(Silverstein 2005). In the last 10 years there have been few or conflicting studies of the incidence of specialized classroom assistance in diabetic youth (Crawford 1995). Thus, earlier studies may no longer accurately reflect the current incidence of special classroom placement.
The Education of All Handicapped Children Act of 1974 (PL 94-142), now called the Individuals with Disabilities Education Act (IDEA), mandates that all states provide a free appropriate public education (FAPE) in the least restrictive environment for children with a handicapping condition, such as special educational or learning needs, to receive federal funds. Services may be mandated based on borderline or lower intellectual abilities or a significant discrepancy between an individually administered IQ score and an achievement test score along with cognitive processing difficulties, such as clinically significant memory problems. If an individual meets these criteria, services may be provided and an Individual Education Plan (IEP) formulated. An IEP documents the special services or accommodations to be provided for a child in the classroom. Only children with diabetes who have a clinically diagnosable learning disability will qualify for these intensive school services. More information about IDEA is available at www.ed.gov/offices/OSERS/OSEP or through the American Diabetes Association (ADA) at http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-school/written-care-plans.
Most children with diabetes qualify for a broader, less intensive range of educational services or accommodations through the Education Rehabilitation Act of 1973. This Act forbids discrimination against individuals on the basis of a “disability,” which can include temporary disabilities such as a broken leg. Under Section 504 of the Act, students with medical conditions can receive accommodations to participate in academic and extracurricular activities the same as other students. Diagnosis with a formal learning disability is not required to receive educational accommodations with a 504 Plan. Often the foundation of a 504 Plan is a Diabetes Medical Management Plan (DMMP) or physician’s order that prescribes recommended school-based medical care plans. The DMMP is the medical basis for an Individualized Health Plan (IHP), written by the school nurse, which specifies what, where, when, and by whom diabetes care tasks will be provided in school. The IHP provides medical care at school but not educational accommodations. A diabetes 504 Plan provides written guidelines for diabetes-related educational accommodations that are protected under federal law. Common services and exceptions may include storing and administering insulin and blood glucose monitoring equipment or supplies at school as well as allowing students to carry and eat snacks in the classroom. More frequent school absences are permitted to accommodate routine medical visits, and extra bathroom breaks or trips to the water fountain are usually allowed. Private schools that receive federal funds must also be responsive to these student-related requests. A teacher, psychologist, school nurse, or principal can organize a 504 meeting. Before a meeting, parents can write a letter that explains their child’s diabetes-related needs and how they can be accommodated in school. If necessary, a physician can write a letter to explain unusual medical needs. More information is available about 504 Plans at http://www.isbe.net/spec-ed/pdfs/parent_guide/ch15-section_504.pdf or via the American Diabetes Association at http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-school/written-care-plans.
Neuropsychological Skills Associated with Learning Problems
Despite generally average IQ scores, subgroups of children may have a higher risk for specific cognitive processing problems or neuropsychological difficulties, in areas such as visual spatial or memory skills. Clinically significant difficulties are defined as more than 15 points below intellectual level (1–2 standard deviations). The following difficulties have been described in subgroups of children with diabetes; individuals may or may not be affected.
Chronic Disease–Related Findings
Earlier disease onset, defined by some authors as <5 years and by others as <7 years, is related to greatest skill disruption, compared with other groups of diabetic children, with lowest scores (4 to 6 points) in mental processing speed, verbal memory, and learning. Differences of this magnitude could be clinically detectable in school performance and may be perceived by children as frustrating and as relative weaknesses compared with their other stronger skills. Slightly lower (2 to 3 points) nonverbal/visual spatial skills, visual memory and learning, and academic achievement are found in children with later disease onset (Ryan 1985, Rovet 1990, Northam 2001, Gaudieri 2008). However, these differences may become greater, up to 7 points, with longer disease duration in adults who had early disease onset (Ferguson 2005).
Longer disease duration, defined as greater than 5 years but usually less than 8 or 9 years in pediatric populations, is related to mildly lower spatial and visual/perceptual skills (2 to 3 points), compared with shorter disease duration under 5 years. Cross-sectional and longitudinal studies indicate that lower verbal memory and failure to make expected developmental gains in vocabulary and other areas of verbal school achievement may be detectable as soon as 2 years after diagnosis with diabetes (Ryan 1985, Rovet 1990, Northam 2001).
Recurrent Severe Hypoglycemia and Chronic Hyperglycemia
Severe hypoglycemia that results in seizures or unconsciousness may have differential age-related effects on the brain, with greater visual spatial and diffuse brain and skill impact on children below the age of 5 or 6 years (Hannonen 2003, Hershey 2003). For older children, controversy exists regarding whether severe hypoglycemia affects verbal memory and, if so, at what glycemic threshold. Clinically, detrimental lasting effects may be seen only with multiple severe hypoglycemic episodes (i.e., over five) or episodes that may interact with a sensitive period of child brain development (i.e., under age 5). At the other end of the glucose continuum, recurrent/protracted hyperglycemia or poorer metabolic control (defined by elevated glycosylated hemoglobin levels >9.0%) is associated with significantly lower general and verbal intellectual ability (7 points) compared with those in better metabolic control (Kaufman 1999, Lynch 2006, Perantie 2008). Significantly poorer visual and verbal learning is found compared with children in better metabolic control (Greer 1996, Lynch 2006), along with significant academic underachievement. In preschool children, protracted hyperglycemia, reflected in higher A1C levels, relates to lower general cognitive ability, poorer receptive language scores, and slower fine motor speed (Patino-Fernandez 2010). In older elementary school–age children, chronic poorer metabolic control has been found to relate to lower academic achievement and poorer attention/memory (Kaufman 1999). Poorer metabolic control may interact with each of the previous disease risk factors and amplify effects.
Acute Disease–Related Findings
Beyond these generally chronic cognitive effects (Gaudieri 2008, Bade-White 2009), evidence of acute, transient cognitive disruption is associated with some diabetes conditions. Acute mild hypoglycemia, defined as >50 mg/dl and <90 mg/dl, is related to transient slowing/disruption in higher-ordered executive functioning (attention, planning, complex decision making) as well as slowed verbal fluency, memory, and motor speed. Accuracy is usually intact (Reich 1990, Ryan 1990, Gonder-Frederick 2009). In the classroom, a hypoglycemic child will have trouble attending to and encoding new information to be recalled. The child may appear sleepy or lethargic. Speed of responding and other cognitive function may not return to normal (prehypoglycemic) levels for up to 45 min once euglycemia is achieved. Despite disrupted blood glucose levels, no evidence of increased rates of attention deficit hyperactivity disorder is reported in association with diabetes. Clinically, attention problems that occur with mild transient hypoglycemia are consistent with the inattentive subtype of attention deficit disorder (Bade-White 2009), although the condition should not be diagnosed if it is secondary to hypoglycemia, i.e., an underlying medical problem. The diagnosis of inattention subtype due to attention deficit disorder would be accurate in the absence of fluctuations in blood glucose, particularly hypoglycemia. Acute transient hypoglycemia that involves seizures or unconsciousness is “severe” and falls under the guidelines for severe recurrent hypoglycemia.
In contrast to hypoglycemia, acute
