Proactive care and Symptomatic management

Diabetes and Learning

Diabetes is a chronic disease, which induces learning disabilities and cognitive disorders. Proactive care and Symptomatic management are critical aspects of diabetes control. Successful intervention involves a collaborative effort on the part of the school staff, parents and health care providers.

Diabetes is a serious health concern for the United States with more than 18.2 million people affected by the disease. The prevalence of Diabetes among children is alarming, as every year more than 13000 are being diagnosed with type-1 diabetes and even more unusual is the increasing incidence of type-2 diabetes[American Diabetes Association]. Studies have indicated that cognitive skills may be severely impaired if diabetes is not properly treated. Left unattended extreme cases of hypoglycemia may even result in severe complications such as seizures or coma. Understanding the effect of diabetes in the learning process is important in our efforts to provide optimal learning ability for the affected children. Let us have a brief study of diabetes in children, its effect on the learning process, and also discuss successful preventive interventions.


Diabetes is a condition in which the body is either unable to produce or utilize insulin, a hormone necessary for the conversion of glucose, starch and other forms of food material into energy. In a normal person the body is able to produce enough insulin to convert glucose into energy. In a diabetic however, there is a high level of glucose in the bloodstream, which is finally excreted in the urine. In this way diabetics waste away (glucose) the main source of fuel for the body. The WHO classifies diabetes into five general types namely insulin dependent (IDDM), non-insulin dependent (NIDDM), other types, gestational and malnutrition related diabetes. Of these IDDM or type -1 diabetes and NIDDM or type-2 diabetes are the most important. [Mayer B. Davidson, 5]

Type -1 diabetes refers to case where the body is unable to produce insulin, which is required for transporting the glucose in the bloodstream into the cells. This condition is more common with children and young adults. Type -1 patients exhibit ketosis, a condition where there is a high level of acidic ketones in their blood. This results because the body uses fats as the alternative source of energy and ketones are formed as the end product. [NHS Online Health Encyclopedia] For type -1 patients intervention in the form of insulin therapy is a must as otherwise they run the risk of diabetic ketoacidosis which is fatal. Hyperglycemia (high glucose in blood), Hypoglycemia (low glucose in blood), celiac disease, etc. are some of the other associated disease conditions.

Type-2 diabetes or non-insulin dependent diabetes is an important type, which is characterized by the absence of ketosis. In these patients there are no ketone bodies in the urine, which is proof enough that the body produces some amount of insulin. Though type-2 diabetes is called insulin independent diabetes as much as 25% of this group require insulin therapy. This form of diabetes is more common with the elderly population and around 80 to 90% of patients are obese. So physicians consider obesity as an important risk factor for type-2 diabetes. [Mayor B. Davidson, 5]

Diabetes and Effect on Students

Diabetic children need special care and attention at school. Brain function is important for any learning activity. Since diabetes directly affects the functioning of the brain it may cause severe learning limitations. The normal blood glucose level is approximately 3.8 to 8.0 mmol/L. However in a diabetic glucose levels either increase steeply (hyperglycemia) or fall as low as <3.0mmol/L (hypoglycemia.), both of which have damaging effects on the brain. Hypoglycemia in particular is shown to directly affect the brain as the brain is starved off its fuel. A student who has had an attack of hypoglycemia would take a long time to recover his normal brain function and hence his performance during this period would be definitely affected. The following research results emphasize the negative effect of diabetes on the learning process of children.

Diabetes and Learning (Some Studies)

Many researchers have studied the link between diabetes and the cognitive skills of children. Ryan et al., 1985 was one of the early studies, which confirmed the direct effect of type-1 diabetes on the learning abilities of children. Ryan and Co researchers found that attacks of hypoglycemia in young children affected the visuospatial and verbal ability in children. A later research by Joanne F. Rovet et al. was modeled on similar experimental conditions but studied subjects who had an earlier onset of type-1 diabetes. For the study two groups of diabetic children were used. Out of a total of 51 children considered for the study 27 children had developed diabetes before the age of 4, (EOD) and the rest of them developed diabetes much later on. (LOD). Siblings of the diabetic children were also considered for the study to understand the difference.

The WISC-R vocabulary subtests and SRA primary mental abilities (PMA) test were used to test for the verbal ability while WISC-R block design and PMA spatial ability tests were used to assess the visuospatial ability. The results found that early onset diabetes (before 4) presents a greater risk for loss of mathematical ability and visuospatial skills. In particular loss of visuospatial skills was attributed to the organic disturbance caused by repeated episodes of hypoglycemia in early onset diabetes. Diabetes in general, was found to have a retarding effect on developing verbal skills. {Joanne F. Rovet]

Another important study by John W. Hagen et al., highlights the difference in cognitive skills between early and late onset diabetic children and non-diabetic children and also compares their academic performance. For the study the researchers took 30 diabetic and 30 non-diabetic children in the age group of 8 to 16.6 years. The diabetic children were again divided into two groups namely EOD and LOD with 15 children in each group. Glycosylated hemoglobin (HBAl) levels, (glucose level of the blood) measured for the diabetic group averaged at 10.7 (HBAl). The average school grades for the EOD and LOD were found to be 6.2 and 7.7 respectively. The WISC-R vocabulary subtests and WISC-R block design were given to all the subjects. To measure the academic performance subtests from the Peabody Individual Achievement test were given. ‘Pause time’ memory tasks were also used to identify the information processing capacity of the subjects.

The WISC-R scores of the three groups were 103, 105 and 113 respectively for EOD, LOD and non-diabetic groups. In four of the five subtests in the WISC-R diabetic children faired poorly and were outperformed by non-diabetic group. The study also highlighted that memory process is greatly affected in EOD children as reflected by the poor scores in the strategic tests. The overall results of the study confirm the fact that ‘Early Onset Diabetes’ and Late Onset Diabetes’ group had impaired cognitive ability when compared to the non-diabetic group. Furthermore early onset diabetic children are more vulnerable for deficiencies in visuospatial skills and in general exhibit more cognitive difficulties. [Hagen et al.]

Golden et al. (1989) is another study, which also confirms the ill consequences of repeated episodes of hypoglycemia. The researchers studied 23 children who developed the disease before the age of five. The duration of diabetes for all the subjects fell within the range of 6 to 78 months. Using memory glucometers the researchers monitored attacks of asymtomatic hypoglycemia in all the subjects. Psychological assessments of the children were performed using the Stanford Binet tests. The results from the visual reasoning tests when correlated with the relative frequency of asymptomatic hypoglycemia clearly showed that children who had frequent attacks of hypoglycemia faired poorly when compared with children who had infrequent hypoglycemia. Thus the relationship between hypoglycemia and neuropsychological changes observed in early onset diabetic patients is clearly established by this study. [Joanne F. Rovet]

Other studies also indicate a clear relation between diabetes and abnormal functioning of the Central Nervous System (CNS). Abnormal Electroencephalograms readings were recorded in 35% of diabetic children and this is attributed to either hypoglycemia or hyperglycemia. Examining the cerebral blood flow has shown that hypoglycemia causes disruptions in frontal lobe and left hemisphere functioning. Cognitive processing speed is also found to be severely limited and neuronal damage inflicted resulting in breakdown or slowing down of signal transmission within the brain. Researchers from the university of Iowa studied 244 diabetic students alongside 110 siblings and 209 anonymous classmates. They analyzed the grades obtained, absenteeism and the behavioral variations of these children over a period of time. The results revealed that diabetic children were absent for a longer and are more prone to abnormal behavioral problems compared with normal non-diabetic children. [Pediatrics]

Special Requirements for Diabetic Students

Diabetes being a chronic disease needs lifelong treatment, which causes considerable psychological ordeal for the patient and the family members. Adding to the woes is the constant fear of developing complications like retinopathy, gangrene, cardiovascular complications etc. Considering the special needs of diabetic students the federal government has included diabetes under the IDEA (Individuals with Disabilities Education Act). State run schools have to comply with the requirements mentioned in the law. The IDEA ensures that diabetic children suffering from cognitive disabilities because of the abnormal fluctuations in the blood glucose level have special support and care to maintain their optimum learning ability. Proactive treatment and management of symptoms is the most effective way of dealing with chronic diseases. Hence schools are also required to provide assistance for the medical needs of the children like glucose testing, insulin administration, etc. [DREDF]

However there is considerable amount of difficulty in implementing special education policies for diabetic students because it involves integration of both medical and academic realms. The confusion that prevails in classification of children under three separate groups of special education needs makes it more difficult. Some schools extend their special education programs only to mentally retarded groups while chronically ill students are neglected. The clause that is included in the IDEA law “adversely affect a child’s educational performance,” restricts the eligibility for the special needs programs only for students who have underachieved. This presents several nagging problems like what is the measure of underachievement and how long a child has to wait to qualify under the IDEA program. It is a serious mistake for educational institutions to wait for the under achievement of the student before approving his qualification for the special needs program. In majority of the cases the class teacher is unaware of the impact of diabetes on the academic performance. A survey shows that 45% of children with chronic illness report lagging behind in their academic works and only 6% have been approved for special education plans suited to their learning ability. This clearly indicates the discrepancy introduced by the confusing terminology used in the legal definition of the IDEA. [Kathleen M]

Schools need to understand the chronic nature and the high incidence of diabetes among children. Identification of candidates for the special needs program is the responsibility of schools and wherever required they must hasten the process as delaying only compromises the future of a child. As maintaining the glucose level is critical in the management of diabetes, students must be allowed if necessary to have food in between the class hours. Access to toilets must be allowed even during examinations as diabetic students may have the need for frequent urination. Children become Ketotic rapidly and hence immediate intervention is a must. Teachers must receive training and be knowledgeable about the disease symptoms. [Simon R. Page, 24]


Every school must take active measures to provide quality education for chronically ill students. There are many complexities involved in management of disease conditions, which necessitate positive intervention from the management of the schools and other educational institutes. Lot of researches have confirmed that diabetes clearly affects the learning process in children. Preventive and interventional treatment is very critical particularly in young children (EOD) since any adverse rise in glucose level may cause cognitive impairment. Children with chronic diseases like diabetes do not only need medical assistance but also need special education assistance programs to achieve optimum learning ability. It would be better if the prevailing confusion in the IDEA terminology is clarified and the special education program made easily accessible for the concerned children. Management of diabetes without compromising on academic performance involves a collective effort on the part of the school staff, parents and health care providers.


Joanne F. Rovet, Robert M. Ehrlich and Maria Hoppe, “Specific Intellectual Deficits in Children With Early Onset Diabetes Mellitus,” Child Development 1988, 225-234

Joanne F. Rovet, Robert M. Ehrlich, Debora Czuchta and Michelle Akler, “Psychoeducational Characteristics of Children And Adolescents with Insulin Dependent Diabetes Mellitus,” Journal of Learning Disabilities, Vol 26, Jan 1990-page 7-22

Thies, Kathleen M, “Identifying the Educational Implications of Chronic Illness in School Children,” Journal of School Health, Dec 1999, Vol 69 Issue 10, pg 392

Davidson Mayor B, “Diabetes Mellitus: Diagnosis and Treatment,” Churchill Livignstone Inc., Third Edition

Author Not Available,” “Diabetes and Learning” Pediatrics, 1/2002

John W. Hagen” et al., “Intellectual Functioning and Strategy Use in Children With Insulin Dependent Diabetes Melitius,” child Development 1990, 61, 1714- 1727

Simon R. Page and George m hall, “Diabetes Emergency and Hospital Management,” BMJ books, 1999

DREDF, “The Individuals with Disabilities Education Act and Children with Diabetes,” retrieved on April 6th 2004, from,

NHS Online Health Encyclopedia, “Ketosis,” retrieved on April 6th 2004, from,

American Diabetes Association, ‘All About Diabetes’, Retrieved on April 5th

2004, at

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