Oxfordshire Children’s Diabetes Service Supporting Young People with Type 1 Diabetes

Oxfordshire Children’s Diabetes Service
Children’s Hospital, Oxford OX3 9DU
Horton Hospital, Banbury OX16 9AL
Supporting Young People with Type 1 Diabetes
In Secondary Schools
Dr Julie Edge, Consultant in Paediatric Diabetes
Elaine O’Hickey, Diabetes Specialist Nurse
Jane Haest, Diabetes Specialist Nurse
Sarah Breton, Commissioner for Children, Oxfordshire CCG
Janet Johnson, SEN Manager, Children, Education and Families Directorate
1. Basic Diabetes Knowledge
1.1 What is Diabetes?
Type 1 diabetes is a condition resulting from destruction of the insulin-producing cells of the pancreas
in children and young adults. Insulin is a hormone which helps the body to use glucose contained in
foods. Without insulin, the glucose from the food cannot be used and the level will rise in the
bloodstream. This causes tiredness, weight loss, excessive thirst and frequent passing of urine.
Around 320 children and young people in Oxfordshire have Type 1 diabetes and this is increasing all
the time.
1.2 How is it Managed?
Although diabetes cannot be cured, it can be treated effectively. The aim of treatment is to keep the
blood glucose levels close to normal range (4-8 mmol/l). This involves:
 Usually at least 4 injections of insulin a day or the use of an insulin pump.
 Regular meals containing carbohydrate and possibly snacks in between.
 Finger prick blood tests before each meal and at any other time when necessary.
Good blood glucose control will reduce the risk of later complications. When a child is treated and
cared for in a supportive environment, they should feel well and will be full of energy. This will enable
them to concentrate in school and, therefore, achieve their educational potential.
High or low blood glucose levels will affect learning (see appendix 2 for more details).
2. Care Required Within Secondary Schools
The care asked of school is the same as is expected of parents at home. Most young people by the
time they reach secondary school are independent in most of the diabetes-related tasks, such as
blood glucose testing and insulin administration. Some young people, particularly at Key Stage 3,
may need reminders to carry out the tasks. Parents will let the school know if this is the case and this
should be recorded in their care plan.
Problems can occur if blood glucose levels are not kept within target levels and it is, therefore,
essential that all school staff have an awareness of this medical condition and the young person’s
needs during the school day. If necessary (only in rare instances), volunteers (who may have this in
their job description) can be trained in the specifics of the care, including blood testing and giving
Paediatric Diabetes Team, Jan 2014
Review Jan 2017
2.1 Blood glucose testing
Young people are generally expected to check their blood glucose levels at certain times, i.e. before
lunch, before and after sport and sometimes before snacks. This is done using a finger prick device
(with a self-contained drum of lancets). These devices are intended for self-monitoring on an
individual person only. The young person will act upon these results if they are outside the target
range (either less than 4mmols/L or greater than 14 mmols/L). Some young people using insulin
pump therapy also use continuous glucose monitoring. These devices will show current glucose
levels and will alarm when glucose levels are outside of range.
If the Blood glucose level is below 4 mmol/l this is called HYPOGLYCAEMIA, if above 14 mmol/l this
2.2 Management of HYPOGLYCAEMIA (low blood glucose levels)
Hypoglycaemia (BGL less than 4 mmol/l) can cause a lot of different symptoms; “stress” symptoms
such as trembling, fast heart rate, pallor, sweaty, and/or effects on the brain function such as difficulty
concentrating, blurred vision, difficulty hearing, slurred speech, poor judgement, problems with shortterm memory.
The young person will immediately need to do a blood test to check the level.
If confirmed to be low, they need to immediately eat or drink fast-acting carbohydrate to treat
the “low”. They will then need some longer-acting carbohydrate, or to have lunch or snack.
They need to be allowed to do this wherever they are at the time, as it is not safe to
make them walk to a different location.
They MUST be allowed to test and treat where they are in the classroom, but if this is not
possible (for example in a science laboratory) they need to do it immediately outside and must
be accompanied.
They should not be left to do this themselves and should not be left alone until they have
See Appendix 1 for the full flow chart of how to manage hypoglycaemia.
2.3 Administration of insulin (using either a pen or pump)
Young people will generally need to give themselves insulin to cover any food that they eat, using a
“bolus” of quick-acting insulin. They will also need a bolus if their blood glucose level is high at any
time. Young people need a safe place to give insulin, but this also needs to become part of their daily
life. It is not necessary for a young person to do this in a medical room and can be carried out at the
dining table if they are happy to do this.
2.4 Activity and exercise within the school environment
It is important that young people with diabetes participate in physical activity for their long-term health.
Activity may affect blood glucose levels, depending on the intensity, duration and how close the
activity is to insulin dosages. Prevention of low blood glucose levels during and after sport is very
important so young people may need a carbohydrate snack before their PE and should ideally be
encouraged to test BGL before during and after sport. They MUST be allowed to eat this at any time
of the school day. They may also need to drink a sports drink during or after sport, or eat a snack
after sport. This needs to be allowed as it ensures the young person’s safety.
2.5 Awareness of the impact of stresses within the school environment
It is well recognised that stress (including anxiety about possible bullying and stress related to
tests/exams) can affect blood glucose levels. This fluctuation may be outside a young person’s ability
to control and, therefore, needs to be taken into consideration when assessing performance.
2.6 Effects of high and low blood glucose levels on school work
High blood glucose levels will make students feel tired, thirsty, need to urinate frequently and
generally make concentration difficult. In contrast, low blood glucose levels will have an impact both
at the time when they are found to be low and for up to 3-4 hours after the level has normalised. Low
levels are likely to affect mental flexibility, planning, decision-making, attention to detail and rapid
responding. Full details of how teachers can support young people can be found in Appendix 2.
Paediatric Diabetes Team, Jan 2014
Review Jan 2017
Guidance on care which may be required at different stages
Involvement of the young person
Care required
Years 7-8
The student is adapting to secondary school
routine, having been completely supervised with all
injections/pump boluses and blood tests at primary
school. They may require regular, but time-limited,
adult support to supervise/oversee their
management of their diabetes.
A young person may need:
Reminders to administer insulin.
A safe place to deliver insulin - at the dining table if the student wishes.
Staff should be trained in interventions required if a young person is hypoglycaemic.
Support to allow blood glucose testing in class/sports field, especially when
Support to allow eating/drinking in class but only to treat hypoglycaemia.
More intensive support and supervision for periods of time if the young person is
struggling to manage their diabetes.
Years 9-11
Some students will require adult support to remind
them about their diabetes particularly around
lunchtime testing and injections.
A young person may need:
Reminders to administer insulin.
A safe place to deliver insulin.
Staff should be trained in interventions required if a young person is hypoglycaemic.
Support to allow blood glucose testing in class,/sports field especially when
Support to allow eating/drinking in class but only to treat hypoglycaemia.
More intensive support and supervision for periods of time if the young person is
struggling to manage their diabetes.
Years 12-13
The majority of students by this stage will be
entirely independent in the management of their
diabetes. On rare occasions, parents or diabetes
team members may request other provision.
A young person may need:
A safe place to deliver insulin.
Staff should be trained in interventions required if a young person is hypoglycaemic.
Support to allow blood glucose testing in class, especially when hypoglycaemic.
Support to allow eating/drinking in class but only to treat hypoglycaemia.
More intensive support and supervision for periods of time if the young person is
struggling to manage their diabetes.
Paediatric Diabetes Team, Jan 2014
Review Jan 2017
Appendix 1 - General Management of Hypoglycaemia: What to do flow chart
A low blood glucose (hypoglycaemia; less than 4 mmol/l) might happen because:
a meal or snack is missed or delayed.
the young person hasn’t eaten enough.
the young person has been exercising a lot with no extra food.
the young person is getting more insulin than their body needs.
Follow the flow chart if a child/young person with diabetes appears to have any of the
following signs:
General Signs of hypoglycaemia
poor concentration
record time and result
in Communication Book
Is the young person
or having a CONVULSION?
Call for Help
Place in the recovery position.
Call 999. State “an unconscious diabetic
young person”.
Stay with the young person.
Do not try to give food/drink or Glucogel.
Ensure that someone alerts the young
person’s parent/carer as soon as
The hypoglycaemia episode should be
recorded in the school’s
Accident/Incident Book, or equivalent
documentation, and in the
Communication Book.
or if no-one available
who has been trained
to do BG testing
If blood glucose less
than 4 mmol/l
 100mls non-diet fizzy drink, fresh fruit
juice or Lucozade Sport.
 OR 2-4 glucose tablets.
 OR Glucogel massaged between gum
and cheek if drowsy - up to whole tube
Wait 10 mins then recheck BG, if above 4mmol give
carbohydrate snack/lunch as per Care Plan.
If under 4mmol repeat Step 1.
If not recovering, repeat steps 1 & 2 and check BG
again after further 10-15 mins to make sure it is now
above 4 mmol/l.
Paediatric Diabetes Team, Jan 2014
Review Jan 2017
Appendix 2 - Diabetes and Learning
There is ample evidence that poorly controlled diabetes can affect learning and this can be in specific areas.
Acute hypoglycaemia at any time will stop a young person concentrating for up to 2 hours and must be taken
into account in the classroom.
Long-term poor control can affect learning and this list has been produced to show teachers what support may
be offered for these specific problems.
Children with diabetes do worse than their peers in demanding classroom environments
Cognitive function is related to the amount of exposure to hypoglycaemic and hyperglycaemic events during
development. Cumulative and chronic exposure to the metabolic abnormalities resulting from diabetes is a major
risk factor related to poorer learning over time.
Being diagnosed with diabetes when young and long-term severe hypoglycaemia increases the
risk of poorer learning and memory
Children are more sensitive to glucose changes in the early years of life because of rapid brain development.
Episodes of severe hypoglycaemia were associated with lower IQ. Early exposure to hypoglycaemia can:
 Affect areas in the brain responsible for language, memory and attention.
 Reduce spatial intelligence and delayed recall
 Reduce short-term verbal memory, phonological processing skills, attention and executive processing.
Seizures caused by hypoglycaemia can also affect memory
In pre-school children the areas most affected by hypoglycaemia are those concerned with motor, sensory and
visuo-spatial function. In 7 to12 year old children the areas most affected are related to memory function.
Being diagnosed with diabetes at a later age affects visual learning and memory, visual motor integration and
psychomotor speed.
Long-term hyperglycaemia may affect cognitive function later in life causing poorer neurocognitive outcomes and lower verbal intelligence
During adolescence the brain areas responsible for planning, organisation and independent thinking are most
vulnerable to the effects of hyperglycaemia. Long-term hyperglycaemia can affect memory and executive
function, fine motor control tasks, verbal intelligence and attention.
Children with diabetes perform worse in reading and spelling
Even small reductions in attention, visuospatial ability and motor speed can result in poorer reading and writing
Differences between boys and girls
Boys with diabetes show more deficits than girls with lower overall learning, particularly in memory, attention and
vocabulary tasks.
Poor memory impacts on the ability to follow aspects of the diabetes regimen
Memory is a critical component in learning. Early identification of working memory difficulties and minor cognitive
decline is essential to self-care skills. Carbohydrate counting and remembering blood testing are both parts of
the diabetes regimen that have high memory demands.
Adolescents are a highly vulnerable group in relation to disruption of organisation and memory. Compensatory
strategies and environmental support can both help offset decline in cognitive abilities and support self care
Teacher reports are essential to understanding links between assessment results and day-to-day
Healthcare professionals, parents and teachers can all monitor children to ensure subtle learning difficulties are
identified and do not take a cumulative educational or psychological toll.
Paediatric Diabetes Team, Jan 2014
Review Jan 2017
Potential Issues
Processing speed
Impact in the classroom
 Homework taking longer.
 Slower note taking.
Slower processing speed  Not showing all knowledge when
results in difficulties in
understanding and
 Frustration – tendency to take
keeping up with new
short cuts.
tasks set.
Dividing attention (reading and
Selective and sustaining
attention – avoiding distraction.
One task at one time.
Short instructions & break down tasks.
Limit distractions.
Sit child at front with a studious buddy.
One-to-one teaching or small group work.
Vary tasks and teaching style.
Movement breaks.
Holding short-term information.
Learning and remembering new
information, homework tasks or
Following a film or a story.
Poor generalisation of
information from one setting to
Elements of new sequenced
Use calculators for maths.
Encourage showing working out.
Repeat instructions and check they have been
Small amounts of new information at a time.
Support error-free learning.
Use diaries, checklists, phone.
Lesson plan & discuss lessons afterwards.
Repetition and rehearsal.
Connect new information and things they already know.
Use visual prompts for sequenced task.
Initiating tasks.
Problem solving.
Spatial awareness.
Transferring 2D info. to 3D.
Locating information on a busy
Visual scanning.
Copying from the board.
Shape, number, letter
Motor planning.
Executive Function
Perceptual Skills
Strategies and support
 Reduce homework & provide handouts.
 Ensure enough time to note tasks.
 If necessary, request extra time allowance for state
 Reward quality of work not just quantity.
 Encourage typing.
Provide structure and prompts and gradually fade them
out over time.
Mind maps to help revision and plan essays.
Practise use of wall calendars with planning for
Work on using mobile phone for reminders.
Model and reward checking of work.
Clear expectations and feedback.
Realistic goals.
Model step-by-step approach to problem solving using
real life situations.
Worksheets without too much information.
Use of highlighter to aid scanning for main ideas.
Multi-sensory learning.
Consistent and routine approach.
Verbal prompts progressing to written prompts and fade
them out.
Lay things out in the sequence they will be needed.
Reference – Griffin, A, Christie, D., (2012) The effects of diabetes on cognitive function. In Christie, D. Martin, C. (Eds)
Psychosocial Aspects of Diabetes. Children, adolescents and their families. Radcliffe, London (pp 65-83)
Paediatric Diabetes Team, Jan 2014
Review Jan 2017