lower verbal memory and vocabulary scores as well as reduced speed of cognitive functioning, similar to the effects of acute hypoglycemia (Gonder-Frederick 2009).
Assessment of Neuropsychological Status
Evaluation of neuropsychological status and associated academic performance should follow generally accepted guidelines for identifying children in need of academic assistance. Specialty tests in memory and other neuropsychological skills are available (Lezak 2001). Although tests can be administered by any licensed psychological practitioner, interpretation of results will be more accurate when provided by a trained neuropsychologist or specialist who works with children who have diabetes. Neuropsychological difficulties often co-occur with learning disorders in specific academic areas such as reading or mathematics. State and federal guidelines mandate formal recertification or reassessment of youth diagnosed with learning disorders every three years (Education Rehabilitation Act of 1973). Adoption of testing guidelines also is appropriate with subclinical learning problems. Generally, if a child has learning difficulties of a magnitude that impedes daily or classroom functioning, the youth should be referred to a pediatric or child psychologist. This recommendation includes children who consistently underachieve in a school subject or who have difficulty with memory or other cognitive processing skills. A teacher or parent referral for a psychoeducational screening can help determine the cause of the problem. A screening test of reading, math, and written skills can be administered by an educational specialist. If a problem is found, follow-up comprehensive testing is necessary to qualify for assistive school services. Medical insurance often covers the cost of psychoeducational assessment administered by qualified personnel. Local school psychologists provide another cost-free option, although this latter choice may entail a longer wait for services.
Assessment Considerations
For children with diabetes it is important to first rule out or otherwise address more common medically related issues of school absences, poorer glycemic control, and glucose fluctuations in the classroom, all of which may relate to lower academic achievement as well as memory and attention problems.
During psychological assessment, psychologists should first make sure a child is able to perform blood glucose tests and treat episodes of hypoglycemia. A child should bring a glucose meter to the assessment session, ideally along with a small snack of juice and crackers, in case they should be needed. Glucose testing should occur immediately before psychological testing is begun to maximize optimal performance. Even mild hypoglycemia (blood glucose level >60 and <90 mg/dl) can adversely impact psychological test performance and scores. If moderate or severe hypoglycemia (blood glucose level ≤50 mg/dl) is detected, psychological testing should be rescheduled for another day to allow time for recovery of optimal cognitive status. However, steps should be taken if mild hypoglycemia is suspected during psychological assessment. The assessment should be paused, a blood check should be performed by the child with the child’s own equipment, and a snack should be consumed by the child. Packets of peanut butter crackers and juice boxes provide a good supplement to a test kit. After ingestion of 15 grams of carbohydrate and a 15-min wait, a child should retest his or her blood glucose level to confirm euglycemia, and psychological testing can proceed.
Treatment of Learning Disorders
Treatment recommendations for learning disorders should be selected with consideration of a child’s underlying cognitive strengths and weaknesses as well as the affected academic area. Traditionally, learning problems, if present, may be handled either with remediation strategies that promote acquisition of delayed skills (deficit-focused) or with compensation strategies that focus on residual abilities and environmental strategies to facilitate optimal skill use (strength-focused) (Kanne 2010). Often a combination of techniques is utilized, but most of the treatment literature has studied individuals with frank neurologic difficulty (Raskin 2010) typically not seen in youth with diabetes. Although these strategies reflect current thinking (Kanne 2010, Raskin 2010), they lack empirical validation of treatment efficacy. Currently no studies exist with youth who have diabetes. Thus recommendations for remediation are based on general recommendations for children with learning disorders.
Recommendations for Intervention
1. Circumvention of the problem. Clinical experience suggests that it is better to teach to “strengths” rather than to drill to remediate “weaknesses.” For example, spatial weaknesses can be minimized by giving oral directions rather than a written or drawn map or by adoption of a phonetic versus sight word reading approach.
2. Assistive learning devices. Dependent upon the problem, use of assistive learning devices can be helpful. For example, for isolated memory problems, use of a calculator can help compensate for memory difficulty with math facts and provide an opportunity for practice and recognition learning.
3. Reduced psychomotor efficiency could necessitate untimed or supplemental time allowances on tests.
4. Avoid stigmatization of children. All individuals have cognitive strengths and weaknesses; the peaks and valleys simply may be a little farther apart for a small percentage of children with diabetes who have diagnosable or subclinical learning disorders.
5. Help the child, family, and academic providers to understand differences between transient cognitive deficits associated with fluctuations in glucose and diagnosed learning differences.
6. Self-esteem difficulties may be present. If they are persistent or severe, psychological treatment should be sought with a school counselor or trained therapist to reassure a child of his or her strengths and to place relative weaknesses in perspective. Children with diabetes are already coping with an altered sense of self because of their illness, which could increase vulnerability to low sense of self-worth (see Chapter 14).
Prevention or Minimization of Cognitive Difficulties
The majority of youth with diabetes do not have learning problems that rise to the level of clinical or subclinical learning disorders. However, transient disruption of memory/attention or slowed psychomotor efficiency could occur relatively routinely in the classroom in conjunction with temporary changes in blood glucose concentrations. Subsequent frustration could impede academic performance. Long-term longitudinal study suggests youth with diabetes have higher dropout rates in secondary school compared with nondiabetic counterparts (Lin 2010), a finding that merits replication.
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