coexisting ADHD into account. A school-based study among 6895 15- and 17-year-old students was performed in the county of Sormland, Sweden in 2011 (response rate 80 %). The questionnaire explored background factors, CCs, protective factors, and health-risk behaviors. CCs were reported by 11 %, while 55 % were healthy. Students with CCs more often reported coexisting ADHD than healthy students. In adolescents with neurological conditions, the odds ratio for having ADHD was 7.34 (95 % CI 3.00-17.99) as compared to healthy peers. Few protective factors (< 4) and clustered health-risk behaviors (a parts per thousand yen4) were more common among students with CCs, especially if ADHD or a combination including ADHD was reported. Conclusion: CCs and coexisting ADHD are associated with few protective factors and clustered-health risk behaviors. Adolescents with ADHD-in addition to a chronic condition-should be specially acknowledged by health care professionals in order to prevent health risk behaviors. ADHD should be considered when studying these outcomes in adolescents.

Keywords
Adolescent medicine, Chronic disease, ADHD, Health behavior, Risk-taking, Protective factors
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-261936 (URN)10.1007/s00431-015-2521-9 (DOI)000359821700009 ()25823759 (PubMedID)
Available from: 2015-09-22 Created: 2015-09-07 Last updated: 2017-12-04Bibliographically approved
Nylander, C., Tindberg, Y. & Fernell, E. (2015). Risky sexual behaviour among adolescents may be related to ADHD [Letter to the editor]. Acta Paediatrica, 104(6), E235-E235
Open this publication in new window or tab >>Risky sexual behaviour among adolescents may be related to ADHD
2015 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 104, no 6, p. E235-E235Article in journal, Letter (Refereed) Published
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-257354 (URN)10.1111/apa.13003 (DOI)000354528100001 ()25761567 (PubMedID)
Available from: 2015-07-03 Created: 2015-07-01 Last updated: 2017-12-04Bibliographically approved
Nylander, C., Seidel, C. & Tindberg, Y. (2014). The triply troubled teenager - chronic conditions associated with fewer protective factors and clustered risk behaviours. Acta Paediatrica, 103(2), 194-200
Open this publication in new window or tab >>The triply troubled teenager - chronic conditions associated with fewer protective factors and clustered risk behaviours
2014 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 103, no 2, p. 194-200Article in journal (Refereed) Published
Abstract [en]

AIM: This study aimed to measure protective factors and risk behaviour among adolescents with chronic conditions (CCs) and to evaluate the impact of protective factors on risk-taking.

METHODS: A population-based study of 7262 students aged 15 and 17 years old was performed in Sörmland, Sweden 2008 (response rate 82%). The questionnaire explored background factors, CCs, risk behaviours and protective factors. CCs were reported by 8%, while 58% had no health problems.

RESULTS: Girls with CCs encompassed less individual protective factors, while boys with CCs tended to over-report all individual risk behaviours compared with healthy peers. Both boys and girls with CCs were more likely to report few protective factors and co-occurrence of risk behaviours. The adjOR for clustered health risk behaviours was 1.6 (1.0-2.5) in youths with CCs and ≥4 protective factors and 6.3 (3.6-10.9) in youths with CCs and 0-3 protective factors, as compared to healthy peers with ≥4 protective factors.

CONCLUSION: Adolescents with CCs reported fewer protective factors and more risk behaviours than their healthy peers. The vulnerability of adolescents with CCs and few protective factors is important to acknowledge. Professionals should provide stronger protection for these adolescents, to prevent risky behaviour.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-215016 (URN)10.1111/apa.12461 (DOI)000330723200022 ()24117768 (PubMedID)
Available from: 2014-01-09 Created: 2014-01-09 Last updated: 2017-12-06Bibliographically approved
Nylander, C., Toivonen, H., Nasic, S., Söderström, U., Tindberg, Y. & Fernell, E. (2013). Children and adolescents with type 1 diabetes and high HbA1c: a neurodevelopmental perspective. Acta Paediatrica, 102(4), 410-415
Open this publication in new window or tab >>Children and adolescents with type 1 diabetes and high HbA1c: a neurodevelopmental perspective
Show others...
2013 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 102, no 4, p. 410-415Article in journal (Refereed) Published
Abstract [en]

Aim

To examine the association between neurodevelopmental problems and high HbA1c among paediatric patients with type 1 diabetes.

Methods

A population-based study was performed among patients with type 1 diabetes (5–16 years) in two Swedish counties (n = 233). The Five to Fifteen (FTF) questionnaire targeted neurodevelopmental qualities. Scores above the 90th percentile in the various domains are considered as definitive problems and scores above the 75th percentile as mild. FTF scores were compared with regard to HbA1c ≤73 mmol/mol and >73 mmol/mol (8.0%).

Results

The response rate was 190 (82%). Neurodevelopmental problems were not overrepresented among patients in general. Memory and learning problems were associated with HbA1c >73 mmol/mol (p = 0.01). This correlation was especially seen in adolescents (12–16 years) where mild executive problems (adjOR 3.1), definite memory problems (adjOR 5.0) and definite learning problems (adjOR 5.0) were associated with HbA1c >73 mmol/mol after adjustment for gender, diabetes duration and age of onset.

Conclusion

Our findings that high HbA1c is more common in adolescent diabetes patients with neurodevelopmental problems generate the hypothesis that these problems might precede poor metabolic control. If so, early detection of neurodevelopmental problems would allow individually tailored treatment that may improve metabolic control and prevent complications.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-196581 (URN)10.1111/apa.12128 (DOI)000316325400030 ()23278767 (PubMedID)
Available from: 2013-03-11 Created: 2013-03-11 Last updated: 2017-12-06Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0003-4689-0769

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