The scene is any class-elementary or high school, general or special education. The teacher is at her desk while the class is taking an exam. Allison raises her hand and asks to go to the bathroom.
The teacher says, "No, not right now, please wait until the end of the exam."
Allison gets up, walks to the teacher's desk and asks again, "May I go to the bathroom and get a drink?"
The teacher repeats her original statement and requests that Allison wait until after the exam.
Allison angrily states, "I'm going now!" and leaves the room.
Under most circumstances, the teacher's response in this seenario may appear to be appropriate, and the student seems to be the one way out of line. But this student is not an ordinary student. She has juvenile diabetes, or Type I insulin-dependent di abetes. Students with diabetes may look or even act like all other students in your classroom, but in actuality, they have health-related issues (which may not be immediately apparent) and often require modifications to their daily routine during the school day.
This article addresses areas of concern for teachers who have a student with diabetes in their classrooms. Teachers need to understand how diabetes affects a student's ability to function successfully in the classroom. We discuss misconceptions about the effects of the disease, how the disease may affect the student in the classroom, and strategies and accommodations that teachers can use to help meet the student's needs. In addition, we discuss how students with diabetes feel about their disease.
What Is Diabetes?
Diabetes is an autoimmune illness, similar to rheumatoid arthritis or multiple sclerosis. Autoimmunity is a problem where the body's white blood cells, which normally fight infection, turn on a part of the body. In diabetes, the white blood cells target the cells that produce insulin. After a certain amount of time, there is a lack of insulin and one of two forms of diabetes, noninsulin-dependent diabetes, the more common form, and insulin-dependent diabetes, better known as juvenile diabetes, eventually develops (Norbury-Glaser, 1997).
Although there are no actual figures on the exact number of diabetics in this country, estimates range from 8 to 14 million persons, of which about 800,000 to 2 million are insulin-dependent. At least 100,000 of those afflicted are children 19 years and younger (1993 estimates) (Klatt, 1997; Norbury-Glaser, 1997). The figures vary for a number of reasons including the fact that many diabetics go undiagnosed and because there is no national registry and estimates are developed from various regional sources (Klatt; Norbury-Glaser). Juvenile diabetes can occur as early as age 6 months and at every age through adulthood (Bates, 1984).
Although juvenile diabetes is categorized under the Individuals with Disabilities Education Act (IDEA) and Americans with Disabilities Act (ADA) as a chronic health impairment because it requires continued medical treatment (Frieman & Settel, 1994), unless otherwise disabled, students with this disease are routinely placed into general education classrooms. Because the disease may accompany other disabilities, however, these students could be placed into any special education classroom. Considering the number of students with diabetes, special education teachers will at some point probably work with one or more of these students.
The parent, administrator, or the school nurse should inform you if a student with diabetes is to be placed into your classroom. This knowledge, however, is not a guarantee that you will know what to do when a specific incident revolving around the diabetes arises, especially because some situations that arise may need specific accommodations or modifications to the student's daily routines.
Understanding Is the Key
To meet the physical and psychological needs as well as the federal mandates for students with diabetes, teachers need to know the basic elements of the disease, the general aspects of the medical management of the disease, the best way to work with parents, and the best approach for including the child into the classroom routines (Frieman & Settel, 1994). In other words, if teachers understand diabetes, they are better prepared to provide appropriate accommodations for the student.
If a teacher is unprepared, he or she may actually cause either bodily or psychological harm to the student. To clarify your understanding of the disease, the following is a brief explanation of juvenile diabetes.
Juvenile diabetes is a chronic disease that impairs the body's ability to use glucose (the form of sugar that serves as an energy source for the body's cells) properly. The hormone insulin must be present for cells to absorb glucose (sugar) and convert it to energy for the cells. In the insulin-dependent diabetic, the pancreas produces little or no insulin. Because the sugar in the blood cannot be used, it builds up in the bloodstream as fat even while the body is literally starving for energy. This breakdown of fats releases acidic chemicals called ketones, which can become poisonous when they build up in the bloodstream. Without proper treatment, the diabetic can fall into a coma (Frieman & Settel, 1994).
Although there is no cure for diabetes, since the discovery of insulin in 1922 (Banting, 1929), it has been possible to control the disease (Rovet, Ehrlich, & Hoppe, 1988). Diabetes control means keeping the level of glucose in the blood as close to normal as possible. A person with this type of diabetes takes one or more injections of insulin daily to stay alive (Juvenile Diabetes Foundation, 1994). Insulin alone, however, does not keep a student under control. Diabetes control is a constant balancing act of food, exercise, and insulin. If the balance is thrown off, there is the danger of one of two diabetic emergencies: hyperglycemia (high blood sugar), or hypoglycemia (low blood sugar) which are insulin reactions (Juvenile Diabetes Foundation). Severe hyperglycemia can cause ketoacidosis, or a chemical imbalance that could produce an acute and serious illness, unconsciousness, coma, and ultimately death. Severe hypoglycemia, caused by taking too much insulin (Kwentus, Achilles, & Goyer, 1982), can produce unconsciousness and seizures (Rovet et al., 1988).
Fortunately, both hyperglycemia and hypoglycemia are accompanied by universal symptoms. Some students have all the symptoms, whereas others have only a few. The following is a list of the classic symptoms of both low and high blood sugar.
The symptoms of hypoglycemia or low blood sugar often occur suddenly. These symptoms include inappropriate responses, confusion and inattention, drowsiness, pale complexion, perspiration, headache, crankiness, lack of coordination, trembling, sudden hunger, dizziness, or the appearance of intoxication.
Universal symptoms of hyperglycemia or high blood sugar include extreme thirst, drowsiness, lethargy, dry hot skin, lack of hunger, fruity or winelike odor on the breath, heavy labored breathing, and eventual stupor or unconsciousness. Unlike low blood sugar, the symptoms of high blood sugar usually occur gradually (Juvenile Diabetes Foundation, 1994).
Students Speak Out About Their Diabetes
Students can give us great insights into how they feel and what effects they think their diabetes has on them-and even dispel common misconceptions about the disease (see box page 40, "Misconceptions"). We interviewed a number of students at various ages with juvenile diabetes to hear their perspective about the "lows" and "highs," as they call it, and how they feel about having them.
When asked to describe the symptoms of low blood sugar, one 12-year-old student described how he feels when he is low. He stated, "Sometimes, I feel horrible! I feel like I am going to fall over. I feel shaky all over. I sometimes even feel nauseous. Other times, I don't even know that I am low."
A 9-year-old student described how he felt: "I feel weak, irritable, hungry, and ready to kill anybody that bothers me."
A 6-year-old boy stated impishly, "My mother told me that she can tell when I'm low when I get off my school bus because I yell at all my friends."
The students were also asked to describe their symptoms of high blood sugar. A 13-year-old said, "It feels very weird. Sometimes I don't even know I am high. When I do think I am high, I feel like I am going to throw up, and I feel like I need to drink every 5 seconds or go to the bathroom."
Besides being aware of how they feel when they are either high or low, students with diabetes also seem to have universal thoughts that go through their minds during these stressful periods. One thought that seems to be universal among those students interviewed was: EAT! (Because I am very hungry). EAT! (Because I could faint). And EAT! (Because the faster I eat the faster I will feel better). One student described the feeling as, "When I am low, all these things go through my head. I know I should eat, but sometimes I can't because I feel very nauseous. I also don't want to overeat and then rebound and get high."
Because it is important that students understand proper health care and food planning, most students are told about possible complications at an early age, and therefore know all too well the complications of diabetes. They also know that many complications are kept to a minimum with good control.
Yet, complications still appear to be a worry for many of these students. For example, when one 10-year-old boy saw his number of 320 (80 to 180 is considered normal) on his glucose monitor, he started crying to his mother, "I don't want my foot to fall off!" Amputations, blindness, kidney failure, and heart attacks are among the many complications of diabetes. Effects on Students in the Classroom
Diabetes will affect students in the classroom in many ways. The most obvious for teachers seems to be the problems that arise from the need for a specific eating regimen. Lunch and snacks must be eaten at a specific time. Unfortunately, these times do not always coincide with the schedules and routines of the classroom. Further, blood sugars may need to be tested because exercise lowers sugar levels after gym or recess. Due to the strict schedules the students adhere to, they always need to be aware of the time of day, as well as their activity level.
Diabetes affects students in other, notso-obvious ways. For example, although diabetes does not affect students' performance in the long run, diabetes may affect learning on specific days (Johnson, Johnson, Johnson, & Kleinman, 1992). Although diabetics do not have a higher incidence of learning problems than do students without diabetes, what does happen is that when they are low they may be thinking about how hungry they are, or that they are dizzy or wobbly, or that they need to go to the nurse. In addition, they may occasionally have problems with reading or writing clearly because of blurred vision. This is a temporary condition caused by either high or low blood sugar levels. Remember, it will clear up as soon as the student gets under control (Bates, 1984).
Additionally, diabetes may affect behavior at specific times. As was the case with the boy whose mother heard him yelling at his friends all the way up the block, many students get belligerent and moody while low. Also, it sometimes appears to teachers that a student has deliberately disobeyed them, when, in fact, the student did what he or she knows is the right thing to do to meet their medical needs. Allison, the girl who went to the bathroom without permission, did so with only the thought of warding off a potentially embarrassing situation or just taking care of the terrible desire for water.
Attendance may also be a problem for some students. However, because the timing of the highs or lows affects all students differently, attendance problems vary for every student. For example, one boy was consistently late in the mornings because that was his "bad" time. Another high school girl was absent from 64 geometry classes because that was her time to get low.
It seems easy to say "Just try harder to get in control" during those bad times, but in actuality it can take months or years to figure out what the solution may be. Most students are working closely with their doctors and parents to rectify these blood sugars that go astray. Keep in mind they are not late or absent because they have chosen to be!
In addition, students with diabetes may be affected by low sugar levels during the night while sleeping. If they are lucky, they wake up when they are low. If not, they can go into insulin shock, which is extremely dangerous. These nocturnal incidents affect the student in the morning. Sometimes a student may be awake for a half hour to an hour in the middle of the night waiting until their blood sugar level is safe enough to go back to bed. By the time their alarm clock goes off in the morning, they may be high because of the rebound effect of eating too much. On these days, many students end up being late for school either because they just do not feel well from the unstable sugar level during the night, or from the headaches and tiredness that come after low blood sugar. Sometimes, those extra minutes of sleep are essential for the rest of the day to go smoothly.
As you can see, diabetic students are certainly not like other students in your classroom. They all have thoughts and feelings to contend with besides what is being taught to them. Although their diabetes doesn't adversely affect their learning directly, they all have those days where the diabetes temporarily takes precedence over their school subjects.
The following strategies may be helpful for teachers to consider when dealing with students with diabetes.
1. Allow students to leave the room as needed. Always grant bathroom, water fountain, and nurse requests immediately, regardless of what else the class is involved in doing. Of course, the student should follow the same procedures that the other students are expected to follow (Bates, 1984).
2. Allow the student to follow his or her routine inconspicuously. The student with diabetes will be able to function as a normal participant in group activities. Although the fact that he or she has diabetes should not be hidden, this student does not want to be singled out for special treatment. A quiet understanding should exist between you and the student about the necessary precautions to be taken (Juvenile Diabetes Foundation, 1994). For example, when the class is having a party, make sure there is food the student can eat, such as sugarless cake or diet drinks. Also, discuss with your student the best time and place for snacks and, if necessary, the best time and place to give themselves the insulin shot. Remember to do this without openly showing any sympathy (Bates, 1984).
3. Be aware of the type of questions that will encourage students to talk about their feelings. The best method for encouraging students to talk is to either ask direct questions or use reflective listening. For instance, if the student is late for class or late getting to school, take the student aside and ask, "Did you have a bad night?" If the student wants to talk, you have given the opening. Then, give the student your full attention and use your most effective listening techniques.
4. Teach the student to describe symptoms. If the student knows when he or she is high or low, try to teach the student to adequately describe the symptoms. For example, teach the student to say: "I'm feeling weak in my knees," "I'm feeling very thirsty," "I need to check myself," or "I think I am low."
5. Keep in constant communication with the parents. When first meeting with parents, explain that you will safeguard any personal information regarding their child (Frieman, 1993). Once you've established a rapport with the parents, you need to inform them if there are any patterns of either highs or lows during the school day. For example, if a student gets low at the same time every day, the times should be reported to the parents so that they can try to gain better control of the diabetes through changes in the insulin regimen.
It is also important to inform parents if there are going to be any strenuous activities that are not part of the daily routine. For example, inform parents if a special basketball match will be held between two classes or if the student may be participating in a special gymnastics game.
6. Educate class members. Young diabetics are often reluctant to reveal the fact that they have diabetes to classmates because they fear rejection by other students. Therefore, you may want to have a health-science lesson on diabetes. You could include the school nurse, or other staff members. If the student volunteers that he or she is diabetic, let the student answer as many questions as possible. The other students should be understanding when they see that you are calm and informed about the diabetes (Bates, 1984). In addition, make sure that you teach the class what the high and low symptoms are so they can assist you when they suspect their friend may be low or high.
7. Be aware of what to do in an emergency. Some students are aware when they are in a diabetic emergency, and some are not. That's when you become of utmost importance to the student. Literally, you need to be aware for the student. Therefore, you need to keep emergency supplies in the classroom at all times. When the student is low, sugar should be given immediately. The Juvenile Diabetes Foundation suggests that the sugar should include one-half cup of fruit juice, or 2 large sugar cubes, or 6-7 LifeSavers, or a bottle of regular soda. If the student doesn't improve in 15 minutes, you need to give the student more sugar and immediately call the doctor or the parent.
When the student is high, have the student drink fluids such as diet soda or water to avoid the dangerous condition of ketoacidosis from developing. Remember to keep the parents informed as to the time and severity of any high or low periods.
8. Be aware of legal accommodations to meet the law. Students with diabetes fall under the auspices of the ADA and IDEA. Therefore, public school teachers are required to accommodate these students whenever necessary. The following are legal accommodations most often needed:
Not penalizing the student for excessive absences and lateness.
Immediate dismissal from class whenever requested.
Modifications of the gym program when requested.
Ability to eat snacks whenever needed.
Of course, it is always a good idea to keep in touch with the parents to assure you that the student is following their routines properly. Finally, to meet these legal mandates, you need to work closely with the school nurse and the administration, especially regarding schoolwide policies.
9. Use information from the diabetes experts. Take advantage of the many pamphlets and books that are available from the American Diabetes Association and the Juvenile Diabetes Association to further help you deal with all aspects of care, especially emergencies that were not dealt with here, yet are concerns to teachers. In addition, you can contact various organizations or educational and treatment centers that specialize in children and adolescents with diabetes.
Caring, Knowledgeable teachers Make a Difference
A student with diabetes must live with this often troubling disease. They cannot live the carefree lives that their peers live; however, they can learn to cope with the restrictions, the structure, and the inconveniences of their condition (Bates, 1984). Caring teachers and aides who are well versed in the ongoing needs of students with diabetes can only enhance the student's environment and thereby help students to achieve their potential. These students will remember those of you who go out of your way to show that you understand their needs and feelings and that you are also there for them when they need the help.
Misconceptions About Students with Diabetes
Although everyone has heard of juvenile diabetes, and many think they understand the disease, there are still many classic misconceptions regarding the manifestations of the symptoms and the effect on learning and classroom behavior. The following is a list of classic myths.
Misconception 1: The student will tell you when he or she is either high or low. This is not always true. Some students do not know when they are high or low. Even when they do know, students want to be the same as everyone else and do not want to draw attention to their condition. They are sometimes embarrassed to say that they are having a diabetic reaction. They would rather just ask quietly to go to the nurse. Also, students may not realize that the particular set of symptoms they are feeling is related to the diabetes.
Misconception 2: Diabetes is affected only by food intake, and if a student eats properly, the diabetes will be under control. This is definitely not true. The level of the student's blood sugar is always a balancing act between the amount of activity, such as a basketball game or dancing, and food intake. In some students, activity can make their blood sugar level lower for up to 12 hours, whereas in others the sugar levels may get higher. In other words, one day the student may have close to normal sugar levels, yet even within the same day, the sugar level may change by 300 points due to a bad food choice or a strenuous activity.
Misconception #3: Bathroom and nurse privileges can wait a few minutes. This is an emphatic, NO, they cannot wait! By the time a student is aware that he or she is low, the minutes of waiting may be crucial, and the student may soon go into a diabetic coma. As long as a student is astute enough to know the feelings of being low, then that is the time to go to check and take care of their needs. Conversely, the symptoms of high blood sugar are just as important to eradicate. Little learning can take place while that dry mouth is present, or while a student has to go to the bathroom.
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Frieman, B. B. (1993). What early childhood teachers need to know about troubled children in therapy. Dimensions of Early Childhood, 21(4), 21-24.
Frieman, B. B., & Settel, J. (1994, Summer). What the classroom teacher needs to know about children with chronic medical problems. Childhood Education, 20, 196-201.
Johnson, R. W., Johnson, S., Johnson, C., & Kleinman, S. (1992). Managing your child's diabetes. New York: MasterMedia Limited.* Juvenile Diabetes Foundation. (1994). A child
with diabetes is in your care [Brochure]. Klatt, E. C. (1997). Diabetes Statistics-1993 Database [Electronic database]. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (Producer). University of Utah (Distributor). Directory: http:// pharminfo.com/cgi-bin/print-hit-bold. pl/disease/diabetes/diabstat.html. Kwentus, J. A., Achilles, J. T., & Goyer, P. F. (1982). Hypoglycemia: Etiology and psy
chosomatic aspects of diagnosis. Postgraduate Medicine, 71, 99-104. Norbury-Glaser, M. (1997). Facts about diabetes [On-line]. Denver, CO: University of Colorado Health Sciences Center: Barbara Davis Center for Childhood Diabetes [Producer and Distributor]. Directory: Mary.firstname.lastname@example.org.
Rovet, J. F., Ehrlich, R. M., & Hoppe, M. (1988). Specific intellectual deficits in children with early onset diabetes mellitus. Child Development, 59, 226-234.
Andrea Rosenthal-Malek (CEC Chapter #691), Associate Professor, Educational Leadership and Special Education Department, Monmouth University, West Long Branch, New Jersey. Jan Greenspan, Resource Center Teacher, Eatontown Public Schools, Eatontown, New Jersey. Address correspondence to Andrea RosenthalMalek (e-mail: email@example.com. edu).…