- Missed instruction
- Poor work completion
- Interpersonal and emotional problems
- Cognitive and academic impairment
What we know:
Missed school days are a risk. Several studies suggest that children with diabetes miss about 8 more days of school per year than their healthy classmates. Another recent study suggests a bigger problem by showing that students with diabetes miss almost 10% of scheduled school days. Interestingly, attendance problems may also spillover over to brothers and sisters. Health care experts speculate that siblings sometimes stay home while parents work, acting as frontline disease managers. A few students with type 1 diabetes appear to exaggerate symptoms to avoid class, although little actual research exists to determine the extent of this potential problem. Less research has been conducted regarding students with type 2 diabetes, but it is likely that, as with any chronic illness, regular attendance is diminished.
Missed school days may be only part of the missed instruction picture. Students with type 1 diabetes may need to leave class to care for themselves and fulfill their particular disease self-management requirements. A 2006 study found that among students (average age 12 years), 56% had to miss class for routine, non-emergent diabetes care. Although some schools permit in-class blood sugar checks (which can minimize time out of class), others require that students go to the nurse’s office to draw blood or check blood sugar levels. No conclusive research, however, has yet established how much instructional time is routinely missed when students are forced to leave class to manage their disease.
Most teachers recognize the crucial importance of regular attendance. More than two decades ago, research confirmed that frequent absences predict problems in reading, spelling, and arithmetic among students with chronic illness.
What to do:
Several factors have been linked to missed school days. These factors include (1) parents who affirm the necessity of regular school attendance, (2) parents who avoid overprotection, (3) families that have achieved successful adjustment to their child’s disease, and (4) a positive family-school relationship. A second set of factors concern the disease itself. Specifically, good metabolic control is associated with good attendance, at least in some studies.
Thus, the EdMedKids website suggests that a first step to improving school attendance is for educators to work with parents to emphasize the value of regular attendance. A second step is for parents to learn more about their youngster’s diabetes. Sites such as the Juvenile Diabetes Research Foundation can provide parents with valuable information. For families with limited literacy or limited Internet access, learning about diabetes and its management directly from a school nurse or a health care provider appear to aid attendance. Extra steps to foster home-school communication also appear to be helpful. Teachers can help facilitate communication with parents by using daily report cards that outline work completion, assignments to be completed, and any health issues seen at school (see the Teacher Toolbox link on the EdMedKids website for an example of a daily report card).
As implied above, good control of blood sugar is also important as a way to improve attendance. For students with access to quality medical care, regular and full involvement with health care providers should be encouraged. For families with limited access or suboptimal knowledge of the health care system, using school social workers or nurses to maximize engagement may be in order, not only for compassionate reasons but also for indirect impact on attendance and learning.
Accommodations to permit in-class glucose checks might reduce excessive time out of class. However, no known research has addressed the implementation of such accommodations to determine their actual effect on classroom functioning.
What we know:
Problems with sustained attention, short-term verbal memory, and psychomotor efficiency are a risk for students with type 1 diabetes. Threats related to working and learning efficiently in class have also been documented in some recent research of students with type 1 diabetes. Equally important, as blood sugar rises and falls, classroom attention and work completion may correspondingly fluctuate. The suggested link between classroom efficiency and blood sugar levels was first suggested when researchers found that episodes of low blood sugar produced an immediate negative impact on fine motor speed, working memory, mental efficiency, planning, decision making, attention to detail, visual scanning, and rapid responding.
When these carefully controlled studies moved from laboratory to classroom, much of the same findings appeared (although only small scale studies exist to date). For example, week-to-week improvement in blood sugar control resulted in an 8%-34% improvement in classroom attention. In another study, the last few months’ degree of blood sugar control predicted nearly one-third of student-to-student differences in classroom attention. Thus, the underlying risk of inattention and work incompletion present among students with type 1 diabetes in general, may be exaggerated when blood sugar control is poor. Unfortunately, no comparable research exists for type 2 diabetes. Still, it is likely these students have some of the same educational risks.
What to do:
Parents and health care providers need to know when attention problems occur because attention problems might be related to poor blood sugar control. EdMedKids suggests that any diabetes treatment adjustments targeting improved classroom attention and work completion should include monitoring the student’s classroom attention (or work completion) before, during, and after treatment adjustments. Feedback to the health care team, working through school team members such as a school nurse, school psychologist, or school counselor, is important in these circumstances. Use of observation checklists when treatment changes are made can help determine if there is a concomitant improvement in attention and work completion (see the Teacher Toolbox link on the EdMedKids website for a sample observation checklist).
The educational literature includes many interventions to improve attention, academic engagement, and efficiency. These include the following:
- Self-management strategies sometimes help students learn. These strategies include requiring students to keep track of time spent on each task, teaching step-by-step problem-solving via modeling appropriate thought processes (e.g. “thinking aloud”), encouraging students to utilize private speech in the completion of tasks, and employing visual prompts (e.g. cue cards).
- Mapping is sometimes used by teachers. Studies indicate that students who create concept maps and story webs while learning new information and reading passages demonstrate better learning and comprehension.
- Peer tutoring programs, also called Peer Assisted Learning (PAL), have empirical support as well. This technique involves students teaching and practicing a concept with one another following direct instruction by the teacher. Teachers can maximize the effectiveness of PAL programs by monitoring tutoring sessions and rewarding proper participation and tutoring behaviors.
- Direct performance feedback can also be used. This technique provides students with informational feedback regarding his or her performance on a specific task and has been demonstrated to motivate students and sensitize them to areas requiring improvement.
- Direct instruction strategies are another set of proven techniques that can be used. These strategies include delivering scripted lessons, instructing students in small groups, encouraging students to respond to questions in unison, using gestures and signals to cue student actions, delivering fast-paced instruction, correcting errors promptly, and immediately praising desired behaviors.
- Cooperative learning groups might also be used. These are exemplified by students advancing through lessons and receiving rewards contingent upon every learning group member demonstrating skill mastery. Although known to increase student motivation and promote effective peer tutoring, cooperative learning groups should be used cautiously for students with diabetes. This is especially so if the student with diabetes is unable to contribute to learning groups because of recurrent absences or diabetes-related learning problems. Understandably, teacher judgment is required when using this technique.
- Modified timing of academic instruction is a diabetes-related intervention. Because students with either type 1 or type 2 diabetes may have predictable episodes of high and low efficiency and attention based on blood sugar patterns, schedule adjustments may be useful. Scheduling adjustments might include moving the most important instructional activities to times when high efficiency and maximum attention occur.
- Reasonable and appropriate expectations are important for all students, and especially those with chronic illnesses. Teachers with proper expectations will not ask students to perform at levels exceeding their capabilities and they take students’ skills and energy levels into account when determining student performance and achievement goals. This requires an accurate appraisal of a student’s cognitive strengths and weaknesses. If in doubt, teachers might ask for a cognitive and academic skills assessment from the school psychologist (see the Teacher Toolbox link on the EdMedKids website for a modifiable letter that can be sent to the school psychologist requesting an academic assessment).
The lists above represent sound teaching practices. However, their precise effectiveness for students with either type 1 or type 2 diabetes has yet to be established by research. Thus, educators are encouraged to monitor the effectiveness of their intervention by collecting data. Asking a school psychologist or school counselor for help in collecting data may make this process feasible (see the Teacher Toolbox link on the EdMedKids website for a sample letter requesting assistance from the school psychologist). If informal attempts to gain assistance are unsuccessful, then EdMedKids website recommends considering a formal OHI designation or using a 504 accommodation plan (see the Disability Rights link on the EdMedKids website).
Interpersonal and emotional problems
What we know:
Emotional problems are overrepresented among children with type 1 diabetes; however, comparable research does not yet appear to exist for type 2 diabetes. For example, in one study, 33.3% of a group of children with diabetes experienced emotional problems compared to just 9.7% of a control group of children. Internal distress, such as somatic complaints, compulsions, and depression, are most common; behavioral problems or misconduct are less of a risk.
Educators should also know that problems with depression may mount with time. One study found that by age 20, nearly one-half of a group with type 1 diabetes had developed a diagnosable psychiatric disorder, with major depression the most prevalent disorder. In fact, over one-quarter had experienced an episode of depression by their 10th year of type 1 diabetes. For girls with type 1 diabetes, eating disorders are a documented risk. Sadly, insulin omission was sometimes used by girls with type 1 diabetes in this study to lose weight. Somewhat more positive are findings from another study of teens with type 1 diabetes that showed that these students were at greater risk for social problems, but not actual depression.
What to do:
Living with diabetes can be stressful, thus it is easy to understand why depressed mood is a common risk. Some approaches that work for depressive symptoms in general may also work when such symptoms are associated with diabetes; one such approach is called cognitive behavior therapy (CBT). CBT is a counseling technique used by therapists to teach students to replace negative attributions that lead to counterproductive behavior, with alternative attributions that lead to more effective behavior. This approach seems to work on some adolescents who have anger, anxiety, and diabetes-related stress. EdMedKids provides a link to the Association for Behavioral and Cognitive Therapies which summarizes some evidence-supported CBT treatments.
Family stress also appears to play a role in the emergence of depression in children with diabetes. Behavioral Family Systems Therapy addresses family communication and teaches families problem-solving strategies. Programs such as this one, and to a lesser extent more straightforward educational support services involving adolescents with type 1 diabetes and their parents, can reduce familial conflict and improve treatment adherence. Educators working with formal or informal teams can sometimes alert families to outside services that can help.
Unfortunately, school-based research studies to promote self-confidence, reduce stress, or enable acquisition of friends have not been conducted. However, when such programs already exist as part of school-based counseling services, or when they might be assigned as part of an IEP’s related services, then their use may be indicated. Nonetheless, baseline measurement of behavioral dimensions targeted by such programs, and ongoing monitoring of these dimensions during intervention, is indicated on the EdMedKids webpage (see the Teacher Toolbox link on the EdMedKids website for sample monitoring forms).
Cognitive and academic impairment
What we know:
IQ appears to be generally unaffected by diabetes. Specifically, the consensus of research suggests little difference (e.g., a 2 to 3 point reduction in those with diabetes) in full scale, verbal, and non-verbal IQ between students with and without type 1 diabetes. Of special relevance to teachers, academic achievement may be a different matter. Several studies indicate that reading and writing scores are lower among students with type 1 diabetes (about 3.6 to 4.2 points lower using an IQ-like metric). In another recent study, teachers rated students with type 1 diabetes lower overall (reading, writing, math) than their healthy brothers and sisters, with potential writing problems most pronounced.
For individual students, of course, larger differences may exist. Some diabetes-related factors, such as early onset or a history of diabetes-related seizures or a coma, predict risk of academic or even IQ problems. However, research is not very clear in this regard. On the other hand, poor blood sugar control may influence classroom learning, as a source of either inattention and work incompletion, or because somehow it makes learning and retaining skills harder over time.
What to do:
When students with either type 1 or type 2 diabetes encounter problems acquiring or maintaining academic skills, they need the best available, scientifically-supported and proven academic materials and programs. Although teachers may have limited flexibility in selecting programs, the EdMedKids website nonetheless offers a link to the What Works Clearninghouse, a Department of Education resource for teachers seeking validated material and programs.
Selecting the best material and techniques (like those listed at the What Works Clearinghouse) works well in schools using a tiered, Response to Intervention (RTI) approach. Such an approach allows students with diabetes to be carefully monitored and for more services to be provided if student progress is inadequate. RTI approaches, however, are geared to prevent learning problems among students in general and to detect the presence of Specific Learning Disabilities (SLD) when progress lags despite increasingly intensified instruction. Although, students with diabetes are at risk for disease-related learning problems, they are not necessarily at risk for SLD. Thus, teachers of students with diabetes are encouraged to familiarize themselves with other options such as the Other Health Impairment (OHI) category, and to take prompt steps if one of their students appears to encounter disease-related special service needs. The EdMedKids link concerning Disability Rights was created to provide information of this type for teachers.