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

Development and psychometric evaluation of the type 1 diabetes mellitus self-management scale for parents

BACKGROUND/AIM

Diabetes has become a global epidemic, necessitating effective self-management strategies. This is particularly crucial for parents of children with type 1 diabetes mellitus, as they must make numerous daily decisions and perform complex care activities. Therefore, the aim of this study was to develop a comprehensive diabetes self-management scale specifically for parents of children with type 1 diabetes. This scale aims to holistically address behaviors impacting diabetes self-management and to evaluate its psychometric properties.

MATERIALS AND METHODS

A methodological, correlational, and cross-sectional study was conducted with a sample of 190 parents of children with type 1 diabetes mellitus. The scale items were reviewed by five experts to ensure they adequately covered the parents' evaluation of their children's diabetes self-management. Following this, a Turkish language expert assessed the draft scale for language accuracy, comprehensibility, and grammar. The data were analyzed using descriptive statistics (numbers and percentages), Cronbach's α reliability coefficient, factor analysis, and correlation analysis.

RESULTS

The Cronbach's alpha for the overall scale was 0.893, and the Cronbach's alpha for the subscales was between 0.757 and 0.845. The item-total score correlations ranged between 0.408 and 0.660 (p < .05). The exploratory factor analysis showed that the scale explained 61.427% of the total variance, and the factor loadings of items ranged from 0.574 to 0.859. The confirmatory factor analysis also showed that the factor loadings of the scale items ranged from 0.574 to 0.859.

CONCLUSION

The validity and reliability analyses revealed that the scale is a valid and reliable measurement tool for the Turkish culture.

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.

Patient- and caregiver-reported factors associated with school absenteeism in children with chronic kidney disease

BACKGROUND

Children with chronic kidney disease (CKD) are at risk for neurocognitive deficits while simultaneously being at risk for chronic school absenteeism (≥ 18 school days per school year). Chronic school absenteeism compounds the negative impacts of CKD on academic achievement. In this study, we examined patient- and caregiver-reported factors associated with school absenteeism in children with non-dialysis- or transplant-dependent CKD in order to help identify which factors could be modifiable and ultimately improve school attendance.

METHODS

We utilized a combination of chart review and questionnaires distributed in person to patients and caregivers at a pediatric nephrology clinic between November 2018 and August 2019 to gather data. We used descriptive statistics to illustrate clinical characteristics of the children included in the study, caregiver characteristics, and examined reported reasons for missing school.

RESULTS

Twenty-one percent of participants (10/48) missed 18 full days of school or more, categorizing them as chronically absent. The top three reasons for missing school were doctor appointments, feeling sick, and being bullied. More specific sequelae of CKD were not highly reported as reasons for missing school.

CONCLUSIONS

Chronic absenteeism is a highly reported phenomenon among children with pediatric CKD. Given that missing school for doctor appointments was a top reason for absenteeism, this data suggests alternative appointment hours and virtual appointments may reduce chronic school absenteeism in children, and by extension improve their health, behavioral, and academic outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.

Hospital service use for young people with chronic health conditions: A population-based matched retrospective cohort study

AIM

This study aims to identify the hospitalised morbidity associated with three common chronic health conditions among young people using a population-based matched cohort.

METHODS

A population-level matched case-comparison retrospective cohort study of young people aged ≤18 years hospitalised with asthma, type 1 diabetes (T1D) or epilepsy during 2005-2018 in New South Wales, Australia using linked birth, health and mortality records. The comparison cohort was matched on age, sex and residential postcode. Adjusted rate ratios (ARR) were calculated by sex and age group.

RESULTS

There were 65 055 young people hospitalised with asthma, 6648 with epilepsy, and 2209 with T1D. Young people with epilepsy (ARR 10.95; 95% confidence interval (CI) 9.98-12.02), T1D (ARR 8.64; 95% CI 7.72-9.67) or asthma (ARR 4.39; 95% CI 4.26-4.53) all had a higher risk of hospitalisation than matched peers. Admission risk was highest for males (ARR 11.00; 95% CI 9.64-12.56) and females with epilepsy (ARR 10.83; 95% CI 9.54-12.29) compared to peers. The highest admission risk by age group was for young people aged 10-14 years (ARR 5.50; 95% CI 4.77-6.34) living with asthma, children aged ≤4 years (ARR 12.68; 95% CI 11.35-14.17) for those living with epilepsy, and children aged 5-9 years (ARR 9.12; 95% CI 7.69-10.81) for those living with T1D compared to peers.

CONCLUSIONS

The results will guide health service planning and highlight opportunities for better management of chronic health conditions, such as further care integration between acute, primary and community health services for young people.

The impact of type 1 diabetes mellitus in childhood on academic performance: A matched population-based cohort study

BACKGROUND AND OBJECTIVE

The impact of type 1 diabetes mellitus (T1D) on academic performance is inconclusive. This study aims to compare scholastic performance and high-school completion in young people hospitalized with T1D compared to matched peers not hospitalized with diabetes.

RESEARCH DESIGN

Retrospective case-comparison cohort study.

METHOD

A population-level matched case-comparison study of people aged ≤18 hospitalized with T1D during 2005-2018 in New South Wales, Australia using linked health-related and education records. The comparison cohort was matched on age, gender, and residential postcode. Generalized linear mixed modeling examined risk of school performance below the national minimum standard (NMS) and generalized linear regression examined risk of not completing high school for young people hospitalized with T1D compared to peers. Adjusted relative risks (ARR) were calculated.

RESULTS

Young females and males hospitalized with T1D did not have a higher risk of not achieving the NMS compared to peers for numeracy (ARR: 1.19; 95%CI 0.77-1.84 and ARR: 0.74; 95%CI 0.46-1.19) or reading (ARR: 0.98; 95%CI 0.63-1.50 and ARR: 0.85; 95%CI 0.58-1.24), respectively. Young T1D hospitalized females had a higher risk of not completing year 11 (ARR: 1.73; 95%CI 1.19-2.53) or 12 (ARR: 1.65; 95%CI 1.17-2.33) compared to peers, while hospitalized T1D males did not.

CONCLUSIONS

There was no difference in academic performance in youth hospitalized with T1D compared to peers. Improved glucose control and T1D management may explain the absence of school performance decrements in students with T1D. However, females hospitalized with T1D had a higher risk of not completing high school. Potential associations of this increased risk, with attention to T1D and psycho-social management, should be investigated.

Association of type 1 diabetes and educational achievement in 16-20-year-olds: A Danish nationwide register study

AIMS

The objective of the study was to compare grade point averages (GPAs) on compulsory school exit exams (exam GPA) and educational attainment at age 16 and 20 for individuals with and without type 1 diabetes.

METHODS

This study was a population-based retrospective cohort study, which included the 1991 to 1998 birth cohorts in Denmark. Follow-up was conducted at age 16 and 20 (follow-up period; 1 January, 2007 to 31 December, 2018). There were 2083 individuals with and 555,929 individuals without type 1 diabetes. Linear regression and generalized linear models compared outcomes with and without adjustments for socio-economic characteristics.

RESULTS

A total of 558,012 individuals (51% males) were followed to the age of 20. Having type 1 diabetes was associated with a lower exam GPA when adjusting for socio-economic status (difference: -0.05 (95% CI, -0.09 to -0.01), a higher relative risk of not completing compulsory school by age 16 (1.37, 95% CI, 1.22 to 1.53)), and a higher relative risk of not completing or being enrolled in upper secondary education by age 20 (1.05, 95% CI, 1.00 to 1.10). Haemoglobin A1c (HbA1c) <58 mmol/mol (7.5%), >7 BGM/day and insulin pump use were associated with better educational achievement.

CONCLUSION

Type 1 diabetes was associated with a marginally lower exam GPA and a higher risk of not completing compulsory school by age 16 and lower educational attainment by age 20. The findings were modified by HbA1c, BGM and insulin pump use.

School practice and preparedness in caring for children with type 1 diabetes: A Saudi nationwide cross-sectional study

AIM

We aimed to identify gaps in school care and support required for students with type 1 diabetes mellitus (T1DM) in Saudi Arabia.

METHODS

We performed a cross-sectional nationwide study using self-administered surveys that targeted teachers and parents of students with T1DM in Saudi Arabia from August to December 2019.

RESULTS

We collected surveys from 632 parents and 983 teachers. Responses were received from all 13 regions in Saudi Arabia, with the majority representing governmental schools. Results showed that 172 students (27.3%) had no available help at school to perform blood glucose measurement, 178 students (28.3%) were left with no hypoglycemia treatment, 374 students (59.6%) took their insulin dose for breakfast at home, and 40.0 (6.4%) students omitted insulin. Overall, school admission refusal was reported by 73 students (11.7%). Students with no available help to manage their hypoglycemia or to inject insulin at school had a higher hemoglobin A1c and poorer academic performance.

CONCLUSION

Our study revealed a significant gap between schools' local practices and international recommendations, which impacted students' safety, diabetes control, and school achievement. Our study findings will support the creation of the Saudi T1DM school practice guidelines necessary to improve the care of students with T1DM.

Intermittently scanned continuous glucose monitoring is associated with high satisfaction but increased HbA1c and weight in well-controlled youth with type 1 diabetes

OBJECTIVE

We undertook a 24-month prospective observational single-center real-world trial to study impact of access to intermittently scanned continuous glucose monitoring (isCGM) on quality of life (QOL) and glycemic control of youth with type 1 diabetes (T1D).

METHODS

Between September 2016 and November 2017, 138 children and adolescents with T1D were recruited. Demographic, metabolic, and QOL data were collected during 24 months of routine follow-up. Primary endpoint was the evolution of QOL, with secondary outcomes change in HbA1c, occurrence of acute diabetes complications, and school absenteeism.

RESULTS

Ninety-two percent of participants found isCGM more user-friendly than capillary finger-stick tests and had high treatment satisfaction, without change in diabetes-specific QOL. HbA1c significantly increased from 7.2% (7.0-7.3) (55 mmol/mol [53-56]) at baseline to 7.6% (7.4-7.8) (60 mmol/mol [57-62]) at 12 months (P < .0001) and was unchanged up to 24 months. Overall increase was mainly driven by children with baseline HbA1c <7.0% (<53 mmol/mol). Additionally, BMI adjusted for age was higher at study end. In year before isCGM, 228 days per 100 patient-years of school absenteeism were reported, which dramatically decreased to 13 days per 100 patient-years (P = .016) after 24 months. Parents of children also reported less work absenteeism (P = .011).

CONCLUSION

The use of isCGM by T1D pediatrics is associated with high treatment satisfaction and fewer days of school absence. However, increased HbA1c and weight may reflect a looser lifestyle, with less attention to diet and more avoidance of hypoglycemia. Intensive education specifically focusing on these points may mitigate these issues.

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.

The DISABKIDS generic and diabetes-specific modules are valid but not directly comparable between Denmark, Sweden, and Norway

BACKGROUND/OBJECTIVES

Government guidance promote benchmarking comparing quality of care including both clinical values and patient reported outcome measures in young persons with type 1 diabetes. The aim was to test if the Nordic DISABKIDS health-related quality of life (HrQoL) modules were construct valid and measurement comparable within the three Nordic countries.

METHODS

Data from three DISABKIDS validation studies in Sweden, Denmark, and Norway were compared using Rasch and the graphical log-linear Rasch modeling. Monte Carlo methods were used to estimate reliability coefficient and target was defined as the point with the lowest SE of the mean. Self-report data were available from 99 Danish (8-18 years), 103 Norwegian (7-19 years), and 131 Swedish (8-18 years) young people.

RESULTS

For the DISABKIDS higher scores on most subscales were noted in the Norwegian population. The Swedish sample had a significantly higher score on the "Diabetes treatment" subscale and scores closer to optimal target than the other countries. For each country, construct validity and sensitivity were acceptable when accounting for differential item function (DIF) and local dependency (LD). Less LD and DIF were found if only Denmark and Norway were included. The combined model was reliable; however, some differences were noted in the scale translations relating to the stem and response alternatives, which could explain the discrepancies.

CONCLUSION

The Nordic versions of the DISABKIDS questionnaires measures valid and reliable HrQoL both within and between countries when adjusted for DIF and LD. Adjusting the Likert scales to the same respond categories may improve comparability.

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.

Childhood Disability and Educational Outcomes: A Systematic Review

PROBLEM

Graduation from high school is an important milestone for all adolescents and affects future health in adulthood. Children with chronic illnesses have additional challenges that affect school attendance, grade retention and graduation. If children with chronic conditions are not able to participate fully in education, this may limit their opportunities for future health. The aim of this study was to integrate the evidence in the past 28 years about educational outcomes of children and adolescents with chronic conditions causing disability.

ELIGIBILITY CRITERIA

Quantitative studies reporting on a chronic condition and attendance, grade retention, or high school graduation, from a peer-reviewed journal in the English language, data collection since 1990, and research conducted with a population in the United States were eligible for review.

SAMPLE

Forty-three studies from a literature search of CINAHL, MEDLINE, ERIC, Teacher Reference Center, Psychology & Behavioral Science Collection, and Academic Search Elite databases, followed by ancestry searches, were included in this review.

RESULTS

In general, chronic conditions are significantly associated with increased absenteeism, grade repetition and not completing high school within four years, although hemophilia does not follow this pattern. Additionally, increased severity of the condition is associated with poorer educational outcomes.

CONCLUSIONS

Nurses and other healthcare providers should include an educational assessment as part of psychosocial assessment of children and adolescents to identify risk, intervene early and limit risk.

Nonverbal intelligence and scholastic performance in children with type 1 diabetes

This study examined nonverbal intelligence and scholastic achievement in children with type 1 diabetes. In a retrospective case–control study, 69 children (35 males) ages 5–10 years with type 1 diabetes and 69 healthy controls matched to patients by age, gender and socioeconomic status were compared according to their performance on Raven’s Coloured Progressive Matrices and their scholastic grades. No differences in nonverbal intelligence and grades were observed between children with type 1 diabetes and healthy control subjects. Raven’s Coloured Progressive Matrices scores inversely correlated with duration of illness both in children with early onset of type 1 diabetes and poor metabolic control. Possible explanations of the results and implications are discussed.

The Link Between School Attendance and Good Health

More than 6.5 million children in the United States, approximately 13% of all students, miss 15 or more days of school each year. The rates of chronic absenteeism vary between states, communities, and schools, with significant disparities based on income, race, and ethnicity. Chronic school absenteeism, starting as early as preschool and kindergarten, puts students at risk for poor school performance and school dropout, which in turn, put them at risk for unhealthy behaviors as adolescents and young adults as well as poor long-term health outcomes. Pediatricians and their colleagues caring for children in the medical setting have opportunities at the individual patient and/or family, practice, and population levels to promote school attendance and reduce chronic absenteeism and resulting health disparities. Although this policy statement is primarily focused on absenteeism related to students' physical and mental health, pediatricians may play a role in addressing absenteeism attributable to a wide range of factors through individual interactions with patients and their parents and through community-, state-, and federal-level advocacy.

Metabolic control and academic achievement over time among adolescents with type 1 diabetes

The relation between metabolic control (HbA1c) and achievement (grade point average [GPA]) was examined over a period of 2.5 years (every 6 months) employing a dynamical systems approach that allowed for the examination of whether HbA1c was associated with change in subsequent GPA and vice versa. Metabolic control tends to deteriorate (i.e., with higher HbA1c reflecting poorer metabolic control) during adolescence. It was hypothesized that these higher levels of HbA1c would limit subsequent increases in GPA. The sample included 252 adolescents (Mbaseline age = 12.49 years, SD = 1.53; 53.6% female) with Type 1 diabetes. Mothers' report and school records provided information on relevant demographics and GPA; medical records provided values of HbA1c. Two simultaneous coupled change equations (i.e., examining current values in 1 variable associated with changes in the other) controlling relevant risk indicators (i.e., age, sex, disease duration, insulin delivery method, IQ) revealed higher levels of HbA1c limited increases in GPA. Higher levels of GPA, however, were not associated with change in HbA1c except for 2 instances where moderation existed by disease duration and IQ. Higher GPA was associated with slower increases in HbA1c over time for youth with shorter disease duration and lower IQ. These results affirm the importance of maintaining good metabolic control to facilitate adequate school performance across the adolescent years. Further, the results suggest that factors related to school achievement may protect adolescents who are newly diagnosed or who have low cognitive ability from subsequent deterioration in metabolic control. (PsycINFO Database Record

Cognition and Type 1 Diabetes in Children and Adolescents

IN BRIEF In children and adolescents with type 1 diabetes, exposure to glycemic extremes (severe hypoglycemia, chronic hyperglycemia, and diabetic ketoacidosis) overlaps with the time period of most active brain and cognitive development, leading to concerns that these children are at risk for cognitive side effects. This article summarizes the existing literature examining the impact of glycemic extremes on cognitive function and brain structure in youth with type 1 diabetes and points out areas for future research.

Academic abilities and glycaemic control in children and young people with Type 1 diabetes mellitus

AIMS

To determine if children and young people aged < 23 years with Type 1 diabetes differ in academic ability from age-matched control subjects without Type 1 diabetes and whether academic scores are related to glycaemic control.

METHODS

Using a cross-sectional study design, we administered cognitive and academic tests (Woodcock-Johnson III Spatial Relations, General Information, Letter-Word Recognition, Calculation and Spelling tests) to young people with Type 1 diabetes (n=61) and control subjects (n=26) aged 9-22 years. The groups did not differ in age or gender. Participants with Type 1 diabetes had a disease duration of 5-17.7 years. History of glycaemic control (HbA1c , diabetic ketoacidosis and severe hypoglycaemic episodes) was obtained via medical records and interviews.

RESULTS

The participants with Type 1 diabetes had a lower mean estimated verbal intelligence (IQ) level compared with those in the control group (P=0.04). Greater exposure to hyperglycaemia over time was associated with lower spelling abilities within the group with Type 1 diabetes (P=0.048), even after controlling for age, gender, socio-economic status, blood glucose level at time of testing and verbal IQ (P=0.01). History of severe hypoglycaemia or ketoacidosis was not associated with differences in academic abilities.

CONCLUSIONS

In children and young people, Type 1 diabetes was associated with a lower verbal IQ. Moreover, increased exposure to hyperglycaemia was associated with lower spelling performance. These results imply that hyperglycaemia can affect cognitive function and/or learning processes that may affect academic achievement.

Evaluation of the correlation between type 1 diabetes and cognitive function in children and adolescents, and comparison of this correlation with structural changes in the central nervous system: a study protocol

INTRODUCTION

Diabetes mellitus type 1 (T1DM) affects nearly 15 million children worldwide and failure to achieve and maintain good glycaemic control in this group can lead to diabetes-related complications. Children with T1DM can experience impairment in cognitive function such as memory, attention and executive function. This study is designed to evaluate the correlation between diabetes and cognitive dysfunction as well as to clarify whether this correlation can be linked to neurological structural changes in 6-11-year-old children with diabetes.

METHODS AND ANALYSIS

310 eligible children with diabetes will be divided into two groups based on glycaemic control according to their HbA1c index. The control group will include 150 children aged 6-11 without diabetes. The following parameters will be measured and investigated: duration of the disease since diagnosis, required daily insulin dose, frequency of insulin administration, hospital admissions due to diabetes, hypoglycaemic episodes during the last year, and episodes of diabetic ketoacidosis. The following components of cognitive function will be evaluated: memory, attention, executive function, decision-making and academic performance. Cognitive function and subsequent subtests will be assessed using Cambridge Neuropsychological Test Automated Battery (CANTAB) tools. Brain structural indices such as intracranial vault (ICV), as well as cerebrospinal fluid (CSF), ventricle, hippocampus, total intracranial, total brain, grey matter and white matter volume will be measured using MRI. ANOVA, correlational tests (Spearman) and regression models will be used to evaluate the hypothesis.

ETHICS AND DISSEMINATION

This study is approved by the ethics committee of the Endocrinology and Metabolism Research Institute (EMRI) of Tehran University of Medical Sciences (TUMS) under reference number 00300. Our findings are to be published in a peer-reviewed journal and disseminated both electronically and in print.

Validation of the Diabetes Family Impact Scale: a new measure of diabetes-specific family impact

AIMS

To develop and validate the Diabetes Family Impact Scale, a scale to measure the impact of diabetes on families.

METHODS

The Diabetes Family Impact Scale was developed by an iterative process, with input from multidisciplinary diabetes providers and parents of children with Type 1 diabetes. The psychometric properties of the Diabetes Family Impact Scale were assessed in parents of children with Type 1 diabetes. This assessment included internal consistency, convergent validity and exploratory factor analysis.

RESULTS

Parents (n = 148) of children (mean ± sd age 12.9 ± 3.3 years) with Type 1 diabetes (mean ± sd duration 6.2 ± 3.6 years) completed the 15-item Diabetes Family Impact Scale. After eliminating one item, the 14-item measure demonstrated good internal consistency (Cronbach's α  =  0.84). Correlations between the Diabetes Family Impact Scale and measures of parent diabetes burden (r = 0.48, P < 0.0001), stressful life events (r = 0.28, P = 0.0007), and child's quality of life (r = -0.52 and -0.54, P < 0.0001 for generic and diabetes-specific quality of life, respectively) supported the convergent validity of the instrument. Factor analysis identified four factors corresponding to the four survey domains (school, work, finances and family well-being).

CONCLUSIONS

The Diabetes Family Impact Scale measures diabetes-specific family impacts with good internal consistency and convergent validity and may be a useful tool in clinical and research settings.

Diabetes management in Swedish schools: a national survey of attitudes of parents, children, and diabetes teams

BACKGROUND

Parents of children with type 1 diabetes often raise complaints about self-care support during school time. The aim of this study was to investigate attitudes to diabetes care in school reported by children with type 1 diabetes, their parents, and their diabetes teams.

METHODS

Children who had completed preschool class or at least one grade in the 9-yr compulsory school system were invited to participate. Data were collected using separate questionnaires for the children and their parents. In addition, the members of the diabetes team answered a separate questionnaire. All pediatric diabetes centers in Sweden were invited to participate in the study.

RESULTS

All Swedish children and adolescents with diabetes are treated at pediatric diabetes centers. Out of 44 eligible centers, 41 were able to participate. The questionnaires were completed by 317 children and adolescents and 323 parents. The mean age was 11.4 ± 2.7 yr and hemoglobin A1c (HbA1c) was 61.8 ± 12.4 mmol/mol (7.8 ± 1.1%). For 57% of the children, there was no member of staff at the school with principal responsibility to support diabetes self-care. A written action plan for hypoglycemia existed for 60% of the children. Twenty-one percent of the parents regularly gave less insulin than they calculated would be needed at breakfast because of fear of hypoglycemia during school time.

CONCLUSIONS

Although Sweden has legislation underlining the specific need for diabetes care in school, this nationwide study demonstrates deficiencies in the support of self-care management.

Glycemic extremes in youth with T1DM: the structural and functional integrity of the developing brain

The adult brain accounts for a disproportionally large percentage of the body’s total energy consumption (1). However, during brain development,energy demand is even higher, reaching the adult rate by age 2 and increasing to nearly twice the adult rate by age 10, followed by gradual reduction toward adult levels in the next decade (1,2). The dramatic changes in brain metabolism occurring over the first two decades of life coincide with the initial proliferation and then pruning of synapses to adult levels.The brain derives its energy almost exclusively from glucose and is largely driven by neuronal signaling, biosynthesis, and neuroprotection (3–6).Glucose homeostasis in the body is tightly regulated by a series of hormones and physiologic responses. As a result, hypoglycemia and hyperglycemia are rare occurrences in normal individuals, but they occur commonly inpatients with type 1 diabetes mellitus (T1DM) due to a dysfunction of peripheral glucose-insulin-glucagon responses and non-physiologic doses of exogenous insulin, which imperfectly mimic normal physiology. These extremes can occur more frequently in children and adolescents with T1DM due to the inadequacies of insulin replacement therapy, events leading to the diagnosis [prolonged untreated hyperglycemia and diabetic ketoacidosis (DKA)], and to behavioral factors interfering with optimal treatment. When faced with fluctuations in glucose supply the metabolism of the body and brain change dramatically, largely to conserve resources and, at a cost to other organs, to preserve brain function (7). However,if the normal physiological mechanisms that prevent these severe glucose fluctuations and maintain homeostasis are impaired, neuronal function and potentially viability can be affected (8–11).

Impact of childhood-onset type 1 diabetes on schooling: a population-based register study

AIMS/HYPOTHESIS

We investigated the impact of type 1 diabetes on educational achievements in compulsory and upper secondary school, as well as potential long-lasting effects.

METHODS

Altogether 2,485 individuals with type 1 diabetes, diagnosed at the age of <15 years and born in 1972-1978, were selected from the Swedish Childhood Diabetes Register, which was linked to national population registers including the Swedish Education Register. For each individual, four controls from the general population, matched for year of birth and residence at the time of diagnosis, were selected by Statistics Sweden (n = 9,940). We analysed the impact of diabetes on final school grades at 16 years (compulsory school) and 19 years (upper secondary school) and on participation in the labour market at 29 years using linear, logistic, ordered logistic and quantile regression analyses, controlling for demographics and socioeconomic background.

RESULTS

Diabetes had a negative effect on mean final grades (scale of 1-5) in compulsory school (-0.07, p < 0.001) and theoretical programmes in upper secondary school (-0.07, p = 0.001). Children with early-onset diabetes (0-4 years) suffered a greater disadvantage as a result of the disease (-0.15, p = 0.001 in compulsory school). The strongest effect was seen in the lowest deciles of the conditional distribution on mean final grades. At age 29, individuals with diabetes were less likely to be gainfully employed (OR 0.82, 95% CI 0.73, 0.91).

CONCLUSIONS/INTERPRETATION

The small but significant negative effect of type 1 diabetes on schooling could affect opportunities for further education and career development. Attention must be paid in school to the special needs of children with diabetes.

Impact of type 1 diabetes mellitus on the family is reduced with the medical home, care coordination, and family-centered care

OBJECTIVES

To examine whether the medical home, care coordination, or family-centered care was associated with less impact of type 1 diabetes mellitus (T1D) on families' work, finances, time, and school attendance.

STUDY DESIGN

With the 2005 to 2006 National Survey of Children with Special Health Care Needs, we compared impact in children with T1D (n = 583) with that in children with other special health care needs (n = 39 944) and children without special health care needs (n = 4945). We modeled the associations of the medical home, care coordination, and family-centered care with family impact in T1D.

RESULTS

Seventy-five percent of families of children with T1D reported a major impact compared with 45% of families of children with special health care needs (P < .0001) and 17% of families of children without special health care needs (P < .0001). In families of children with T1D, 35% reported restricting work, 38% reported financial impact, 41% reported medical expenses >$1000/year, 24% reported spending ≥11 hours/week caring or coordination care, and 20% reported ≥11 school absences/year. The medical home, care coordination, and family-centered care were associated with less work and financial impact.

CONCLUSIONS

In childhood T1D, most families experience major impact. Better systems of health care delivery may help families reduce some of this impact.

Academic skills in children with early-onset type 1 diabetes: the effects of diabetes-related risk factors

AIM

The study aimed to assess the effects of diabetes-related risk factors, especially severe hypoglycaemia,on the academic skills of children with early-onset type 1 diabetes mellitus (T1DM).

METHOD

The study comprised 63 children with T1DM (31 females, 32 males; mean age 9 y 11 mo,SD 4 mo) and 92 comparison children without diabetes (40 females, 52 males;mean age 9 y 9 mo,SD 3 mo). Children were included if T1DM had been diagnosed before the age of 5 years and if they were aged between 9 and 10 years at the time of study. Children were not included if their native language was not Finnish and if they had a diagnosed neurological disorder that affected their cognitive development. Among the T1DM group, 37 had and 26 had not experienced severe hypoglycaemia and 26 had avoided severe hypoglycaemia. Severe hypoglycaemia, diabetic ketoacidosis(DKA), and glycaemic control were used as T1DM-related factors. Task performance in reading, spelling, and mathematics was compared among the three groups, and the effects of the T1DM-related factors were analysed with general linear models.

RESULTS

The groups with (p<0.001) and without (p=0.001) severe hypoglycaemia demonstrated a poorer performance than the comparison group in spelling, and the group without severe hypoglycaemia showed a poorer performance than the comparison group in mathematics (p=0.003).Severe hypoglycaemia, DKA, and recent glycaemic control were not associated with poorer skills,but poorer first-year glycaemic control was associated with poorer spelling (p=0.013).

INTERPRETATION

An early onset of T1DM can increase the risk of learning problems, independently of the history of severe hypoglycaemia or DKA. Poorer glycaemic control after the first year of T1DM is associated with a poorer acquisition of academic skills indicating the effect of the timing of metabolic aberrations on cognitive development.