The effects of diabetes mellitus on the school attendance and school achievement of adolescents

Educational Attainment and Childhood-Onset Type 1 Diabetes

OBJECTIVE

To quantify associations of educational outcomes with type 1 diabetes status and glycemic management (HbA1c).

RESEARCH DESIGN AND METHODS

This was a record linkage study of schools and higher (college) education data sets linked to national diabetes audits. The population includes all Welsh children attending school between 2009 and 2016, yielding eight academic cohorts with attainment data, including 263,426 children without diabetes and 1,212 children diagnosed with type 1 diabetes. Outcomes include standardized educational attainment for those aged 16 years, higher education participation for those aged ≥18 years, and school absences among those aged 6-16 years.

RESULTS

Comparison between children with type 1 diabetes and children without diabetes showed no strong evidence of associations for student attainment (0.001 SD, 95% CI -0.047 to 0.049, P < 0.96, n = 1,212 vs. 263,426) or higher education entry rates (odds ratio 1.067, 95% CI 0.919-1.239, P < 0.39, n = 965 vs. 217,191), despite nine more sessions of absence from school annually (P < 0.0001). However, attainment in children in the most optimal HbA1c quintile was substantially better than for children without diabetes (0.267 SD, 95% CI 0.160-0.374, P < 0.001) while being worse than for children without diabetes in the least optimal quintile (-0.395 SD, 95% CI -0.504 to -0.287, P < 0.001). Attainment did not differ by duration of "exposure" to diabetes based on age at diagnosis.

CONCLUSIONS

Despite more school absences, diabetes diagnosis is not associated with educational attainment or entry into higher education, although attainment does vary by HbA1c level, which may be explained in part (or wholly) by unobserved shared personal, family, or socioeconomic characteristics associated with both success in education and effective glycemic self-management.

Priorities in the Interdisciplinary Approach of Specific Learning Disorders (SLD) in Children with Type I Diabetes Mellitus (T1DM). From Theory to Practice

BACKGROUND

A considerable endeavor had taken place in order to understand the associated challenges for children and adolescents with Specific Learning Disorder (SLD) and Type 1 Diabetes Mellitus (T1DM) but also in order to describe the necessary skills and approaches that the care givers have to develop to assist both children and parents. (1) Aim: The aim of this review is twofold. Firstly, to highlight the T1DM's potential impact on psychological well-being, on cognitive functioning and on school performance in children and adolescents who confront SLD. Secondly, to discuss the necessity of a multidiscipline approach of poor school performance in students with SLD and T1DM, presenting the serious contribution of care providers: (a) parents/carers in the family setting, (b) teachers and psychologists in the school setting and (c) health specialists (pediatricians, nutricians, nurses, child psychiatrists and psychologists) in the medical setting. (2) Methods: In this narrative literature review of 12 selected articles, each one studies a special aspect of approach, during the diagnosis and the treatment of individuals with T1DM and SLD. The review concerns the arising problems and difficulties in the adherence to diagnosis, the management of insulin, the mental and physical wellbeing, the school performance, the cognitive functioning and learning difficulties of patients. We tried to synthesize an interdisciplinary approach that involves collaboration between family, school and medical frame; facilitating children's and adolescents' difficulties management, as well as parent and teacher involvement during the intervention implementation. (3) Results: The main issues of concern were examined through the available literature, as different factors had to be re-examined in the previous studies, regarding the potential impact of T1DM in cognitive and psychological functioning, as well as the effects of the intervention/approach/treatment of children and adolescents with SLD and T1DM. (4) Conclusions: Although T1DM diagnosis and demanding treatment are a heavy burden for children and their families, T1DM may or may not be associated with a variety of academic and psychological outcomes. Despite the variability of the reviewed research design quality, it was clearly defined that the impact of T1DM is not uniform across educational and mental variables. Strengthening the children's physical, psychological and social wellbeing is an especially important factor, as it facilitates the insulin's management as well as the learning difficulties. This is possible by supporting the parental and teacher involvement in the intervention process. This review highlights the need to reduce the distance between theory/research and practice, in some of the proposed areas in this field of knowledge.

Association of Prodromal Type 1 Diabetes With School Absenteeism of Danish Schoolchildren: A Population-Based Case-Control Study of 1,338 Newly Diagnosed Children

OBJECTIVE

To investigate school absenteeism before the clinical diagnosis of type 1 diabetes in children who develop the disease.

RESEARCH DESIGN AND METHODS

This population-based, retrospective case-control study involved all Danish children who developed type 1 diabetes and attended public schools (n = 1,338) from 2010 to 2017. Those children were matched at a 1-to-5 ratio, on the basis of sex and date of birth, to children without diabetes (n = 6,690). Case and control absenteeism were compared monthly, starting with 12 months prior to the type 1 diabetes diagnosis through 12 months after diagnosis.

RESULTS

Before the diabetes diagnosis (7-12 months), the mean number of days absent from school per month was 0.93 (SD 1.78) among children with diabetes and 0.93 (1.82) among control children (difference -0.004 days, P = 0.94). From 4 months before the diagnosis, children who developed diabetes had a statistically significant increase in absenteeism compared with control children (difference 0.24 days, P < 0.05).

CONCLUSIONS

Children who were diagnosed with type 1 diabetes had increased school absenteeism 4 months before diagnosis.

Structural Alterations in Deep Brain Structures in Type 1 Diabetes

Even though well known in type 2 diabetes, the existence of brain changes in type 1 diabetes (T1D) and both their neuroanatomical and clinical features are less well characterized. To fill the void in the current understanding of this disease, we sought to determine the possible neural correlate in long-duration T1D at several levels, including macrostructural, microstructural cerebral damage, and blood flow alterations. In this cross-sectional study, we compared a cohort of 61 patients with T1D with an average disease duration of 21 years with 54 well-matched control subjects without diabetes in a multimodal MRI protocol providing macrostructural metrics (cortical thickness and structural volumes), microstructural measures (T1-weighted/T2-weighted [T1w/T2w] ratio as a marker of myelin content, inflammation, and edema), and cerebral blood flow. Patients with T1D had higher T1w/T2w ratios in the right parahippocampal gyrus, the executive part of both putamina, both thalami, and the cerebellum. These alterations were reflected in lower putaminal and thalamic volume bilaterally. No cerebral blood flow differences between groups were found in any of these structures, suggesting nonvascular etiologies of these changes. Our findings implicate a marked nonvascular disruption in T1D of several essential neural nodes engaged in both cognitive and motor processing.

Educational and Health Outcomes of Children Treated for Type 1 Diabetes: Scotland-Wide Record Linkage Study of 766,047 Children

OBJECTIVE

This study was conducted to determine the association between childhood type 1 diabetes and educational and health outcomes.

RESEARCH DESIGN AND METHODS

Record linkage of nine Scotland-wide databases (diabetes register, dispensed prescriptions, maternity records, hospital admissions, death certificates, annual pupil census, school absences/exclusions, school examinations, and unemployment) produced a cohort of 766,047 singleton children born in Scotland who attended Scottish schools between 2009 and 2013. We compared the health and education outcomes of schoolchildren receiving insulin with their peers, adjusting for potential confounders.

RESULTS

The 3,330 children (0.47%) treated for type 1 diabetes were more likely to be admitted to the hospital (adjusted hazard ratio [HR] 3.97, 95% CI 3.79-4.16), die (adjusted HR 3.84, 95% CI 1.98-7.43), be absent from school (adjusted incidence rate ratio [IRR] 1.34, 95% CI 1.30-1.39), and have learning difficulties (adjusted odds ratio [OR] 1.19, 95% CI 1.03-1.38). Among children with type 1 diabetes, higher mean HbA_1c (particularly HbA_1c in the highest quintile) was associated with greater absenteeism (adjusted IRR 1.75, 95% CI 1.56-1.96), increased school exclusion (adjusted IRR 2.82, 95% CI 1.14-6.98), poorer attainment (adjusted OR 3.52, 95% CI 1.72-7.18), and higher risk of unemployment (adjusted OR 2.01, 95% CI 1.05-3.85).

CONCLUSIONS

Children with type 1 diabetes fare worse than their peers in respect of education and health outcomes, especially if they have higher mean HbA_1c. Interventions are required to minimize school absence and ensure that it does not affect educational attainment.

The feasibility of detecting neuropsychologic and neuroanatomic effects of type 1 diabetes in young children

OBJECTIVE

To determine if frequent exposures to hypoglycemia and hyperglycemia during early childhood lead to neurocognitive deficits and changes in brain anatomy.

RESEARCH DESIGN AND METHODS

In this feasibility, cross-sectional study, young children, aged 3 to 10 years, with type 1 diabetes and age- and sex-matched healthy control (HC) subjects completed neuropsychologic (NP) testing and magnetic resonance imaging (MRI) scans of the brain.

RESULTS

NP testing and MRI scanning was successfully completed in 98% of the type 1 diabetic and 93% of the HC children. A significant negative relationship between HbA1c and Wechsler Intelligence Scale for Children (WISC) verbal comprehension was observed. WISC index scores were significantly reduced in type 1 diabetic subjects who had experienced seizures. White matter volume did not show the expected increase with age in children with type 1 diabetes compared with HC children (diagnosis by age interaction, P=0.005). A similar trend was detected for hippocampal volume. Children with type 1 diabetes who had experienced seizures showed significantly reduced gray matter and white matter volumes relative to children with type 1 diabetes who had not experienced seizures.

CONCLUSIONS

It is feasible to perform MRI and NP testing in young children with type 1 diabetes. Further, early signs of neuroanatomic variation may be present in this population. Larger cross-sectional and longitudinal studies of neurocognitive function and neuroanatomy are needed to define the effect of type 1 diabetes on the developing brain.

Type 1 diabetes mellitus and school: a comparison of patients and healthy siblings

Children and adolescents with type 1 diabetes mellitus (T1DM) are at risk for a variety of problems at school. Well-controlled studies using data collected in schools, however, are limited. The purposes of this study are to determine whether selected school problems are associated with T1DM and to investigate an association between these problems and medical variables. Teachers rated 95 diabetic students (M = 11.8; SD = 3.0 yr old) and 95 of their siblings (M = 12.1; SD = 3.0 yr old) regarding academic skills, work completion, day-to-day variability, and classroom attention. Medical and school records also were accessed. The T1DM group had lower academic skills ratings overall (p < 0.02), especially in writing (p < 0.01), a trend toward poorer classroom attention (p < 0.08), and many more missed school days (p < 0.001). Diabetics on intensive therapy protocols had better academic ratings overall (p < 0.02), including in math (p < 0.03) and fewer missed school days (p < 0.03), but they unexpectedly were rated as having more classroom behaviors that jeopardize work completion (p < 0.05) than counterparts on conventional therapy. Among all diabetics, glycated hemoglobin (HbA(lc)) levels were moderately related to each academic skill rating (r = -0.34 to -0.37; p < 0.01) and strongly related to classroom attention (r = 0.53; p = 0.000). T1DM itself appears to be a relatively minor influence to several important aspects of school. Furthermore, although intensive therapy alone may well promote school success, meticulous glycemic control, however achieved, appears more important in mitigating prospective classroom attention and academic problems.

The effects of timing of pediatric knee ligament surgery on short-term academic performance in school-aged athletes

BACKGROUND

Orthopaedic injuries negatively affect the academic lives of children.

HYPOTHESIS

The timing of anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) reconstructions affects academic performance in school-aged athletes.

STUDY DESIGN

Cohort study; Level of evidence, 2. Methods Records of patients < or = 18 years old who underwent ACL or MPFL reconstructions from 2001-2007 were reviewed retrospectively. Subjects had been administered a unique questionnaire to evaluate school life in the immediate postoperative period as well as International Knee Documentation Committee (IDKC), Lysholm, and Kujala knee-specific questionnaires. Patients were in 1 of 3 study cohorts: group A (surgery during school year), group B (surgery during school holiday), and group C (surgery during summer break).

RESULTS

There were 62 subjects (53 ACL and 12 MPFL reconstructions). A higher proportion of patients in group A required being driven to school (88.5%) than groups B (63.6%) or C (64.7%) (P < .05). A lower proportion of patients in group A returned to school immediately after surgery (3.8%) than groups B (36.4%) or C (88.2%) (P < .005). Among children who had never failed a test before surgery, a higher proportion of patients in group A failed a test (36.4%) after return to school than groups B (0%) or C (0%) (P < .05). Patients in group C had higher mean Likert scores (4.5) than groups A (3.8) or B (3.7) (P = .05) in response to the question "my grades suffered in my classes." Delay in surgery was negatively correlated with IKDC, Lysholm, and Kujala questionnaire scores (P < .05).

CONCLUSION

In school-aged athletes with ligamentous knee injuries receiving operative treatment, surgery on a school day causes more academic difficulties than surgery during a holiday or summer break. Academic benefits of delaying surgery during the school year must be weighed against potentially worse outcomes encountered with prolonged surgical delay.

Unlocking the Energy Dynamics of Executive Functioning: Linking Executive Functioning to Brain Glycogen

Past work suggests that executive functioning relies on glucose as a depletable energy, such that executive functioning uses a relatively large amount of glucose and is impaired when glucose is low. Glucose from the bloodstream is one energy source for the brain, and glucose stored in the brain as glycogen is another. A review of the literature on glycogen suggests that executive functioning uses it in much the same way as glucose, such that executive functioning uses glycogen and is impaired when glycogen is low. Findings on stress, physical persistence, glucose tolerance, diabetes, sleep, heat, and other topics provide general support for this view.

Hypoglycemia: a complication of diabetes therapy in children

The experience of hypoglycemia is probably the most feared and hated consequence of life with type 1 diabetes among pediatric patients and their parents. Although transient detrimental effects are clearly disturbing and may have severe results, there is surprisingly little evidence of long-term CNS damage, even after multiple hypoglycemic episodes, except in rare instances. Despite the latter evidence, we advocate that every treatment regimen be designed to prevent hypoglycemia without inducing unacceptable hyperglycemia and increasing the risk of micro- and macrovascular complications.

Pediatric orthopaedic injuries: the effect of treatment on school attendance

This study aims to determine whether children experience difficulty attending school after an acute orthopaedic injury and, if so, what the barriers are to attendance. Seventy-eight school-aged patients receiving treatment of acute orthopaedic injuries or conditions at the authors' institution were enrolled in this prospective study. Follow-up interviews were conducted with children who could not return to school. Fifty-three percent of the children were able to return to school immediately; those who were not were absent for 35.9 days on average. Nearly three quarters of absentees attributed the nonattendance to refusal by the school, and only 36.7% received home instruction during their absence. A regression model showed that children using crutches were five times less likely to attend school than children without crutches. This study indicates that orthopaedic injuries and their treatments contribute to school absence. Refusal by the school to accommodate the injured child was the primary barrier to attendance.

Hypoglycemia, hypoglycemia unawareness and counterregulation in children and adolescents with type 1 diabetes mellitus

Three clinical phenomena have been defined in the last decade in patients with diabetes mellitus as a dangerous iatrogenic sequel of hypoglycemia. These are hypoglycemia unawareness, defective glucose counterregulation and a lowered hypoglycemic threshold for hypoglycemic symptoms. Former mild hypoglycemia episodes cause a decrease and a delay in the protective hormonal counterregulatory response and warning symptoms in subsequent episodes, and in the absence of these, risk of severe hypoglycemia increases considerably. It has been demonstrated that when protection is provided against hypoglycemia with strict monitoring programs designed to avoid even mild hypoglycemia episodes, blunted autonomic symptoms and counterregulatory hormonal responses are rectified. Therefore, the best course of action in the treatment of pediatric diabetes mellitus is frequent blood sugar measurements, flexible multiple dose insulin regimens facilitating insulin dose adjustments as required, and a diet. In order to implement this, it is essential to organize an intensive training program with the patient and family, and to provide psychological support and close coordination with the diabetes treatment team.

Influence of an early-onset age of type 1 diabetes on cerebral structure and cognitive function

OBJECTIVE

Children who develop type 1 diabetes before age 7 years (early-onset diabetes; EOD) have comparatively poorer cognitive abilities. Whether this relates to psychosocial consequences of chronic illness or organic factors related to diabetes and its complications remains unresolved. We hypothesized that if differences in neuroradiological structure and cognitive ability coexisted in those who had EOD, then an organic component to their etiology was likely.

RESEARCH DESIGN AND METHODS

A cohort of 71 young adults with long-duration type 1 diabetes diagnosed during childhood or adolescence participated in a cross-sectional evaluation of cognitive ability (neuropsychological test battery) and brain structure (magnetic resonance imaging). Diabetes onset age, preceding severe hypoglycemia exposure, retinopathy status, and diabetes duration were examined as potential correlates of cognitive and neuroradiological differences. No participants had previous neuropsychological pathology.

RESULTS

In EOD participants (n = 26), current intellectual ability (Wechsler Adult Intelligence Scale-Revised performance IQ; P = 0.03) and information processing ability (Choice Reaction Time; P = 0.006) were comparatively poorer than was observed in those with later- onset diabetes (n = 45). Furthermore, lateral ventricular volumes were 37% greater (P = 0.002) and ventricular atrophy was more prevalent (61 vs. 20%; P = 0.01) in the EOD group than in those who had later-onset type 1 diabetes.

CONCLUSIONS

An early childhood onset of type 1 diabetes was associated with mild central brain atrophy and significant differences in intellectual performance in adulthood, implying that neurodevelopment may be adversely affected by EOD. The differences observed in brain structure support an organic contribution to their etiology but do not exclude a coexistent contribution of psychosocial factors.

Cerebral dysfunction in type 1 diabetes: effects of insulin, vascular risk factors and blood-glucose levels

Type 1 diabetes can lead to several well-described complications such as retinopathy, nephropathy and peripheral neuropathy. Evidence is accumulating that it is also associated with gradually developing end-organ damage in the central nervous system. This relatively unknown complication can be referred to as "diabetic encephalopathy" and is characterised by electrophysiological and neuroradiological changes, such as delayed latencies of evoked potentials, modest cerebral atrophy and (periventricular) white matter lesions. Furthermore, individuals with type 1 diabetes may show performance deficits in a wide range of cognitive domains. The exact mechanisms underlying this diabetic encephalopathy are only partially known. Chronic metabolic and vascular changes appear to play an important role. Interestingly, the differences in the "cognitive profile" between type 1 and type 2 diabetes also suggest a critical role for disturbances of insulin action in the central nervous system.

Psychological aspects of diabetes mellitus

Diabetes mellitus (DM) presents itself in two forms: insulin-dependent (type 1 DM) and non-insulin-dependent (type 2 DM). Although type 2 DM usually has an adult onset, in recent years there has been a significant rise in the number of children diagnosed with type 2 DM in the United States. Reasons for this increased frequency are believed to be a larger percentage of children who are overweight, a family history of diabetes, and a considerable increase in the use of psychotropic medication in children. The diagnosis of DM is a significant stressor not only for patients but also for their environment. Children with DM are sometimes stigmatized by their peers and relatives who do not understand the illness or are frightened by it. Some children also may need to alter several of their customary routines and are often scared to participate in activities in which they were previously engaged. The family's response to the diagnosis of DM may have a negative effect on glycemic control. Differences have been found in the way patients with type 1 DM and type 2 DM cope with and adapt to their diagnosis.

Psychosocial issues in the child with chronic conditions

Psychosocial issues in children, adolescents and families who suffer with chronic illnesses require careful identification and treatment. Since more of these young people survive into adulthood, their risk of psychosocial distress and psychiatric illness is increased, although many adapt well. The literature is vast, but limited in its usefulness: criteria for the variables described, including chronicity and severity, are poorly defined; outcome measures are not standardized; and few randomized controlled clinical trials exist. This chapter focuses the attention of physicians on overt and covert signs of psychosocial distress in the patient and family with chronic illness. Common issues for all chronic diseases are discussed and a non-categorical approach is taken. The importance of the family as a focus of intervention is highlighted. The meaning and treatment of unexplained medical symptoms, non- adherence with treatment recommendations, school refusal, sexuality and substance use and abuse are discussed.

Factors associated with academic achievement in children with type 1 diabetes

OBJECTIVE

To examine academic achievement in children with diabetes and to identify predictors of achievement.

RESEARCH DESIGN AND METHODS

Participants were 244 children, ages 8-18 years, with type 1 diabetes. Measures included school-administered standardized achievement tests (Iowa Tests of Basic Skills and Iowa Tests of Educational Development [ITBS/ITED]), grade point averages (GPAs), school absences, behavioral assessment, age at disease onset, hospitalizations, and HbA(1c). Statistical differences between subgroups of children were evaluated using t test and ANOVA, statistically controlling for socioeconomic status. Regression analyses were carried out to examine predictors of academic performance.

RESULTS

Reading scores and GPA were lower for children with poor metabolic control than for children with average control. Children with hospitalizations for hyperglycemia had lower overall achievement scores than children with better metabolic control and fewer hospitalizations for hyperglycemia. The small group of children with tight metabolic control and hypoglycemic hospitalizations scored particularly low on the ITBS/ITED. Other variables had less clear relationships with academic achievement. Neither early onset of diabetes nor frequent school absence was associated with lower scores on the ITBS/ITED. Sex comparisons found that boys performed better than girls only in math. Socioeconomic status and parent ratings of behavior problems were significantly correlated with academic achievement, but medical variables added only slightly to predictive precision.

CONCLUSIONS

For most children with diabetes, medical variables are not as strongly associated with academic achievement as are factors such as socioeconomic status and behavioral factors. Poor metabolic control and serious hypoglycemia, however, are a potential concern for a subset of these children.

A systematic literature review of the effectiveness of diabetes education of school personnel

PURPOSE

This paper describes current knowledge levels of school personnel about diabetes, discusses the findings of a systematic review of the literature on the effectiveness of diabetes educational interventions for school personnel, and presents recommendations for future research.

METHODS

English language literature published between January 1966 and May 2001 regarding the effectiveness of diabetes education of school personnel was systematically reviewed using multiple electronic databases.

RESULTS

Four studies that examined the effectiveness of diabetes education of school personnel were identified. One study demonstrated improvement in teacher knowledge of treatment, another reported significant improvement in comprehensive knowledge scores, and a third study demonstrated significant knowledge deficits across 4 measures of teacher knowledge about diabetes. A fourth study demonstrated a decrease in the cumulative frequency of diabetic ketoacidosis.

CONCLUSIONS

The literature regarding the effectiveness of diabetes education of school personnel is scant, the methodology is inadequate, the results are mixed, and the focus is on a narrow range of outcomes. Further research is needed to define effective interventions for improving the health and quality of life of school-age children and adolescents with diabetes.

Effects of diabetes on learning in children

OBJECTIVE

Subtle neuropsychological deficits have been found in some children with type 1 diabetes. However, these data have been inconsistent, and it is not clear what the impact of these deficits might be on the learning of children with diabetes over time. The purpose of this study was to determine whether type 1 diabetes significantly interferes with the development of functional academic skills. It was hypothesized that 1) children with type 1 diabetes would demonstrate deficits in academic performance and behavior when compared with sibling or classmate control subjects and 2) that academic performance in children with type 1 diabetes would decline slightly but significantly over time whereas the performance of siblings or classmates would not.

METHODS

Three groups of children from 5 pediatric diabetes clinics in a primarily rural Midwestern state participated in this study: children with type 1 diabetes (n = 244), a sibling control group (n = 110), and an anonymous matched classmate control group (n = 209). The mean age of the children with diabetes was 14.8 years (standard deviation: 3.2) and of the siblings was 14.6 years (3.2); the mean grades were 8.1 (2.9) for the children with diabetes and 7.9 (3.1) for the siblings. The Hollingshead 2-factor index revealed that the children were from primarily middle- to upper-middle-class families. The mean age of onset of diabetes for the children with diabetes was 8.3 years (3.7) with a mean disease duration of 7.1 years (3.9). Because the matched classmate data were obtained anonymously, demographic information was not available on this group. Academic achievement was measured using both standardized tests and data on classroom performance. The standardized test data included scores from the Iowa Tests of Basic Skills (ITBS) for grades 3 through 8 and the Iowa Tests of Educational Development (ITED) for grades 9 through 12. Scores in 3 broad academic areas that are obtained on children of all ages were examined: math, reading, and core total (a composite score of reading, language, and math). ITBS/ITED data were obtained on all participants. School data including the number of days absent, school years repeated, and grade point averages for math and reading were obtained on the children with diabetes and their siblings. A short, 50-item screening scale (PBS-50d), adapted from the longer 165 item Pediatric Behavior Scale (PBS), was completed by the parents to obtain information on the behavioral characteristics of the children with diabetes and their siblings. Diabetes variables measured included metabolic control (HbA1c), age at onset, and disease duration. This study looked at both the current academic performance of children with diabetes and their performance over time in relation to 2 control groups: siblings and matched classmates. A cross-sectional approach was used to evaluate current performance. Statistical differences between groups were evaluated using matched t tests or McNemar's test for differences between related samples as appropriate. Differences across time were evaluated using hierarchical linear modeling. Comparisons of ITBS/ITED test scores across grades used national percentile ranks that were converted to standard scores (SS) with a mean of 100 and a standard deviation of 15. Students in this study performed above the national average, which is typical of students in the state where this study was conducted. Data from participating clinics were compared, and no differences in current achievement scores, grade point averages, or socioeconomic status were noted for either children with diabetes or their siblings. Therefore, all subsequent analyses used data combined from all sites.

RESULTS

Current academic performance on the ITBS/ITED did not show lower performance by children with diabetes compared with either control group; in fact, children with diabetes performed better than their siblings on math (mean SS: 115.0 vs 111.1) and core total scores (mean SS: 113.9 vs 110.5) and better than their matched classmates on reading (mean SS: 108.9 vs 106.8). When subgroup comparisons based on diabetes metabolic control were made among children with diabetes, poorer academic performance tended to occur in children with poorer diabetic control. However, this pattern was also noted in sibling scores when the siblings were grouped on the basis of the level of diabetic control of their brother or sister with diabetes. Children with diabetes had significantly more school absences (Mean = 7.3 per year) than their siblings (M = 5.3) and more behavioral problems. Behaviorally, the 2 groups did not differ on the 4 general factors of Aggression/Opposition, Hyperactivity/Inattention, Depression/Anxiety, and Physical Complaints. However, children with diabetes did differ significantly from their siblings on items that reflected compliance, mood variability, and fatigue, but not learning. These were 4 areas included in the PBS-50d to reflect potential concerns for children with diabetes. Academic achievement growth curves for the ITBS/ITED for each group revealed no statistically significant differences between groups when tested using hierarchical linear modeling. Individual differences in the growth trajectories were too small and inconsistent to be detected.

CONCLUSIONS

For most children, type 1 diabetes is not associated with lower academic performance compared with either siblings or classmates, although increased behavioral concerns are reported by parents. The results of this study suggest that the subtle cognitive deficits often documented in children with type 1 diabetes may not significantly limit the functional academic abilities of these children over time. However, careful monitoring is still needed to ensure that episodes of hypoglycemia associated with seizures are not adversely affecting learning.

Psychosocial therapies in diabetes: report of the Psychosocial Therapies Working Group

OBJECTIVE

To review key advances in the behavioral science literature related to psychosocial issues and therapies for persons with diabetes, to discuss barriers to research progress, and to make recommendations for future research.

RESEARCH DESIGN AND METHODS

Key findings from the literature on psychosocial research in diabetes are reviewed separately for children and adults. Specific issues covered include psychosocial adjustment and psychiatric disorders, neurocognitive functioning, quality of life, and psychosocial therapies. Barriers that must be addressed to allow research in this area to progress are discussed. Recommendations are then made concerning high-priority areas for advancing research in the field.

CONCLUSIONS

A substantial amount of behavioral science research has demonstrated that psychosocial factors play an integral role in the management of diabetes in both children and adults. Research has also shown the efficacy of a number of psychosocial therapies that can improve regimen adherence, glycemic control, psychosocial functioning, and quality of life. More research in this area is needed to develop psychosocial intervention programs for specific patient populations and to demonstrate the cost-effectiveness of these approaches.

Child and parental mental ability and glycaemic control in children with Type 1 diabetes

AIMS

Many psycho-social factors can affect the glycaemic control of children with Type 1 diabetes, but the influence of the intelligence of the child and their parents has not been reported.

METHODS

Seventy-eight children and adolescents with Type 1 diabetes and their mothers performed standardized tests to assess psychometric intelligence. The children were aged (median (range)) 12.0 (5-17) years with duration of diabetes 5.0 (1.0-13.0) years and required an insulin dose of (mean +/- SD) 1.0 +/- 0.3 U/kg per day. The children completed the Wide Range Achievement Test 3 reading test (WRAT3) and Raven's Standard Progressive Matrices (RSPM). A mean annual HbA1c was calculated for each subject (8.6 +/- 1.4%). The mothers performed the National Adult Reading Test (NART) and provided details of the occupation of the main wage-earner in the family from which social class (SC) was derived.

RESULTS

The HbA1c of the child correlated with their age (r = 0.26, P = 0.02), SC (Kendall's rank correlation, tau = 0.17, P = 0.03) and with the NART error score of their mother (r = 0.28, P = 0.01), but no correlation was observed with the child's WRAT3 or RSPM score. Stepwise regression revealed that age and NART error score were the strongest independent determinants of glycaemic control (total adjusted r2 = 0.117).

CONCLUSIONS

Parental intelligence appears to have a significant influence on the glycaemic control of a child with Type 1 diabetes, accounting for 7.6% of the reliable variance in HbA1c.

Children with diabetes mellitus and family functioning: translating research into practice

The specific challenges of living with diabetes mellitus (DM) which the child and parent must confront at each developmental stage are identified from infancy through adolescence. This discussion is divided into four developmental stages: 1) DM in infancy (0-2 years of age); 2) DM in toddlers and preschoolers (2-5 years); 3) DM in the school-age child (6-11 years); and 4) DM during early- to mid-adolescence (12-16 years). The central milestones of normal psychosocial development are reviewed and a summary is provided of recent research at each developmental stage with an emphasis on clinical implications for pediatric diabetes care teams.

Hypoglycemia: a complication of diabetes therapy in children

Hypoglycemia is the most common acute complication in insulin-treated type 1 diabetic patients. Most surveys have demonstrated that the tighter the glycemic control, and the younger the patient, the greater the frequency of both mild and severe hypoglycemia. However, people in poor metabolic control, with high glycosylated hemoglobin levels, are not protected from experiencing severe hypoglycemia. Focusing on the pediatric population, we review new or controversial issues surrounding the prevalence of hypoglycemia, its causes, its consequences and preventive strategies, and discuss possible mechanisms underlying the variability of responses to hypoglycemia.

Hypoglycemia in children with type 1 diabetes mellitus. Risk factors, cognitive function, and management

This article examines the relationship between hypoglycemia and brain function in children with type 1 diabetes. Hypoglycemic episodes occurring in the first 5 years of life may permanently disrupt cognitive function in a subset of children with diabetes, and a single acute episode of hypoglycemia may produce a transient reduction in mental efficiency, alter the electroencephalogram, and increase regional cerebral blood flow. Because iatrogenic development of hypoglycemic unawareness and autonomic failure are the most likely mediators of moderately severe hypoglycemia, medical management efforts should be directed at the prevention of frequently recurring, mild hypoglycemia.

Acute hyperglycaemia impairs cognitive function in children with IDDM

OBJECTIVE

The effects of acute hyperglycaemia on cognitive function in children remain controversial. This study was designed to investigate the suggestion that acute hyperglycaemia impairs cognition in IDDM children.

DESIGN

To examine this question we studied 12 randomly selected children with IDDM (6 boys, 6 girls, mean age 12.4 years). Cognitive performance was assessed on two occasions at least six months apart (7.4 +/- 1.4 mths, range: 6.3-11.1 mths) under randomised conditions of hyperglycaemia (20-30 mmol/l) on one occasion and euglycaemia (5-10 mmol/l) on the other. Target glucose levels were achieved using a modified clamp technique with subjects and psychologist blinded to the glycaemic level. Cognitive tests chosen to assess performance skills were subtests from the Wechsler Intelligence Scale for Children-3rd Edition (WISC-111).

RESULTS

No significant learning effect was present. However, there was a reduction in performance IQ at hyperglycaemia compared with euglycaemia (106 +/- 4.3 vs 112 +/- 4.5 IQ points respectively, p < 0.05). Under hyperglycaemic conditions the mean decrease in percentile score for performance IQ was 9.5%. Of the 12 children tested, 8 had a decrease in IQ when hyperglycaemic, which was independent of duration of diabetes and long term metabolic control assessed by HbA1c.

CONCLUSION

Acute hyperglycaemia results in impairment of complex cognitive function in children with IDDM. This may have important implications for school performance.

Education and employment for young people with diabetes

Educational achievements and employment experiences were examined using a postal questionnaire in a random sample of diabetic clinic attenders and non-diabetic control subjects aged 16-21 years, selected from 13 different centres in Great Britain. A response rate of 63% and 42% for diabetic and control subjects, respectively, was obtained. The diabetic group experienced a significantly greater number of health difficulties and problems at school (compared with their control group (21% vs 11%, p = 0.01) and there was a significant difference in perceived useful careers advice obtained at school for the two groups (5% vs 59%, p < 0.0001, diabetic and control groups, respectively). There was no difference in the number of General Certificates of Secondary Education (GCSEs) and Advanced (A) level qualifications obtained between the two groups. Of the young people who had left school, diabetic adolescents were significantly more likely to report having lost their jobs than their non-diabetic counterparts (19% vs 6%, p = 0.002). The diabetic group were also more likely to report that they were unable to do the job they wanted compared with the non-diabetic group (28% vs 16%, p = 0.005) and were more likely to report shift work problems (41% vs 12%, p = 0.04). With the increasing rate of unemployment it is important that youngsters with diabetes obtain specific diabetes-orientated vocational guidance in order to plan their careers and provision should be made for this in educational establishments.

Psychoeducational characteristics of children and adolescents with insulin-dependent diabetes mellitus

In recent years, researchers have observed selective neuropsychological impairment associated with insulin-dependent diabetes mellitus in childhood. At increased risk are children who develop diabetes before the age of 5, who experience severe hypo- and hyperglycemia, or who have frequent episodes of mild to moderate hypoglycemia. This article explores the existing literature to establish frequency and consistency of general and specific neurocognitive deficits in this pediatric patient population, as well as the impact of these deficits on school achievement and learning disabilities. Studies are integrated to identify contributing diabetes and nondiabetes factors. This is followed by a reanalysis of the data from two studies of diabetic children to determine the learning disability characteristics of this population and the factors contributing to dysfunctional school performance. Findings are discussed in terms of the impact of different factors reflecting adequacy of diabetes control on specific psychoeducational abilities.

The social consequences of insulin-treated diabetes mellitus in patients 20-50 years of age. An epidemiological case-control study

In order to investigate the social consequences of diabetes we sent a questionnaire to all diabetic patients aged 20-50 years and 1.125 matched non-diabetic controls living in the county of Västerbotten in Northern Sweden. The response rate was 87% and 72%, respectively. Patients more often lived alone (18 vs 13% p less than 0.05) and had no children (39 vs 31% p less than 0.01). They were more often the only child of their parents (14 vs 8%, p less than 0.01). Thirty-seven percent of the patients and 22% of the controls (p less than 0.001) had been absent from work because of illness more than one month continuously during the last 3 years and had more often than controls prematurely retired from work (8 vs 2% p less than 0.001). Patients more often had hobbies (86 vs 76%, p less than 0.001) and were participating in social activities (52 vs 41%, p less than 0.001), but were less satisfied with their leisure time (71 vs 80%, p less than 0.001). Forty percent of the patients vs 31% of the controls (p less than 0.01) did not visit neighbours. Fifty-one percent of the patients vs 44% of the controls (p less than 0.05) never spent leisure time with their work mates. No significant differences were found in education, socioeconomic class, dwelling or household economy. The study shows that there are social differences between diabetic patients and non-diabetic people even though they are not overwhelming.

Mild hypoglycemia associated with deterioration of mental efficiency in children with insulin-dependent diabetes mellitus

To assess the effects of mild hypoglycemia on cognitive functioning in diabetic children, we used an insulin glucose clamp technique to induce and maintain a hypoglycemic state. Eleven patients, 11 to 18 years of age, completed a series of cognitive tests during a baseline euglycemic state (100 mg/dl (5.5 mmol/L] and repeated those measures at the beginning and end of a hypoglycemic plateau (55 to 65 mg/dl (3.1 to 3.6 mmol/L], and again at restoration of euglycemia. At plasma glucose levels of 60 to 65 mg/dl (3.3 to 3.6 mmol/L), a significant decline in mental efficiency was found. This was most apparent on measures of mental "flexibility" (Trial Making Test) and on measures that required planning and decision making, attention to detail, and rapid responding. Moreover, complete recovery of cognitive function was not contemporaneous with restoration of euglycemia, particularly on those tests requiring rapid responding and decision making (choice reaction time). Not all subjects showed evidence of cognitive impairment during hypoglycemia. The very high degree of intersubject variability suggests that, in addition to plasma glucose values, unknown physiologic variables are responsible for triggering cognitive impairments in school-aged youngsters with diabetes during an episode of mild hypoglycemia.