Pediatric School Psychology
Diabetes in School-Age Children: Assessment and Eligibility Issues
By Joel B. Winnick & Shirley A. Woika
Approximately 215,000 or 1.8 in 1,000 school age youth have been diagnosed with Type 1 or 2 diabetes within the United States (Centers for Disease Control and Prevention [CDC], 2011; SEARCH for Diabetes in Youth Study Group [SEARCH], 2006). Accordingly, based on the National Association of School Psychologists (NASP, 2010) recommended caseload of 500–700 students, a school psychologist should be prepared to work with 1 to 2 youth and their families managing diabetes as part of his or her annual caseload. The purpose of this article is to review the etiologies, symptoms, and treatments of Type 1 and 2 diabetes; discuss the impact of diabetes on achievement and cognition; review applicable federal laws; identify the importance of diabetes care plans in school; and discuss making decisions related to eligibility for specialized instruction and accommodations. Additionally, a case study and functional assessment approach will be presented related to eligibility decisions.
The common element of Type 1 and 2 is the inability of the body to produce a sufficient amount of insulin. Insulin is a hormone necessary for regulating blood glucose levels within the body. Insulin, generated in the pancreas, allows glucose in the bloodstream to enter into the cells of the body where it is metabolized for energy. Without insulin, glucose cannot enter the cells and remains in the bloodstream (Beaser, 2007; National Diabetes Education Program [NDEP], 2010).
Type 1. There are significant differences between Type 1 and Type 2. Type 1 is an autoimmune disorder where the body's immune system destroys insulin-producing beta cells within the pancreas (CDC, 2011). Type 1, previously referred to as juvenile-onset diabetes, typically occurs in young, nonobese children. The majority of youth diagnosed with diabetes are diagnosed with Type 1 (CDC; NDEP, 2010; SEARCH, 2006).
While Type 1 has been reported to occur across ethnic groups (American Indians, African Americans, Hispanic/Latino Americans, and Asians/Pacific Islanders), most new diagnoses of Type 1 occur in school-age youth identified as non-Hispanic Whites (CDC, 2011). Less than 10% of youth with a genetic predisposition eventually develop Type 1 (Knip, Veijola, Virtanen, Hyoty, Vaarala, & Akerblom, 2005). Some researchers have hypothesized that an unidentified environmental factor such as a common cold virus or environmental toxin might trigger the autoimmune response (Beaser, 2007).
Type 2. Type 2 is a condition where an individual has developed insulin resistance or the amount of insulin being produced is insufficient to meet the demands of the body (NDEP, 2010). Risk factors associated with its development include old age, obesity, family history of diabetes, physical inactivity, and ethnicity (CDC, 2011). Of individuals with Type 2, 74% to 100% have a first- or second-degree relative with the same condition (ADA, 2000). In contrast, 5% to 10% of individuals with Type 1 have a first- or seconddegree relative with the same condition (Rosenbloom & Silverstein, 2003). Most new cases of Type 2 in school-age youth occur in adolescents (10–19 years of age; SEARCH, 2006). Furthermore, health disparities have been evidenced as adolescents identified, as American Indians, African Americans, Hispanic/Latino Americans, and Asians/Pacific Islanders are particularly at risk for developing Type 2 (CDC, 2011; SEARCH, 2006).
Regarding environmental risk factors, the rising incidence rates of Type 2 for children and adolescents within the United States is related to the increasing rates of obesity and decreasing levels of physical activity among this age group (ADA, 2000). Type 2 was previously referred to as adult-onset diabetes. Thus, the increase in the number of youth being diagnosed with what was once considered to be a disease of adulthood is concerning to health professionals.
Symptoms may manifest as inattentive behavior during a testing session, or they can rapidly progress into an acute, life-threatening condition requiring immediate care (NDEP, 2010). Elevated blood glucose levels (hyperglycemia), caused by insufficient insulin, can lead to long-term serious health conditions resulting in damage to eyes, kidneys, nerves, and blood vessels (CDC, 2011). Long-term adverse health complications include heart disease, stroke, hypertension, periodontal disease, blindness, and nontraumatic limb amputation (NDEP, 2010). Acute symptoms of high blood glucose levels include head- aches, difficulty concentrating, blurred vision, frequent urination, increased thirst, fatigue, increased sleepiness, lethargy, and a depressed level of consciousness. Conversely, low blood glucose levels (hypoglycemia) can result in acute symptoms that range from dizziness, disorientation, irritability, argumentativeness, and an inability to concentrate to life-threatening emergencies leading to seizures, coma, and death (NDEP, 2010).
Type 1. The standard of care for an individual with Type 1 follows an intensive regimen of multiple daily injections of insulin and blood glucose level checks in coordination with an individualized diet and exercise plan (ADA, 2012; Silverstein et al., 2005). The effectiveness of this regimen in reducing the risk of diabetes-related complications was established in the Diabetes Control and Complications Trial (1993). While insulin is a life-saving treatment, it is not a cure. In fact, hypoglycemia related to insulin therapy presents the most immediate danger to individuals with Type 1 diabetes (NDEP, 2010). Hypoglycemia may also occur due to prolonged, strenuous exercise; skipping scheduled meals or snacks; or not consuming enough carbohydrates at meals or snacks (NDEP, 2010).
Type 2. Treatments for Type 2 involve an individualized exercise and diet plan that might include oral medications (ADA, 2000). Daily injections of insulin are sometimes prescribed in advanced cases (ADA, 2000). Lifestyle changes including the adoption of a healthy diet and an increase in physical activity have shown promise in delaying or even preventing the development of Type 2 in at-risk individuals (CDC, 2011). Evidence supporting lifestyle changes as methods of preventing the development of Type 2 is good news for our at-risk students. In contrast, Type 1 is an autoimmune disorder, such as multiple sclerosis, and currently there is no known way to prevent or delay Type 1 (CDC, 2011).
Impact on Academic and Cognitive Functioning
Previous research has indicated that complications from Type 1 can impair both cognition and academic performance (Gaudieri, Chen, Greer, & Holmes, 2008; Kent, Chen, Kumar, & Holmes, 2010; Naguib, Kulinskaya, Lomax, & Garralda, 2009). While most students with diabetes will demonstrate average cognitive ability and achievement scores, longterm disease complications, namely early disease onset and poor blood glucose control, may substantially impair functioning for a small proportion of students with diabetes (Kucera & Sullivan, 2011; Gaudieri et al., 2008; Kent et al., 2010; Naguib et al., 2009). In a meta-analysis by Gaudieri et al. (2008), youth identified with early onset of diabetes (4–7 years of age) demonstrated moderate effect sizes in poorer outcomes for verbal (ES = -.49) and visual (ES = -.44) learning and memory, attention and executive function (ES = -.39), overall cognition (ES = -.29), and academic achievement (ES = -.28) compared to children without diabetes. Consequently, these moderate effect sizes may impair classroom performance and result in a deficit of approximately half of a standard deviation in standardized assessment scores (Gaudieri et al., 2008). Nevertheless, while only some students with diabetes will experience long-term impairment, all youth with diabetes may demonstrate transitive cognitive impairment due to fluctuations in blood glucose levels (Gonder-Frederick et al., 2009; Ryan et al., 1990; Wodrich, Hasan, & Parent, 2011).
Thus, school psychologists need to be mindful of potential impairments in cognitive and academic performance as well as behavioral issues related to diabetes. Namely, fluctuations in mood or difficulty sustaining attention in the classroom might result from poor glucose control rather than an underlying psychopathology (Kucera & Sullivan, 2011). To this end, school psychologists are well-suited to advocate for students with diabetes (Kucera & Sullivan, 2011; Schmitt, Wodrich, & Lazar, 2010; Power, Mc- Goey, Heathfield, & Blum, 1999). As such, school psychologists should be knowledgeable about diabetes in order to implement federal laws.
Section 504 of the Rehabilitation Act of 1973 requires public schools to make reasonable accommodations to ensure that students with disabilities have equal opportunity to benefit from programs and activities (Jacob & Hartshorne, 2007). Accessibility issues in schools and other public buildings are addressed through the Americans with Disabilities Act of 1990. The IDEIA (2004) ensures that services are provided to students through an Individualized Education Program (IEP) if they meet eligibility criteria for 1 of 13 disability categories and demonstrate a need for specially designed instruction.
Guidance on the issue of IDEIA eligibility is provided by the NDEP, a joint program of the National Institutes of Health and the Centers for Disease Control and Prevention. In 2010, the NDEP published Helping the Student With Diabetes Succeed: A Guide for School Personnel. The following is an excerpt from this publication:
An example of a child with diabetes who may qualify under IDEIA is a student who may have difficulty paying attention or concentrating in the learning environment because of recurring high or low blood glucose levels that adversely affect the student's educational performance. (p. 121)
Thus, the critical issue in determining if an IEP is warranted depends on whether the child's educational performance is adversely impacted by diabetes (Kucera & Sullivan, 2011; Schmitt et al., 2010).
In short, a Section 504 Plan is primarily designed for students who need related aids and services such as the administration of insulin, assistance with checking blood glucose levels, allowance to eat snacks in the classroom, bathroom breaks as needed, and access to drinking water. An IEP is most appropriate when attention, concentration, or accuracy of schoolwork are adversely impacted by diabetes (NDEP, 2010). In the remainder of this section, factors to consider related to both IEPs and Section 504 Plans will be discussed in further detail.
IEP. If the child is thought to be eligible under the IDEIA, the disability category of other health impairment (OHI) may warrant consideration. According to the IDEIA, OHI means having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that
- Is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, and Tourette syndrome; and
- Adversely affects a child's educational performance.
As such, a child with diabetes might be identified as a student with an OHI if educational performance is adversely impacted by the disease. Moreover, scheduled or unscheduled absences from school due to illness are factors to consider that may affect academic performance. All students who are eligible for special education services under the IDEIA are also eligible for services under Section 504; however, an IEP provides greater protection for students than a Section 504 service agreement. Therefore, eligibility under the IDEIA should initially be considered in order to determine if the student's health impairment is adversely impacting educational performance. If eligibility under the IDEIA is ruled out, then eligibility under Section 504 should be determined. Similarly, if a student receiving services under a Section 504 service agreement is evaluated and found eligible under the IDEIA, the Section 504 service agreement would be discontinued in lieu of the IEP.
Section 504. Section 504 of the Rehabilitation Act of 1973 was amended by the Americans with Disabilities Act Amendments Act (ADAAA) of 2008, which went into effect on January 1, 2009. Although the primary focus was on employment, eligibility of K–12 students under Section 504 was also expanded. Children with health concerns such as diabetes may qualify for accommodations under Section 504 of the Rehabilitation Act of 1973. Under Section 504, a person is considered to have a disability if that person:
- has a physical or mental impairment which substantially limits one or more of such person's major life activities,
- has a record of such an impairment, or
- is regarded as having such an impairment.
The ADAAA expanded the list of major life activities to include reading, concentrating, thinking, and various major bodily functions. Notably, eligibility is not limited to impairments concerned with learning. Learning is just one of many major life activities that need to be considered. Additionally, school teams may no longer consider the ameliorative effects of mitigating measures when making a disability determination, but they remain relevant in evaluating needs. The ADAAA provided a list of mitigating measures including medication, mobility devices, low-vision devices (except eye glasses/contacts), hearing aids, prosthetic devices, cochlear implants, assistive technology, “learned behavioral or adaptive neurological modifications,” and reasonable accommodations.
Evaluation for eligibility under Section 504 occurs when eligibility under the IDEIA has been ruled out. The steps of a Section 504 evaluation involve securing permission, issuing procedural safeguards, attaining relevant records (information from parents, physicians' reports, other medical records), conducting additional assessments if warranted, and convening a meeting to review the information and to determine eligibility. If the student is determined to be eligible under Section 504, then next steps involve developing a Section 504 service agreement and implementing the agreement.
Section summary. In general, the critical issue in determining if an IEP is warranted is whether or not the child's educational performance is adversely impacted by diabetes (Kucera & Sullivan, 2011; NDEP, 2010; Schmitt et al., 2010). If a student with diabetes only requires accommodations concerning medical care tasks, then a Section 504 plan is likely sufficient. Conversely, an IEP is appropriate if a student with diabetes experiences severe fluctuations in blood glucose levels that influence educational performance or school attendance requiring specialized instruction in addition to accommodations related to disease management. When making a determination, it is useful to document adverse effects of the child's condition on typical daily educational performance in the classroom through means such as a functional assessment (Kucera & Sullivan, 2011; Power et al., 1999). The following case study provides an example of how this determination process and a functional assessment approach can be incorporated into an evaluation.
Grace, a 4th grader diagnosed with Type 1 diabetes, was being serviced through a Section 504 service agreement. A previous multidisciplinary team (MDT) evaluation found her intellectual ability and achievement commensurate, ranging from average to high average. The MDT determined that Grace was not eligible for special education services be- cause she did not meet definitional criteria for a specific learning disability. Her parents, however, were still concerned with Grace's school performance. They reported that they spent 2 to 3 hours each evening redoing assignments that were completed with low accuracy in the classroom and reteaching concepts in order to complete homework assignments. They presented a summative math assessment on which Grace earned a 45%. She skipped three items on the assessment, her printing was difficult to read, and she misspelled simple words. One item asked Grace to justify her response and she wrote, “is the Rule” in the 7 lines provided. Grace's parents requested an independent evaluation for eligibility under the IDEIA because they believed that their daughter demonstrated a need for specially designed instruction.
In the initial evaluation report, the school psychologist reported that the evaluation was conducted during times when the child's blood sugar range was within a defined ideal range based on information from the child's diabetes healthcare team. Ability and achievement results were commensurate and ranged from average to high average. Accordingly, the team found that the child was not eligible for special education services because she did not evidence a specific learning disability.
An independent evaluation was then conducted by one of the authors. Alternate ability and achievement measures yielded similar results, and the independent evaluator also concluded that Grace did not meet definitional criteria as a student with a specific learning disability. Additional testing was conducted to explore the impact of the child's diabetes on her academic performance. The school psychologist devised a series of equivalent, curriculum-based-measurement math worksheets that the student was asked to complete over a period of a few weeks directly following regularly scheduled blood glucose checks with the school nurse. Thus, no manipulations of blood glucose were performed nor were any additional or unscheduled blood glucose checks required. Furthermore, if the child was experiencing hypoglycemia or hyperglycemia, treatment was provided and not withheld while the child completed the worksheet. Results showed that when her blood sugar was ideal, the child's average accuracy rate was 91%. Under the low blood sugar condition, it was 80%, and it was 73% under the high condition. The scores on the CBM worksheets provided evidence that the child's academic performance, at least when completing mathematics calculations, appeared to be impacted by her medical condition.
The tasks were also timed, and a curvilinear relationship emerged between time on task and blood sugar level. When her blood sugar levels were low or high, she had difficulty maintaining her attention to task and worked quickly. When in the ideal range, she was able to focus and spent the most time on the tasks. Of course, previous analysis also indicated that she had the highest accuracy under the ideal condition.
In this case study, the child's health impairment was well documented. She had been diagnosed at age 4 with Type 1 diabetes and a history of difficulty controlling her blood glucose levels was established. The question of her eligibility hinged upon whether her diabetes also adversely affected educational performance to the point that she required special education and related services. Given that both speed and accuracy were impacted while completing math tasks due to blood glucose fluctuations that typically occurred during the school day, the independent examiner concluded that Grace's educational performance was adversely impacted by diabetes. Thus, Grace met definitional criteria as a student with an OHI. Although the school did not initially agree with the outside opinion, the dispute resolution process ultimately resulted in an IEP for the child that met with the parents' approval.
Diabetes Care Plans in School
Successful diabetes management in the school requires collaboration between educators, school administrators, caregivers, medical professionals (e.g., school nurse, child's physician), and school support personnel (e.g., bus driver; NDEP, 2010). The NDEP states that effective diabetes management is critical:
- For the immediate safety of students with diabetes
- For the long-term health of students with diabetes
- To ensure that students with diabetes are ready to learn and participate fully in school activities
- To minimize the possibility that diabetes-related emergencies will disrupt classroom activities (p. 8)
The NDEP recommends using individualized Diabetes Medical Management Plans (DMMP) and Individualized Health Care Plans (IHP) as the basis for formulating Section 504 Plans or IEPs (NDEP, 2010). Templates for generating DMMPs, IHPs, and emergency care plans for hypoglycemia and hyperglycemia are provided freely by the NDEP for use in schools. DMMP and IHP templates can be downloaded from http://ndep.nih.gov/media/youth_schoolguide.pdf.
Specially Designed Instruction and Accommodations
Making decisions regarding specialized instruction or accommodations should include consultation between the regular education teacher, the special educator, the school nurse, caregivers, and the child's diabetes healthcare team. Overall, any appropriate empirically supported academic and behavioral interventions are recommended for this population as there has been no contraindicating evidence to suggest otherwise. Furthermore, students experiencing difficulties in classroom performance might benefit from reteaching if concepts were initially introduced while the student was unable to concentrate due to fluctuations in blood glucose levels.
It is important for school psychologists to recognize that children with diabetes might be at risk for cognitive and academic impairments (Naguib et al., 2009; Gaudieri et al., 2008). Moreover, children with diabetes may demonstrate academic or cognitive performance issues due to daily fluctuations in blood glucose levels (NDEP, 2010; Gonder- Frederick et al., 2009). For children like Grace whose educational performance was impacted by diabetes, a Section 504 plan might not have been sufficient to meet all of her educational needs. In her case, an evaluation conducted by the school's MDT determined that she was not eligible for specially designed instruction based on traditional assessment procedures, whereas a functional assessment provided evidence that her educational performance was indeed adversely impacted by diabetes.
In conclusion, all youth with diabetes should have a written care plan supported by an applicable federal law (ADA, 2012). When assessing children with diabetes, a reasonable evaluation procedure might include (a) collaborating with other professionals (e.g., school nurse) and the child's caregivers to assess the student in accordance with his or her diabetes care plan, (b) interpreting the assessment results in the context of the child's chronic health condition, (c) documenting potentially adverse effects of the child's condition on typical daily educational performance through methods such as functional assessment (Kucera & Sullivan, 2011; Power et al., 1999), and (d) ruling out eligibility under IDEIA before proceeding with a Section 504 evaluation. Additionally, school psychologists might also consider seeking out opportunities for professional development such as asking the school nurse to conduct staff trainings in diabetes care and management. Furthermore, advocating for children with chronic health conditions helps to safeguard the rights of this at-risk population and ensure well-being for optimal learning.
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Joel B. Winnick received his doctorate at Penn State University's graduate program in school psychology in May 2014 where Shirley A. Woika, PhD, NCSP, is the director of clinical and field training.