The Journal of the Arkansas Medical Society Med Journal Sept 2019 FInal 2 | Page 12

EDITORIAL PANEL: Chad T. Rodgers, MD, FAAP | Elena M. Davis, MD, MPH | Shannon Edwards, MD | William L. Mason, MD | Michael Moody, MD | J. Gary Wheeler, MD, MPS
Impact of Caregiver’s ACEs
on Their Child’s Diabetes Outcomes
RACHEL EKDAHL, MD; HEATHER CANTRELL, APN; ANNIE WANG, MD; and EMIR TAS, MD
T
ype 1 Diabetes (T1DM) is
a complex chronic disease
that requires adherence with
a rigorous and regimented
care plan to achieve optimal control.
Non-adherence leads to poor control
and an increased risk for complica-
tions. Pediatric diabetes is unique in
that caregivers are intimately involved
in disease management. The ideal
caregiver involvement should be
inversely proportional to the child’s
developmental stage, focusing on
providing support as needed and
supervision of treatment adherence.
The Hemoglobin A1C (HbA1c) test
is used to monitor adherence to dia-
betes treatment. An HbA1c of 7.5 per-
cent or lower indicates good diabetes
control; 9 percent or higher indicates
poor control. During the first year of
diagnosis, good diabetes control is
often attained easily due to produc-
tion of endogenous insulin; known
as a honeymoon period. The American
Diabetes Association recommends
follow-up for diabetes every three
months, starting at diagnosis.
Adverse Childhood Experiences
(ACEs) — stressful, traumatic events
occurring before age 18 — have
become a popular topic in pediatric
care. The hallmark Kaiser ACE Study
found a strong dose-response
association between the number of
ACEs and negative health outcomes
in later life. Further studies suggest
the intergenerational transmission
of trauma, including the role of
epigenetics and the influence of
maltreatment experiences on later
parenting practices. Given the
importance of caregiver involvement
in pediatric diabetes care, caregiver
ACE scores could reflect caregiver
challenges that might affect diabetes
control in young patients. Data on
the impact of the caregiver’s ACE
score on children’s chronic disease
management is limited.
Arkansas has the highest preva-
lence of children in the United States
who have experienced ACEs. A devas-
tating 56 percent of Arkansas’ children
have experienced at least one ACE;
one in seven have experienced three
or more ACEs.
We conducted a study to deter-
mine the impact of caregiver ACEs on
management of their child’s diabetes
at Arkansas Children’s Hospital’s dia-
betes clinic. We used the standardized
ACE Questionnaire to calculate care-
givers’ scores. This self-report measure
identifies childhood experiences of
abuse and neglect, including psy-
60 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
chological, physical or sexual abuse;
emotional or physical neglect; loss
of a parent; mother treated violently;
substance abuse; mental illness or
criminal behavior in the household.
The questionnaire was distributed to
caregivers of patients up to age 13
during regular diabetes clinic visits.
Patients with a T1DM diagnosis within
the last year were excluded to avoid
data skewed by a potential honey-
moon period. The primary caregiver
was asked to notate the number of
questions that applied to them, but
no specific answers were collected.
Other data collected and results are
summarized in Table 1. The student
t-test was used to compare the
means, and chi-square was used to
compare categorical variables.
Sixty-one families completed the
questionnaire between December
2018 and March 2019. Study partici-
pants’ average HbA1c was 8.1 percent,
indicating marginal diabetes control.
Only 13 percent of children in this
cohort were seen in clinic four times
per year, as recommended and this
subgroup had a better average HbA1c
(7.5%). The caregiver ACE scores were
not low in this subgroup.
We compared the mean data of
children of caregivers with ACE scores
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