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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: Sci Diabetes Self Manag Care. 2022 Apr 21;48(3):157–162. doi: 10.1177/26350106221094525

A Pandemic Perspective: Analyzing the Impact of COVID-19 on Diabetes Management and Mood Through the Lens of Location and Family Conflict

Hailey Moore 1, Fayo Abadula 2, Sydney Garretson 3, Nkemjika Okonkwo 4, Randi Streisand 5, Sarah Jaser 6
PMCID: PMC9830656  NIHMSID: NIHMS1862508  PMID: 35446187

Abstract

Purpose:

The purpose of this study was to examine the influence of COVID-19 on teens’ diabetes management and mood and their association with family conflict.

Methods:

One hundred and nineteen teens ages 13 to 17 (M = 15.5 ± 1.3 years, 61.3% female, 57.1% non-Hispanic White) and 119 parents (83.2% female, 75.6% married, 63.9% non-Hispanic White) enrolled in an ongoing two-site randomized behavioral clinical trial. At baseline, dyads completed the Revised Diabetes Family Conflict scale and a survey measuring the impact of COVID-19 on teens’ mood and diabetes management.

Results:

Parent- and teen-reported impacts of COVID-19 on diabetes management and teen mood were positively correlated. Higher levels of both parent- and teen-reported family conflict were associated with greater parent-reported impact of COVID-19 on diabetes management and teen mood. In addition, teen-reported impact of COVID-19 on their mood varied by geographical location but not population density.

Conclusions:

COVID-19 influenced teen diabetes management and mood, and the impact of COVID-19 was related to diabetes-related family conflict and differed by geographic location. Findings lend support for mental health interventions targeting teens with T1DM affected by COVID-19 and monitoring the long-term effects of the pandemic.

The COVID-19 pandemic has a distinct impact on teens1 and specific negative effects on people with diabetes2 and is likely to complicate diabetes management for teens with type 1 diabetes (T1DM) and their families. T1DM requires an intensive medical regimen that includes closely monitoring blood glucose levels and administering insulin as appropriate, and teens with T1DM and their parents often experience distress and family conflict related to managing these tasks.3,4 This distress can negatively affect mood and often leads to poorer health outcomes in teens with T1DM.5 The COVID-19 pandemic not only shifted the home and social lives of teens with T1DM but also affected their already rigorous medical regimen. The sudden transition to remote activities at the pandemic’s onset shifted medical routines for many teens with T1DM and their parents. For example, a study conducted during the start of the pandemic found that adolescents with T1DM and their mothers endorsed a loss of routine due to COVID-19 that negatively affected teens’ diabetes management (eg, disrupted their sleeping and eating schedules, caused them to skip more blood glucose checks).6 Another major change during the early stages of the pandemic was the transition from in-person clinic visits with diabetes providers and educators to telehealth appointments. While this shift to telehealth clinic visits may not have significantly reduced access to care for most patients with T1DM, it was found that disparities in historically marginalized groups (non-English-speaking or those who are Medicaid-insured) existed, with those groups being less likely to complete a visit via telemedicine.7

The COVID-19 pandemic affected teens’ medical routines and the amount of time spent at home. In response to the COVID-19 crisis, national social distancing and isolation recommendations led to school closures, resulting in teens attending school from home. This resulted in an increase in parent-child interactions, both positive and negative.8 The stress of balancing home and work life amid a pandemic catalyzed family conflict, with families reporting having shouted at or disciplined their child more often since the start of the pandemic.8 While the association between mood and diabetes management has been examined in prior research, less is known about the relationship between the COVID-19 pandemic and its influence on diabetes management, teen mood, and diabetes-related family conflict. Furthermore, it is unknown how these effects may vary based on geographic location, given differences in COVID-related policies.

Despite national COVID-19 response recommendations set forth by reputable public health organizations such as the World Health Organization and Centers for Disease Control, there were noticeable differences in social response to the virus related to geographic location and political climate. The responsibility of containment, testing, and treatment protocols for the COVID-19 pandemic was largely placed on the respective state and local governments, resulting in variations in response efforts.9 A large determinant of COVID-19 response was tied to political party affiliation, with public health recommendations being implemented earlier and more strongly enforced in Democratic-represented areas, such as New York and Washington, DC, in comparison to Republican-led states such as Tennessee and Alabama.10 As a result, state regulations for mask mandates, stay-at-home orders, restrictions on public gatherings, and higher rates of testing and vaccinations strongly differed between regions.11 Regional differences not only include geographic location but also population density (ie, differences between rural vs urban areas). For example, urban school districts were much less likely to offer fully in-person instruction to students than those in rural districts, impacting the amount of time students spent away from home.12 Individuals residing in urban and more densely populated regions were also more likely to comply with public health ordinances in comparison to rural regions.13 These geographic and population differences may be reflected in differing impact of the pandemic on diabetes management and mood, which are believed to be unstudied as of yet. This study examined the influence of COVID-19 on teens’ diabetes management and mood and their relationship with diabetes-related family conflict. Differences in COVID-related impact related to geographic location and population density were also explored.

Methods

Research Design

The current study is a secondary analysis of baseline data from participants enrolled in an ongoing clinical trial of a positive psychology intervention to treat diabetes distress in teens with T1DM (NCT03845465).14 The purpose of the ongoing clinical trial is to evaluate the effect of a text-message-based positive affect intervention on adolescents’ diabetes distress, self-management, and glycemic control. As part of baseline data collection, prior to randomization, teens and parents completed measurements of positive and negative emotions, perceived adherence to the teens’ diabetes regimen, diabetes-related family conflict, stress and coping, resilience, and health-related quality of life. Data collection for the ongoing clinical trial began in December 2019, prior to the COVID-19 pandemic. After the onset of the COVID-19 pandemic, surveys examining the impact of COVID-19 on teens’ diabetes management were added (July 2020). The purpose of this secondary analysis is to examine the impact of COVID-19 on teens’ diabetes management and mood in relation to diabetes-related family conflict. Participants included 119 teens ages 13 to 17 (M = 15.5 ± 1.3 years, 61.3% female, 57.1% non-Hispanic White) and 119 parents (83.2% female, 75.6% married, 63.9% non-Hispanic White). Table 1 includes demographic information about teen and parent participants included in the current analyses.

Table 1.

Parent and Teen Demographics

Teen Parent
Race (% non-Hispanic White) 57.1 63.9
Race (% non-Hispanic Black) 22.7 18.5
Race (% Asian) 5 5.9
Race (% American Indian)   .8   .8
Race (% multiracial) 8.4   2.5
Ethnicity (% Hispanic) 4.2   3.4
Sex (% female) 61.3 83.2
Age (y) 15.5 ± 1.3 —
Marital status (% married) — 75.6
Mean A1C (N = 102 due to missing data) 9.1 ± 2.0 —
CGM use (% reported using CGM) 76.5 —
Pump use (% reported using pump) 56.3 —
Pump and CGM use (% reported using both pump and CGM) 49.6 —
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Abbreviation: CGM, continuous glucose monitor.

Procedures

Participants were recruited from 2 large pediatric diabetes clinics: 1 in Washington, DC, serving the DC, Maryland, and Virginia areas with a mix of urban and suburban areas, and the other in Nashville, TN, serving a 5-state catchment area, including urban and rural areas. The single institutional review board (IRB No. 191245) approved this study for both sites. Adolescents ages 13 to 17 years were recruited for participation in the ongoing 2-site clinical trial (see Jaser et al14 for additional recruitment information and eligibility criteria). After obtaining consent and assent, parents and teens completed psychosocial surveys at baseline.

Measures

The Revised Diabetes Family Conflict Scale, completed by both parents and teens, is a 19-item self-report questionnaire that measures diabetes-specific family conflict. Examples of items included are “During the past month, I have argued with my child about taking more or less insulin depending on results” or “During the past month I have argued with my parent/caregiver about school absences.”4 The total score is a sum of items rated on a 3-point Likert scale (1 = never argue, 2 = sometimes argue, and 3 = always argue), and higher scores indicate higher levels of conflict. In the current sample, Cronbach’s α = .85 for the teen version and α = .81 for the parent version.

The COVID Impact Survey, completed by teens and parents, is a questionnaire that assesses the impact of the COVID-19 pandemic on diabetes management (10 items, parent/teen α = .57/.68) and teens’ mood (8 items for parent report/10 items for teen self-report α = .80/.57). Items include questions about changes in diabetes management, mood, living situations during the pandemic, and the extent to which people in and around the family have come into contact with the COVID-19 virus. A team of pediatric psychologists developed the COVID-19 survey for use in ongoing studies,6,15 and sample questions include “In what ways has COVID-19 impacted your T1DM management?” and “Overall, how worried or anxious has YOUR CHILD been about the COVID-19 pandemic?” In the current analyses, the Impact on Diabetes Management (parent/teen report) subscale and Impact on Mood (parent/teen report) subscale were used. Questions on the diabetes management and mood subscales are scaled on a 5-point Likert scale and summed, with higher scores indicating a greater impact of COVID-19 on diabetes management and teen mood.

Results

As seen in Table 2, parent-reported impact of COVID-19 on their child’s diabetes management was moderately positively associated with teen-reported impact of COVID-19 on their diabetes management. Parent-reported impact on diabetes management was also weakly positively correlated with both teen and parent-reports of diabetes conflict. Similarly, teens’ self-reported impact of COVID-19 on their diabetes management was moderately positively associated with self-reported impact of COVID-19 on their mood and parent-reported impact of COVID-19 on teens’ mood.

Table 2.

Associations Between the Impact of COVID-19 on Diabetes Management, Teen Mood, and Diabetes-Related Family Conflict

Variables 1 2 3 4 5 6
1. Parent-report diabetes-related family conflict — — — — — —
2. Teen-report diabetes-related family conflict   0.20* — — — — —
3. Parent-report impact of COVID-19 on diabetes management   0.32** 0.25* — — — —
4. Teen-report impact of COVID-19 on diabetes management   0.14 0.09 0.40** — — —
5. Parent-report impact of COVID-19 on teen mood   0.23* 0.31** 0.41** 0.30** — —
6. Teen-report impact of COVID-19 on teen mood −0.06 0.11 0.18 0.40** 0.40** —
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*

P < .05.

**

P < .01.

Higher parent-reported rates of impact of COVID-19 on their child’s mood was related to higher levels of teens’ report of diabetes-related family conflict (r = 0.31, P < .01) and parents’ report of diabetes-related family conflict (r = 0.23, P = .03). Device use was also found to be associated with parent-reported rates of impact of COVID-19 on their child’s mood, with parents of teens who used both insulin pumps and continuous glucose monitors reporting less of an impact of COVID-19 on teens’ mood (M = 20.3, SD = 4.6) than parents of teens not using both devices (M = 23.6, SD = 7.6); t(75.5) = 2.5, P = .014. Device use was not associated with teen- or parent-reported impact of COVID-19 on diabetes management or with teens’ self-reported impact on mood. There was also a significant effect of gender on self-reported impact of COVID-19 on teens’ mood, with females reporting a greater impact of COVID-19 on their mood (M = 30.9, SD = 8.1) than males (M = 27.3, SD = 7.7); t(90) = −2.15, P = .035. There was not a significant gender difference in self-reported impact on diabetes management. In addition, there were no significant associations between race/ethnicity and impact of COVID-19 on teens’ mood or diabetes management.

In terms of geographical location, significant differences between sites were observed, with teens in the mid-Atlantic site (Washington, DC) reporting a significantly greater effect of the COVID-19 pandemic on their mood (M = 30.8, SD = 8.2) than teens at the southeastern site (Nashville, TN; M = 27.2, SD = 7.7); t(92) = −2.10, P = .039. No other significant site differences were observed. To assess for differences related to population density, the association between urban (population of ≥50 000 people) and nonurban populations (population of <50 000) in relation to COVID-related impact was examined. No significant differences were found in the impact of COVID-19 on teen mood or diabetes management related to density.

Discussion

This is one of the first studies to examine the influence of the COVID-19 pandemic on diabetes management and mood of adolescents with T1DM6 and the relationship between COVID-19’s impact on diabetes management, mood, and diabetes-related family conflict. Results suggest that the COVID-19 pandemic had a negative effect on teens’ diabetes management and mood and that greater impact was associated with higher levels of diabetes-related family conflict. In addition, differences in the impact on teens’ mood associated with location were identified.

The current study also aimed to examine the relationship between diabetes-related family conflict and the impact of COVID-19 on teens’ mood and diabetes management. Previous research has shown that family conflict is negatively associated with adolescents’ mood.16 Recent reports also indicate that adolescents (without diabetes) experienced escalated conflicts with parents during the pandemic, and COVID-19-related worries predicted adolescents’ increased depression and anxiety.17 It is understandable that parent-adolescent conflict has increased during the pandemic, partially due to increased time spent together at home with stay-at-home orders and social distancing.18 This could help to explain the association between diabetes-related family conflict and the impact of COVID-19 on teens’ mood—more time spent at home could exacerbate diabetes-related family conflict, which is associated with teens’ increased negative affect. More time spent at home could also explain the association between diabetes-related family conflict and the impact of the pandemic on diabetes management. Due to lockdown measures, many parents and adolescents were spending more time together,18 and parents were able to observe more of their teen’s diabetes management tasks (or lack of completion of these tasks), which may have led to increased conflict over management.

Because this study was conducted at 2 sites with differing COVID-19 policies and attitudes, site differences in the effects of COVID-19 were able to be evaluated. While no significant differences in teens’ reports of the impact on diabetes management emerged, teens at the Washington, DC, site reported significantly higher impact on mood compared to teens at the Nashville, TN, site. These differences between participant responses could be attributed to differences in how the virus was handled between the locations. For instance, Washington, DC, adopted and enforced stricter public health protocols than Tennessee, such as extended mask mandates and limitations on public gatherings, which impinged more on the lives of those teens.10 Previous studies have shown that higher restrictions due to lockdown measures and reduction of social contacts were associated with greater mental health impairments.19 Because teens in DC had to deal with more extensive restrictions on their lives, they may have experienced greater negative effects on their mood. Previous research has found that additional discrepancies in COVID-19 preventive behavior adherence existed between urban, more densely populated communities and rural areas, with rural residents being less likely to engage in COVID-19-related preventive health behaviors.20 The results from the current study were no consistent with these prior findings. Rather, findings suggest that geographic location—and potentially political climate—had more of an effect on COVID-19’s impact on teens’ mood than did population density.

While COVID-19 had a greater impact on teens’ mood in the DC site, it is important to note that this is not the only metric by which the impact of COVID-19 should be measured. With the increased restrictions present in DC, the rate of COVID-19 infections per 100 000 people and the rate of deaths due to COVID-19 per 100 000 people were lower in DC compared to Tennessee over the course of data collection.21 These different approaches at looking at the impact of COVID-19 (i.e., impact on teens’ mood vs examining the rate of infection or death) highlight the trade-offs to different risk-assessment approaches.

Findings from the current study have important clinical implications, lending support for the implementation of mental health interventions targeting teens with T1DM affected by the COVID-19 pandemic. Engaging community mental health partners (e.g., psychologists, social workers, counselors, etc.) as part of the health care team may increase communication between parents, children, and providers about how outside events may affect teens’ mood and diabetes management. Diabetes care providers should be aware of the impact of mental health concerns on diabetes management,22 and asking how teens and parents are managing with the ongoing pandemic-related challenges could be incorporated in routine diabetes clinic visits. Interventions specifically aimed at assessing and reducing the stress of being a teen with a chronic illness during a global pandemic are also needed.

This cross-sectional study offers valuable insight for the way the COVID-19 pandemic affected diabetes management and family conflict for teens with T1DM at the time participants were surveyed. The 2 study sites reflect some of the many differing governmental and social responses to the pandemic by geographic location, showing how varied social distancing measures may have impacted teen mood and family conflict in different parts of the country. Study surveys were completed by participants through REDCap, which allowed the study team to easily update and add questionnaires at the onset of the pandemic and to distribute surveys remotely through emails and automated reminders in REDCap. Because this study was cross-sectional in nature, more longitudinal data are needed to fully understand the long-term effects of the pandemic on diabetes management. The demographics of this sample of children and parents demonstrates greater racial/ethnic diversity than often reported in studies of T1DM23 yet also included mostly female parents (83.2%), indicating that the results may be more descriptive of a maternal/child relationship. Continuing to monitor the impact of the COVID-19 pandemic on teen mood, family conflict, and glycemic control among a more diverse population may inform the future of mental health interventions for teens with T1DM.

Funding

This work was supported by the National Institutes of Diabetes and Digestive and Kidney Diseases (R01DK121316)

Conflict of Interest

Sarah Jaser is reporting the grant funding R01DK121316.

Contributor Information

Hailey Moore, Children’s National Hospital, Center for Translational Research, Washington, District of Columbia.

Fayo Abadula, Vanderbilt University Medical Center, Nashville, Tennessee.

Sydney Garretson, Vanderbilt University Medical Center, Nashville, Tennessee.

Nkemjika Okonkwo, Vanderbilt University Medical Center, Nashville, Tennessee.

Randi Streisand, The George Washington University School of Medicine, Washington, District of Columbia.

Sarah Jaser, Vanderbilt University Medical Center, Nashville, Tennessee.

References

  • 1.Imran N, Zeshan M, Pervaiz Z. Mental health considerations for children & adolescents in COVID-19 pandemic. Pak J Med Sci. 2020;36(Covid19-S4):S67–S72. doi: 10.12669/pjms.36.COVID19-S4.2759 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Gujral UP, Johnson L, Nielsen J, et al. Preparedness cycle to address transitions in diabetes care during the COVID-19 pandemic and future outbreaks. BMJ Open Diabetes Res Care. 2020;8(1):e001520. doi: 10.1136/bmjdrc-2020-001520 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Tareen RS, Tareen K. Psychosocial aspects of diabetes management: dilemma of diabetes distress. Transl Pediatr. 2017;6(4):383–396. doi: 10.21037/tp.2017.10.04 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Hood KK, Butler DA, Anderson BJ, Laffel LM. Updated and revised Diabetes Family Conflict Scale. Diabetes Care. 2007;30(7): 1764–1769. doi: 10.2337/dc06-2358 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Fisher L, Mullan JT, Arean P, Glasgow RE, Hessler D, Masharani U. Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care. 2010;33(1):23–28. doi: 10.2337/dc09-1238 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Goethals ER, Bergner EM, Mayberry LS, Novak LL, Erfe F, Jaser SS. Distressed families demonstrate resilience in the context of COVID-19: perspectives of adolescents with type 1 diabetes and their mothers. Diabetes Spectr. Published online November 18, 2021. doi: 10.2337/ds21-0026 [DOI] [PMC free article] [PubMed]
  • 7.Tilden DR, Datye KA, Moore DJ, French B, Jaser SS. The rapid transition to telemedicine and its effect on access to care for patients with type 1 diabetes during the COVID-19 pandemic. Diabetes Care. 2021;44(6): 1447–1450. doi: 10.2337/dc20-2712 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Lee SJ, Ward KP. Stress and Parenting During the Coronavirus Pandemic. University of Michigan Parenting in Context Research Lab; 2020. [Google Scholar]
  • 9.Bergquist S, Otten T, Sarich N. COVID-19 pandemic in the United States. Health Policy Technol. 2020;9(4):623–638. doi: 10.1016/j.hlpt.2020.08.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Baccini L, Brodeur A. Explaining governors’ response to the COVID-19 pandemic in the United States. Am Polit Res. 2021;49(2):215–220. doi: 10.1177/1532673x20973453 [DOI] [Google Scholar]
  • 11.Schuchat A. Public health response to the initiation and spread of pandemic COVID-19 in the United States, February 24-April 21, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(18):551–556. doi: 10.15585/mmwr.mm6918e2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Schwartz HL, Diliberti MK, Berdie L, Grant D, Hunter GP, Setodji CM. Urban and Rural Districts Showed a Strong Divide During the COVID-19 Pandemic: Results From the Second American School District Panel Survey. Research Report. RR-A956-2. RAND Corporation; 2021. [Google Scholar]
  • 13.Haischer MH, Beilfuss R, Hart MR, et al. Who is wearing a mask? Gender-, age-, and location-related differences during the COVID-19 pandemic. PLoS One. 2020;15(10):e0240785. doi: 10.1371/journal.pone.0240785 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Jaser SS, Datye K, Morrow T, et al. THR1VE! Positive psychology intervention to treat diabetes distress in teens with type 1 diabetes: rationale and trial design. Contemp Clin Trials. 2020;96:106086. doi: 10.1016/j.cct.2020.106086 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Wang CH, Hilliard ME, Carreon SA, et al. 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. Pediatr Diabetes. 2021;22(7):1071–1080. doi: 10.1111/pedi.l3255 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Sigfusdottir ID, Asgeirsdottir BB, Sigurdsson JF, Gudjonsson GH. Physical activity buffers the effects of family conflict on depressed mood: a study on adolescent girls and boys. J Adolesc. 2011;34(5):895–902. doi: 10.1016/j.adolescence.2011.01.003 [DOI] [PubMed] [Google Scholar]
  • 17.Magson NR, Freeman JYA, Rapee RM, Richardson CE, Oar EL, Fardouly J. Risk and protective factors for prospective changes in adolescent mental health during the COVID-19 pandemic. J Youth Adolesc. 2021;50(1):44–57. doi: 10.1007/si0964-020-01332-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Russell BS, Hutchison M, Tambling R, Tomkunas AJ, Horton AL. Initial challenges of caregiving during COVID-19: caregiver burden, mental health, and the parent-child relationship. Child Psychiatry Hum Dev. 2020;51(5):671–682. doi: 10.1007/s10578-020-01037-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Benke C, Autenrieth LK, Asselmann E, Pané-Farré CA. Lockdown, quarantine measures, and social distancing: associations with depression, anxiety and distress at the beginning of the COVID-19 pandemic among adults from Germany. Psychiatry Res. 2020;293:113462. doi: 10.1016/j.psychres.2020.113462 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Callaghan T, Lueck JA, Trujillo KL, Ferdinand AO. Rural and urban differences in COVID-19 prevention behaviors. J Rural Health. 2021;37(2):287–295. doi: 10.1111/jrh.l2556 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.CDC. CDC Covid Data tracker. Published 2020. Accessed November 11, 2021. https://covid.cdc.gov/covid-datatracker/#datatracker-home
  • 22.Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(12):2126. doi: 10.2337/dcl6-2053 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Trojanowski PJ, Niehaus CE, Fischer S, Mehlenbeck R. Parenting and psychological health in youth with type 1 diabetes: systematic review. J Pediatr Psychol. 2021;46(10):1213–1237. doi: 10.1093/jpepsy/jsab064 [DOI] [PubMed] [Google Scholar]

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