Introduction:
Diabetes mellitus can be referred to as
some metabolic diseases that have some main features such as blood high glucose
levels which is also known as:"hyperglycemia" which usually occurs
due to malfunctioning in insulin action and or insulin secretion. The human
blood circulation usually contains glucose defined amounts within and they
usually come from the liver or from the gastrointestinal tract as a result of
processing the food there. Diabetes is usually prevailing among people of KSA
so it is considered a main health problem. This raised the importance of
implementing a program on the national level for disease prevention which
should be prepared to show its risk factors locally and how to avoid having the
disease. In Western countries which are industrialized, Central America, South
America, Africa and Asia, there are about 5% to 10% of their adult are affected
with diabetes mellitus. According to (IDF) estimations, in 2000, the number of
people having diabetes was 151 million people, and The
International Diabetes Federation (IDF) estimates the current number of affected people is
also about 147 million persons. People affected with diabetes in 2003 according
to the IDF were estimated with 194 million persons and the IDF suggests the
number to increase in 2025 to be 334 million persons. Community based surveys
and hospitals were the main resources for providing diabetes population
clinical features. (Alqurashi et al 2011)
One in 500 children is affected by diabetes
Type 1. (Gaudieri et al ,2008)Cognitive difficulties are found to affect
children who have diabetes type1 as being compared to a control sample but
their pattern and magnitude are not to be clear through research results
because the samples included heterogeneous ones and this is also because of the
study designs, sampling procedures and the assessed cognitive abilities.
Literature review:
In USA, there are about 215,000 kids in the school age estimated with a
percentage of 1,8 in each one thousand kids having diabetes types 1 or2. About
500 to 700 students in a caseload recommended by the National Association of
School Psychologists were found to need a psychologist to work at schools with
one student or two to manage diabetes with them and their families.
(NASP, 2010)
Classification:
Diabetes could be basically classified to type1 and type2. There are
different syndromes and conditions that associate diabetes mellitus and
gestational diabetes. There are different causes for each type of diabetes and
each type varies from the others in treatment and clinical course. This system
of classifying types depends on two methods; there are differences in each
category persons according to research findings and the patients are able to
move from a category to the other one which is not applicable for type1
diabetes patients. Example for this is moving a patient that has gestational
diabetes to the category of type 2 diabetes as she is a woman after delivery.
Pre-diabetes can be either classified to be impaired fasting Glucose (IFG) or
to be impaired glucose tolerance. (IGT). It represents a case of falling of the
concentration of blood glucose between two levels; one of the diabetes and the
normal ones.
There are descriptions of two diabetes types; (DMT1) and(DMT2). Diabetes
mellitus type 1 (DMT1) is a condition that makes the patient unable for
producing the needed insulin amounts. This type can be referred to as (IDDM) which
means insulin-dependent diabetes mellitus which is found to be more common
among adolescents and children that's why it is referred to in literature as
"juvenile diabetes". (Burn,
2010; von Herrath, Sanda, & Herold, 2007; Ma & Chan, 2009); Diabetes
mellitus type 2 is a condition in which some cases have insulin deficiencies and
most cases resisting insulin. (Athanasakis et al., 2010; Gershell, 2005). In
literature, it is also called adult-onset diabetes or (NIDDM) which means
non-insulin-dependent diabetes mellitus. If treatment was not properly provided
for diabetes' patients, many complications may occur such as chronic renal
failure, hypoglycemia, diabetic ketoacidosis, retinal damage and cardiovascular
disease. Treatment for diabetes should include the proper clinical management
of drugs and controlling blood pressure with having a healthy patient lifestyle
with proper dietary program. Insulin replacement must be provided for DMT1
affected students due to their having complete insulin deficiency. Insulin
secretion cannot be restored by agents of oral hypoglycemic. (Smeltzer et al
2010)
Diabetes and
children education
Insulin which is a hormone that gives sugar(glucose) the chance to get
in the cells to be energy, is not well used in diabetes patients as their
ability to use it is weak due to its shortage. Type1 diabetes is usually
occurring to patients in their adolescence or childhood while type2 diabetes
occurs as a result of less activity of the body and obesity and it occurs in
older ages mostly over 40 years old people and it refers to a percentage of 90%
to 95 % of cases of diabetes. Yet type 2 is also found too much in teenager and
children with obesity. It has been found that type2 diabetes has been increasing
among youth and type 1 diabetes has been increasing to occur among children
without understanding reasons for such increases. There were findings of the
past century in North America and Europe regarding the occurrence of diabetes
type1 that showed 350 fold increasing. Researches published showed that there
are relations between type1 diabetes occurring in children and their
achievement academically, school attendance and children cognitive abilities. Some
of these published articles show that there is a relation between being early
affected with diabetes during first five years or having early episodes of hard
hypoglycemic problems as decreased levels of the blood sugar and having poor
cognitive functions. Studies are different in describing the psychoeducational
deficit nature according to researches' used measures and the mentioned
population's characteristics that differ from a study to another. The studies
showed that many aspects are affected by diabetes as verbal IQ, memory of
patients, nonverbal functioning and attention. This was asserted in a research
since 1994. Data differs in researches but most or all researches assert that
children affected by diabetes have academic problems. (Kent et al 2010)
Children who suffer diabetes academic problems are usually early
affected and having great fluctuations in their metabolic controlling and this
is more in a child who had unconsciousness, seizures or who had ketoacidosis
due to having weak control. The greater risk of academic problems is in boys
more than in girls. School practices can only affect one of these two risk
factors which is the second : preventing the fluctuations in controlling
glucose. Sever fluctuations prevention in children was made in the past 5 to 10
years by letting children access to modern technologies prepared for this
purpose. Insulin pump is one of the most important of these technologies, it
consists of a device with a computer, it uses a flexible tube for delivering
insulin to the patient's body and there is a needle under the skin which is
attached to the tube. These devices should be used at schools to provide good
glucose control to students with diabetes to improve their academic
functioning. Educational systems whether public ones or the private should give
due care to the modern technologies of treating diabetes and the care provided
for patients students because this increases students' academic functioning and
educational systems should help their students overcome this disease. (Kucera
and Sullivan 2011)
There is a study for Gaudieri et al (2008) prepared to measure the cognitive problems
that diabetes type 1 causes and the results of having the disease in early ages
and having hard hypoglycemia. It had a sample of 2144 child with 1393 subjects
of study having diabetes type 1and 751 subjects of the sample as control
subjects and this was from 19 studies. There was a general cognition for diabetes 1
which is a little lower(ES_0,13) and if being compared to control subjects, it
is found having small differences but the similar were memory and learning in
the two groups. Children having early-onset diabetes(EOD) had more effects on
the skills of memory and learning than those with late onset diabetes(LOD) as
verbal and visual skills were(_0,28 and _0,25)also their function skills were
affected whether attention or executive function skills to be (_0,27)Effects of
EOD were more if being compared with the control subjects without diabetes as
there was SD lower with more than a half specially for memory and
learning(_0,49)There was an ES of _0,6 which is negligible in seizures
associated with light cognitive effects express the existence of opposing
effects of the metabolic control which is worse against better. This shows that
pediatric diabetes was associated with less cognitive scores which are mild
enough and that EOD was more having cognitive effects and the control subjects
had slight better performance. Inconsistent performance differences were
connected with seizures.
Erkolahti and Ilonen (2005) found out that when adolescents have good
metabolic control, it is rare to find diabetes mellitus complications. Having
skills of adaption was found not to lead to more learning problems and also
this leads to having positive relations between the highest scores of the world
and the students' school grades. Cognitive functioning of children was
negatively affected by diabetes mellitus and this was clear in learning skills,
memory, the speed of processing data, attention rates, spatial skills and the
visual skills. In the recent years, researchers started to research about
children having chronic illnesses regarding their cognitive functioning due to
their understanding of the impact of metabolic abnormalities on children
brains. There were many investigations regarding children having diabetes
mellitus as metabolic control of diabetes mellitus was mostly discussed as well
as its duration and onset. By comparing the control group to affected children
with diabetes mellitus, the affected children were found to be normal at
schools and learning functioning but with some problems in processing
information and attention. Using the WISC-R on the late onset group, vocabulary
lower performance was stated and also PAIT was used to measure lower
performance which was found in reading comprehension. Verbal area deficiencies
were found by researchers to be more prevailing in late onset diabetes mellitus
children and they also had cognitive deficiencies but less efficiency in using
information was found more in children with the disease in early onset. Poor
attention problems and completing tasks problems were stated by parents of children
who are affected with early onset diabetes mellitus.
Akay (2010) conducted a study related to the present study as it
discussed (IDDM) insulin dependent diabetes mellitus influence on 7 to 12 aged
children's behavioral problems, learning difficulties and cognitive
functioning. It used a sample of children at elementary schools in Turkey,
Ankara. A form was used for gathering data and it was a demographic information
one, some tests were used also to get data such as (CDI) Children Depression
Inventory, (SDQ) Strength and Difficulties Questionnaire, Specific Learning Disability
Scale and (WISC-R) and Wechsler
Intelligence Scale for Children–Revised. Examining the differences in
children's different levels of income, school achievement, parents education,
learning difficulties, depression, behavioral problems and adherence of
children to IDDM according to scores of WISC-R was done by using the one way
ANOVAs. According to the results, it was found that depression and behavioral
problems were found in children with IDDM adherence. Mean differences among
control group and IDDM and also the variables in relation to depression,
behavioral problems and learning difficulties were examined by using T-tests
according to scores of WISC-R. Children having IDDM were found to have less
WISC-R similarities, information, arithmetic and scores totally compared to the
control group. IDDM having children had several low scores in their
achievements such as in writing and reading tasks and many arithmetic points.
Moreover, testing IDDM adherence impact, illness duration and age of onset upon
learning, behaviors and cognitive functioning were done by using the analyses
of the hierarchical multiple regression. According to the results, there were
not any findings showing that IDDM variables left clear effects on the learning,
behaviors or cognitive functioning of the children and it is to mention that
these results were discussed with relation to the literature which is very
relevant.
Meo and others(2013) stated that diminished neuronal functioning is
associated with diabetes and it usually is followed by cognitive dysfunction
that affects learning memory, intelligence, attention, executive functioning,
academic achievement and information processing. It was found that diabetes
impairing understanding, memory, intelligence, attention and intelligence
quotient both verbal and overall in adolescents and children. (Ni and Xin
2012). Cognitive problems in the period of adolescence and disease duration and
metabolic control quality are associated with type1 diabetes. (Ohmann et al
2010). Children who have diabetes may also be affected in an adverse way in
their academic knowledge and in their general performance academically. As
being compared to control group, patients having diabetes were found to have
deteriorated neurocognitive performance which is related to learning, memory
and reasoning. (Hannonen et al 2010; Naguib et al 2009). The disease duration
and also the hyperglycaemia were found to have relation to cognitive problems
and the risk factors of having learning problems are high in early onset of
diabetes. (Hannonen et al 2012). Present findings are associated with the
mentioned data as low grades were found more in patient students with diabetes
more than in control group which is healthy without diabetes. In spite of the
present study findings, diabetes was stated not to impair children general
academic performance and it was noticed that records of diabetes having
students in reading and Mathematics were better than those of the control
healthy group students. Explaining this can be by applying the methodology of
grade assessment using examination on the class performance. In Sweden, there
was a study on students having diabetes and results showed low scores in
academic performance but slight ones in patient children versus control group
students. (Dahlquist et al 2007). The sample size of the study of Moe and
others (2013) is considered a limited one as the number of the sample is small
and the study duration is also short. Students ethnic background was the same
of all the students in addition to matching age, sex, school environment and
social status of the group. There was a standardized measuring for the
students' academic achievement according to the obtained overall scores via
English, Physics, Chemistry, Humanities, Biology and Mathematics exams that are
based to represent cognitive functions domains. In conclusion, students with diabetes type1
had lower scores compared with students without diabetes. It is important to
apply more studies with longer durations and wider cohorts.
It was stated by previous research that type1 diabetes complications are
able to impairing academic and cognitive performance both (Gaudieri
et al 2008; Kent et al 2010; Naguib et al 2009). Although achievement scores and average cognitive
abilities were found to be with diabetes having students, a small amount of
students with diabetes were found to have long term complications of the
disease especially those with early onset diabetes and those with poor
controlling of blood glucose. (Kucera and Sullivan 2011; Gaudieri
et al 2008; Kent et al 2010; Naguib et al 2009). Gaudieri et al. (2008)made a
study of a meta analysis on youth who had early diabetes at ages of 4 to 7 who
recorded poor visual (ES = -.44)and verbal(ES = -.49) memory and learning outcomes , executive
functioning and attention(ES = -.39), academic achievement (ES = -.28)
and (ES = -.29) for overall cognition and this is by being compared to students
who do not have diabetes. As a result of this, classroom performance and results may be impaired
by the mild effect sizes in the limited amount of the standard deviation half
in the scores of the standardized assessments.(Gaudieri et al
2008). Yet, although some of the patients
students will have impairments on the long run, transitive
cognitive impairment will be found in students with diabetes because of the fluctuations in
the levels of the blood glucose. (Gonder-Frederick et
al 2009; Wodrich et al 2011).
It is very essential for the school psychologists to think of students'
academic performance and the issues of behaviors that are resulting from being
affected with diabetes. Poor glucose control can lead to poor classroom
attention and low achieving academically. (Kucera and Sullivan 2011). Thus
school psychologists are those who should call for giving due care to the
students who have diabetes and are in need for care. (Kucera and Sullivan 2011;
Schmitt et al 2010).
