Table of Contents

    Topic review

    Type I Diabetes Mellitus

    Subjects: Clinical Neurology
    View times: 63


    A considerable endeavor had taken place in order to understand the associated challenges for children and adolescents with Specific Learning Disorder (SLD) and Type 1 Diabetes Mellitus (T1DM) but also in order to describe the necessary skills and approaches that the care givers have to develop to assist both children and parents.

    1. Introduction

    School performance, especially in children with specific learning disorders (SLD), is adversely affected by the coexistence of a chronic disease, such as Type 1 Diabetes Mellitus (T1DM) (previously called juvenile diabetes or insulin-dependent diabetes). Being diagnosed with a chronic illness can be overwhelming; especially at the start it can be stressful for the child and its family. We are conscious that living with T1DM can be really challenging for children, adolescents, and their families, regarding the complexity of the treatment, the involvement of the adult care givers and the needed support from the school setting. Children with T1DM and SLD confront major challenges, managing both insulin and learning difficulties within the school setting.

    Data from studies reviewed in this research, show that students with learning difficulties have higher rates of diabetes compared to the general population. The report of Public Health England, NHS Digital in 2016, supports the occurrence of higher rates of both diabetes types, in all age groups, in the population with SLD compared to the general population, and with early onset, recorded at a younger age [1][2]. In addition, a greater risk of autoimmune manifestations-including T1DM-that is recorded in Down’s syndrome [3], could explain the T1DM leading rates among children and adolescents with SLD [2]. Furthermore, SLD is also associated with higher rates of developing Type 2 Diabetes Mellitus (T2DM) later in adulthood [4][5][6], higher risk of obesity, due to a lifestyle with low level of exercise and high-fat diets, as well as higher levels of prescribed antipsychotic medication [2][7].

    Initially, since in literature we find only a few facts about the coexistence/comorbidity of SLD and T1DM, it is important to clarify some points about prevalence and phenomenology that characterize them.

    1.1. Specific Learning Disorders (SLD)

    Specific learning disorder (SLD) is also referred as learning disorder/disability, representing a neurodevelopmental [8] and neurobiological [9] disorder, that usually begins during the early school-age, and possibly not recognized until adolescence and even adulthood [8][10][11][12]. According to the diagnostic criteria of DSM-5, SLD is characterized by three types of continuous difficulties in the ability of learning, concerning one out of three fundamental domains of reading, writing and math; manifesting as a failure in the development of these skills, in correspondence to the expected for the age grade [8][9][13]. Apart from these three core areas, other disorders, such as memory problems, inattention and difficulties in social interaction, may also contribute fundamentally to failure in school performance, requiring a more specific intervention [13]. If not recognized and managed at an early age, beyond having lower academic achievement, ongoing difficulties may have a negative long-term impact in adult life [8][9][10][14]. Various difficulties, such as low self- esteem, behavioral and social problems, due to school failure, are associated with low academic achievements and dropping out of school in youths; mental distress, unemployment or under- employment later in adult life [8][10][11][15][16][17][18][19]. In numerous studies, SLD reflects different prevalence in relation to age, gender, psychosocial stage of development and environmental features [15]. The comorbidity of SLD with other disorders, is usually associated with more complicated manifestation and severe emotional and behavioral symptoms, that render interdisciplinary intervention crucial [15].

    SLD is a multifactorial disorder, caused by inherent or acquired factors affecting brain structure and function [20]. Genetic and family load, developmental factors, cognitive skills, native language, academic degree, environmental factors, such as socioeconomic status, are mentioned in many studies as severe etiological factors [13][15]. In Table 1 various risk factors are defined as predeterminants for SLD, indicating that the prevalence of SLD is increased among children with the mentioned characteristics regarding family history, medical history and socioeconomic status [13][15][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57]. A plethora of research studies have indicated that the prevalence of SLD shows considerable cross-national variation [55] and gender variation, with higher rates among boys comparatively to girls [8].

    Table 1. Risk factors for Specific learning disorder (SLD).

    Family history

    1.      SLD [13][21][22][23][27][29][30][31]

    2.      Level of parental education [27][32]

    3.      Special education services or educational supports [27][28][32]

    4.      ADHD diagnosis [27][29][33]

    5.      Not reading for pleasure [27][34]

    6.      Genetic disorders [27][35]

    Medical history

    1.      Prenatal and perinatal: premature labor or after risky pregnancies (diabetic gravidas), low/very low birth weight, complicated deliveries, hypoxia during labor and delivery, low Apgar score, neonatal jaundice, in utero substance exposure (e.g., alcohol, tobacco, radiation exposure, infections) [27][36][37][38][40]

    2.      Other developmental (e.g., early speech-language delay [27][43] and mental health conditions (e.g., ADHD, disruptive behavior disorders, autism, anxiety disorders, and depression) [13][27]

    3.      Neurocutaneous disorders (e.g., neurofibromatosis, Sturge- Weber syndrome, tuberous sclerosis complex) [27][35]

    4.      Neurologic conditions or insults (e.g., seizure disorders, Tourette syndrome, history of central nervous system infection or irradiation or traumatic brain injury [27][29][35][42]

    5.      Genetic disorders, syndromes or metabolic disorders, chromosomal disorders (e.g., fragile X syndrome, Turner syndrome, Klinefelter syndrome) [27][31][41][42]

    6.      Medical conditions (e.g., recurrent otitis media, asthma) [27][29]

    7.      Certain chronic medical conditions (e.g., T1DM, HIV infection) [13][27]

    Socioeconomic status

    1.      low-income families/low socioeconomic status [13][24][25][26]

    2.      cultural considerations [27][37][44]

    3.      environmental disadvantage [27][37][44]

    4.      poverty [27][34]

    5.      under stimulating environments [13][24][25][26]

    6.      neglect, abuse, domestic violence or unsafe home environment (e.g., parental substance abuse) [27][44]

    7.      Adverse childhood experiences [27][45]

    8.      Lack of adequate instruction [27][46]

    Information from references [13][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46].

    Table 2 shows the differential diagnosis of SLD, as there are conditions with high risk of learning issues in children and adolescents -that may not meet the diagnostic criteria of SLD- and if left untreated, may be confused with SLD [13][17][27][58][59].

    Table 2. Differential Diagnosis for Specific learning disorder (SLD).

    1.      Developmental delays (global and specific) [8][13][17][27][29][38][58][59][60][61]

    2.      Genetic syndromes or metabolic disorders [8][13][17][27][31][41][42][58][59]

    3.      Hearing impairment [8][13][17][27][58][59][62]

    4.      Visual impairment [8][13][17][27][58][59][63]

    5.      In utero substance exposure [27][38][40]

    6.      Mild intellectual disability (formerly mental retardation) [8][13][17][27][36][58][59][60][61]

    7.      Psychiatric conditions, ADHD or emotional disturbance (e.g., depression or anxiety) [8][13][17][58][59]

    8.      Neurocutaneous disorders (e.g., neurofibromatosis, Sturge- Weber syndrome, tuberous sclerosis) [8][13][17][27][35][58][59]

    9.      Neurologic conditions or insults (e.g., seizure disorders, Tourette syndrome, history of central nervous system infection or irradiation or traumatic brain injury [8][13][17][27][29][35][42][58][59]

    10.   Seizure disorder (e.g., absence, partial, partial- complex) [27][29]

    11.   Genetic causes [8][13][17][21][22][23][24][25][26]

    12.   Parent/school expectations that are discordant with the student’s abilities and interests [8][13][17][58][59]

    13.   Environmental factors (e.g., lack of opportunity, frequent school absences, poor teaching, and cultural factors, such as English as a second language) [8][13][17][58][59]

    14.   lead poisoning, medication side effects, substance abuse [8][13][17][58][59]

    15.   Sleep disorders [27][63]

    Information from references [8][13][17][27][29][31][35][36][38][39][40][41][42][58][59][60][61][62][63][64].

    The assessment of these conditions includes a series of essential examination, laboratory diagnostic tests, and supplemental appraisal, or more specialized testing and/or referral such as blood lead level, audiological and vision screening tests etc. Qualitative observations and/or the student’s report card can often identify SLD, but to make a formal diagnosis, psychometric testing is needed (Wechsler Intelligence Scale for Children- WISC) [13][27].

    The presence of SLD along with the conditions listed above is common [13]. Anxiety disorders [27][62], behavioral disorders [27][37][65][66], depressive disorders [27][29][62], motor delays/ disorders [27][65], neurodevelopmental disabilities (such as Attention Deficit Hyperactivity Disorder-ADHD) [27][37][62][65], speech-language delays/disorders [27][29][30][39][43][60], social-emotional problems and substance abuse [27][67] are the most common comorbidities with SLD [27].

    Regarding terminology, in the present literature review, the terms: “SLD”, “Specific Learning Disability”, “learning disability”, “learning difficulties” [8][11][12][68]; refer to miscellaneous group of disorders/difficulties revealed through unsuccessful attempts to obtain knowledge, which subsequently could be retrieved and utilized efficiently [13]. The “SLD”, which as a medical term, constitutes a diagnostic terminology [8], usually mentioned as “learning disorder” [8][11][12][68]; and the “Learning disability”, as an academic and legal term [11][12]; are not precisely identical. “Learning difference” represents a commonly accepted term, contributing in the destigmatization of children and adolescents, helping them reveal and communicate to others the difficulties that they face in learning and school performance, without labeling them as “disordered” [12][68]; or “disabled”, in a sense that the term “learning disability” reveals intellectual disability, formerly mentioned as “mental retardation” [13].

    1.2. Type 1 Diabetes Mellitus (T1DM)

    Type 1 Diabetes Mellitus (T1DM) in children, is also mentioned as “insulin-dependent” or “juvenile” Diabetes, usually firstly diagnosed during childhood and adolescence, can appear at any age and is a life-long disease. It accounts for about 5% of all patients with diabetes, while its incidence and its prevalence are increasing in the world [69][70][71][72].

    Childhood and adolescence are periods characterized by prompt developmental transitions and major changes occurring in the brain, which maybe more vulnerable to extremes of glycemia [73][74]. T1DM with an early onset in young age may have a negative impact on the development of the central nervous system (CNS), reflected in the decrement of cognitive and psychomotor efficiency, mental flexibility and attention; due to secondary conditions (such as chronic hyperglycemia, microvascular abnormalities etc.) [73]. As various prospective studies emphasize, the decline in cognitive functioning is associated more with early onset in young age and microvascular complications (such as retinopathy, nephropathy, neuropathy), than with severe hypoglycemia; while higher HbA1c levels are indicative for mental and psychomotor malfunctioning [73][75]. In addition studies in preschoolers, with severe hypoglycemic episodes at a younger age of 5–7 years old, recorded declines in spatial cognition and information recall, indicative of the susceptibility of the developing CNS to severe hypoglycemia [73][76][77]. Other studies, support that both hypoglycemia and microvascular abnormalities, are risk factors for cognitive malfunctioning [73][76][78][79][80]. Adults with T1DM compared to non-diabetics, presented significant decrease in psychomotor functioning, without any difference occurring in the skills of learning, recall, problem solving [73][79][80][81]. Although numerous studies reveal the association between T1DM and structural- functional changes in CNS, there is no etiological association with specific decline of cognitive efficiency. Research using neuroimaging techniques, such as structural MRI studies, highlighted the lower findings in gray and white substance in population with T1DM compared to non-diabetic peers; associated with severe hyperglycemia, early onset and longer duration of diabetes [73][82]. The clinical manifestations of the reduced white substance in patients with T1DM, were associated with inattention and lower performance in speed of information processing and executive function [73][83]. Age of onset and duration of diabetes, along with microvascular complications in intraparenchymal cerebral arterioles are associated with structural changes, specifically, with white matter lesions (WML) [73][83][84][85][86].

    Diagnosis in children can be overwhelming, as symptoms are individualized, occurring differently in each child, especially in the beginning [87][88]; usually including excessive thirst, dehydration, frequent urination, high levels of glucose in the blood and urine, unusual hunger or loss of appetite, fruity breath, tachypnea, nausea, vomiting, abdominal pain, weakness, fatigue, mood changes and irritability, severe diaper rash, yeast infection in girls etc. [87][88]. The American Diabetes Association (ADA) in the Position Statement “Care of Children and Adolescents With Type 1 Diabetes”, published in 2005 [70][89], highlighted the essential differentiations of diabetes with early onset in childhood, from adult diabetes; regarding developmental stage, epidemiology, pathophysiology, as well as care response [70][90][91]. In children and adolescents, the management of diabetes must not be concluded from adult diabetes therapy, but from the awareness of child’s developmental stage and needs, as well as environmental context. Punctual interdisciplinary intervention is a nodal point in preventive care for children and their families [70].

    Despite the wealth of data from the significant number of studies reviewed, it is worth noting that children with SLD and T1DM are less frequently researched. Through the narrative review significant issues arose from the data of the recruited research. The themes that were deduced are introduced under distinct titles, highlighting the following three points:

    2. The Potential Impact of Diagnosis and Management of T1DM in Children’s Mental Health and Adherence to Insulin Therapy

    We are conscious that living with T1DM can be really demanding compared to other chronic conditions. A higher risk of mental comorbidities is linked with T1DM in childhood [93][94][100][101] and adolescence [70][102][103]. Regarding the prevalence of psychological distress, behavioral and mood disorders in population with T1DM, several studies confirm that despite the fact that in childhood, may not differ from the general population, in adolescence the frequency is 2–3 times higher in comparison to non-diabetic peers [70][102][103]. Mental comorbidities may increase disease’s load for both children and carers, worsening metabolic control [94][100][104][105], leading in further deterioration of microvascular complications and increasing mortality rates [106][107]. Even though most of the children and adolescent patients cope sufficiently with daily glucose controls and insulin treatment, overcome difficulties and withstand challenges, demonstrating incredible resilience [98], some appear to suffer more, experiencing severe mental issues; usually depression, eating disorders [98][108]. Although depression is associated to a moderate degree with maladaptation to treatment of T1DM in children [93], adolescents with depression fail to maintain a sufficient metabolic control, facing a greater risk of exposure to short and long-term complications [98][108][109]. Some studies revealed as predictive factor for psychiatric comorbidities, high HbA1c levels in the early phase of the T1DM onset [94][100]; and highlighted an important clinical problem, estimating that there is a high risk of developing a mental disorder 15–20 years since the T1DM onset (reaching 30% [8]) [94][100]. Psychological well-being is associated with competent metabolic control and a supportive and psychologically healthy environment, that will react timely when depression’s symptoms are identified or suspected in a child or an adolescent diagnosed with T1DM, as a responsible adult needs to secure safe diabetes’s management and require help from a mental health professional [98].

    3. The Potential Impact of T1DM on Cognitive Learning Function and Its Relation to Academic Deficits

    Children and adolescent diabetic patients must cope with a demanding and complicated daily routine, concerning blood glucose (BG) levels control, insulin injections, diet and exercise; while continuing to live a “normal life” as their peers do. However, T1DM as a chronic disease along with the stressful BG control and psychosocial effects, is associated with a huge negative impact on school performance [106], inattention and lower spelling performance. The later, was related to greater hyperglycemia exposure [79][80]. For children with SLD and T1DM, daily routine, learning skills and academic attendance are burdened with low cognitive efficiency, due to the coexistence of these two conditions [92].

    Numerous studies suggest that although students with T1DM have an average performance on tests of general intelligence, they may demonstrate mild difficulties in cognitive skills, especially in reading [92]. In addition, there is no clear evidence regarding the impact of nearly undetectable neuropsychological deficiency that may occur in children with T1DM, gradually, on their learning skills [92]. Lamentably, there is no substantive data, as the number of studies of learning difficulties in children with T1DM is limited, concerning small and selective samples, using cross-sectional designs, inconsistent control groups and resulting contradictory conclusions [92]. Regarding the performance of this population on specific neuropsychological tests, opposing results are reported, as some studies showed deficits in verbal intelligence [92][110], memory [92][111][112], motor and visuospatial abilities [92][113][114][115]; whereas others identified deficits in abstract/visual reasoning [92][116], attention [92][111][117], work rate and processing speed [92][114]. The T1DM onset before the age of 7 years old [92][111][112][113][118][119] and school absences [92][115][120], are highlighted as risk factors to neuropsychological deficits. The documented subtle neurocognitive impairments among children with T1DMat several ages may not provide assessable detriment in school performance, even gradually [92], in accordance with studies concluding that severe cognitive impairment with a long-term impact in children with T1DM cannot be associated with the effects of diabetes, with the exception of the attribution to hypoglycemic seizures [92][110][111][112][113][114][115][116][117][118][119][120][121].

    Despite these findings, monitoring and preventive treatment of hypoglycemia, seizures or coma are essential to secure learning abilities [92].

    4. Challenges Related to Diabetes Management for Children and Parents

    The successful management of T1DM differs significantly among other chronic diseases in children and adolescents, as it requires along with a high complexity intervention and family involvement; also a supportive school environment [96][97][122]. There’s no cure for T1DM and although advances in BG monitoring and insulin delivery have improved patients’ quality of life, constant management and ongoing targets and tests can be overwhelming and stressful for both parents and child, as they must learn how to give injections, count carbohydrates and monitor BG.

    Diabetes 1 diagnosis constitutes a major crisis for both children and their parents [98]. They experience grief, as they have to confront the life-long nature of the disease and the undercurrent fear of the potential complications [98][123][124][125]. Initially, in the early period, when it is first diagnosed, the young patients usually express sadness, anxiety, irritability, despondency, and negativism in taking insulin or attending school [96][97][98][117][126]. Patients’ parents usually mention that they share with their children feelings of despair, anxiety, along with guilt and worries about the uncertain future [96][97][98][117][126]. These are regular responses that usually occur the first year after diagnosis [96][97][98][117][126]. However, children with underlying maladjustment, may develop in the future, adherence difficulties, psychosocial problems or/ and difficulties in metabolic control [96][126][127], that tend to pick in adolescence [70][94][96][97][98][128]. This could be attributed to the developmental changes that take place during “normal” puberty, such as physiological changes and insulin resistance [70][92][70].

    The entry is from 10.3390/brainsci11010004


    1. Public Health England, NHS Digital, 2016. Available online:
    2. Kachika, J. RightCare Pathways Lead, Learning Disability Programme, NHS RightCare Pathway: Diabetes, England. 2017. Available online: (accessed on 20 October 2020).
    3. Guaraldi, F.; Rossetto, G.R.; Lanfranco. ; Motta. G.; Gori. D.; Arvat. E.; Ghigo. E.; Giordano. R. Endocrine Autoimmunity in Down's Syndrome. In Endocrine Immunology; Savino, W.; Guaraldi, F., Eds.; Front Horm. Res./ Karger: Basel, Switzerland, 2017; Volume 48, pp. 133–146.
    4. Macrae, S.; Brown, M.; Karatzias, T.; Taggart, L.; Truesdale-Kennedy, M.; Walley, R.; Sierka, A.; Northway, R.; Carey, M.E.; Davies, M. Diabetes in people with intellectual disabilities: A systematic review of the literature. Dev. Disabil. 2015, 47, 352–374, doi:10.1016/j.ridd.2015.10.003.
    5. Walwyn, R.E.A.; Russell, A.M.; Bryant, L.D.; Farrin, A.J.; Wright-Hughes, A.M.; Graham, L.; Hulme, C.; O’Dwyer, J.L.; Latchford, G.; Stansfield, A.J.; et al. Supported self-management for adults with type 2 diabetes and a learning disability (OK-Diabetes): Study protocol for a randomised controlled feasibility trial. Trials 2015, 16, 342, doi:10.1186/s13063-015-0832-9.
    6. McVilly, K.R.; McGillivray, J.; Curtis, A.; Lehmann, J.; Morrish, L.; Speight, J. Diabetes in people with an intellectual disability: A systematic review of prevalence, incidence and impact. Med. 2014, 31, 897–904, doi:10.1111/dme.12494.
    7. Taggart, L.; Cousins, W. (Eds.) Health Promotion for People with Intellectual and Developmental Disabilities; Open University Press: London, UK, 2014; p. 229.
    8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Press: Washington, DC, USA, 2013.
    9. Silver, C.H.; Ruff, R.M.; Iverson, G.L.; Barth, J.T.; Broshek, D.K.; Bush, S.S.; Koffler, S.P.; Reynolds, C.R. Learning disabilities: The need for neuropsychological evaluation. Clin. Neuropsychol. 2008, 23, 217–219, doi:10.1016/j.acn.2007.09.006.
    10. Gerber, P.J. The impact of learning disabilities on adulthood: A review of the evidenced-based literature for research and practice in adult education. Learn Disabil. 2012, 45, 31–46, 201.
    11. Tannock, R. DSM-5 Changes in Diagnostic Criteria for Specific Learning Disabilities (SLD): What are the Implications? Available online: (Accessed on 10 October 2020).
    12. Shaywitz, S. Overcoming Dyslexia, Yale Center for Dyslexia and Creativity; Random House: 2005.
    13. Von Hahn, L.E. Specific Learning Disabilities in Children: Clinical Features. 2011. Available online: .
    14. Gabbard, G.O. Gabbard’s Treatments of Psychiatric Disorder, 5th ed.; American Psychiatric Publishing: Washington, DC, USA, 2014; 1213.
    15. Görker, I. The Prevalence and Gender Differences in Specific Learning Disorder; Inthchopen: London, UK, 2020.
    16. Alesi, M.; Rappo, G.; Pepi, A. Self-Esteem at School and Self-Handicapping in Childhood: Comparison of Groups with Learning Disabilities. Rep. 2012, 111, 952–962, doi:10.2466/15.10.pr0.111.6.952-962.
    17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders–Text Revision (DSM-IV-TR™, 2000), 4th ed.; First, M.E., Ed.; American Psychological Association: Washington, DC, USA, 2000.
    18. Taanila, A.; Yliherva, A.; Kaakinen, M.; Moilanen, I.; Ebeling, H. An epidemiological study on Finnish school-aged children with learning difficulties and behavioural problems. J. Circumpolar Health 2011, 70, 59–71, doi:10.3402/ijch.v70i1.17799.
    19. Whitsell, L.J. Learning Disorders as a School Health Problem—Neurological and Psychiatric Aspects. Med. 1969, 111, 433–445.
    20. American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. Joint statement--Learning disabilities, dyslexia, and vision. Pediatrics 2009, 124, 837.
    21. Snowling, M.J.; Gallagher, A.; Frith, U. Family Risk of Dyslexia Is Continuous: Individual Differences in the Precursors of Reading Skill. Child Dev. 2003, 74, 358–373, doi:10.1111/1467-8624.7402003.
    22. Snowling, M.J.; Muter, V.; Carroll, J. Children at family risk of dyslexia: A follow-up in early adolescence. Child Psychol. Psychiatry 2007, 48, 609–618, doi:10.1111/j.1469-7610.2006.01725.x.
    23. Vogler, G.P.; Decker, S.N.; DeFries, J.C. Family History as an Indicator of Risk for Reading Disability. Learn. Disabil. 1985, 18, 419–421, doi:10.1177/002221948501800711.
    24. Learning disabilities and young children: Identification and intervention. A Report from the National Joint Committee on Leaming Disabilities October, 2006. Learn Disabil. Q. 2007, 30, 63-72.
    25. Margai, F.; Henry, N. A community-based assessment of learning disabilities using environmental and contextual risk factors. Sci. Med. 2003, 56, 1073–1085, doi:10.1016/s0277-9536(02)00104-1.
    26. Fujiura, G.T.; Yamaki, K. Trends in Demography of Childhood Poverty and Disability. Child. 2000, 66, 187–199, doi:10.1177/001440290006600204.
    27. Curtin, M.J.; Willis, D.R.; Enneking, B. Specific Learning Disabilities: The Family Physician’s Role. Fam. Phys. 2019, 100, 628–635.
    28. Landerl, K.; Moll, K. Comorbidity of learning disorders: Prevalence and familial transmission. Child Psychol. Psychiatry 2010, 51, 287–294, doi:10.1111/j.1469-7610.2009.02164.x.
    29. Schieve, L.A.; Gonzalez, V.; Boulet, S.L.; Visser, S.N.; Rice, C.E.; Braun, K.V.N.; Boyle, C.A. Concurrent medical conditions and health care use and needs among children with learning and behavioral developmental disabilities, National Health Interview Survey, 2006–2010. Dev. Disabil. 2012, 33, 467–476, doi:10.1016/j.ridd.2011.10.008.
    30. Haworth, C.M.; Kovas, Y.; Harlaar, N.; Hayiou-Thomas, M.E.; Petrill, S.A.; Dale, P.S.; Plomin, R. Generalist genes and learning disabilities: A multivariate genetic analysis of low performance in reading, mathematics, language and general cognitive ability in a sample of 8000 12-year-old twins. Child Psychol. Psychiatry 2009, 50, 1318–1325, doi:10.1111/j.1469-7610.2009.02114.x.
    31. Samango-Sprouse, C.; Stapleton, E.J.; Mitchell, F.L.; Sadeghin, T.; Donahue, T.P.; Gropman, A.L. Expanding the phenotypic profile of boys with 47, XXY: The impact of familial learning disabilities. J. Med Genet. Part A 2014, 164, 1464–1469, doi:10.1002/ajmg.a.36483.
    32. Friend, A.; DeFries, J.C.; Olson, R.K. Parental Education Moderates Genetic Influences on Reading Disability. Sci. 2008, 19, 1124–1130, doi:10.1111/j.1467-9280.2008.02213.x.
    33. Rosenberg, J.; Pennington, B.F.; Willcutt, E.G.; Olson, R.K. Gene by environment interactions influencing reading disability and the inattentive symptom dimension of attention deficit/hyperactivity disorder. Child Psychol. Psychiatry 2011, 53, 243–251, doi:10.1111/j.1469-7610.2011.02452.x.
    34. Dilnot, J.; Hamilton, L.; Maughan, B.; Snowling, M.J. Child and environmental risk factors predicting readiness for learning in children at high risk of dyslexia. Psychopathol. 2016, 29, 235–244, doi:10.1017/s0954579416000134.
    35. Coutinho, V.; Kemlin, I.; Dorison, N.; De Villemeur, T.B.; Rodriguez, D.; Dellatolas, G. Neuropsychological evaluation and parental assessment of behavioral and motor difficulties in children with neurofibromatosis type 1. Dev. Disabil. 2016, 48, 220–230, doi:10.1016/j.ridd.2015.11.010.
    36. Johnson, S.; Strauss, V.; Gilmore, C.; Jaekel, J.; Marlow, N.; Wolke, D. Learning disabilities among extremely preterm children without neurosensory impairment: Comorbidity, neuropsychological profiles and scholastic outcomes. Early Hum. Dev. 2016, 103, 69–75, doi:10.1016/j.earlhumdev.2016.07.009.
    37. Reinke, W.M.; Herman, K.C.; Petras, H.; Ialongo, N.S. Empirically Derived Subtypes of Child Academic and Behavior Problems: Co-Occurrence and Distal Outcomes. Abnorm. Child Psychol. 2008, 36, 759–770, doi:10.1007/s10802-007-9208-2.
    38. Cho, K.; Frijters, J.C.; Zhang, H.; Miller, L.L.; Gruen, J.R. Prenatal exposure to nicotine and impaired reading performance. Pediatr. 2012, 162, 713–718.e2, doi:10.1016/j.jpeds.2012.09.041.
    39. O’Callaghan, F.V.; Al Mamun, A.; O’Callaghan, M.; Alati, R.; Williams, G.M.; Najman, J.M. Is smoking in pregnancy an independent predictor of academic difficulties at 14 years of age? A birth cohort study. Early Hum. Dev. 2010, 86, 71–76.
    40. Oei, J.L.; Melhuish, E.; Uebel, H.; Azzam, N.; Breen, C.; Burns, L.; Hilder, L.; Bajuk, B,; Abdel-Latif, M.E.; Ward, M.; et al. Neonatal abstinence syndrome and high school performance. Pediatrics 2017, 139, e20162651.
    41. Ekström, A.-B.; Hakenäs‐Plate, L.; Tulinius, M.; Wentz, E. Cognition and adaptive skills in myotonic dystrophy type 1: A study of 55 individuals with congenital and childhood forms. Med. Child Neurol. 2009, 51, 982–990, doi:10.1111/j.1469-8749.2009.03300.x.
    42. Brankaer, C.; Ghesquière, P.; De Wel, A.; Swillen, A.; De Smedt, B. Numerical magnitude processing impairments in genetic syndromes: A cross-syndrome comparison of Turner and 22q11.2 deletion syndromes. Sci. 2017, 20, e12458.
    43. Elbro, C.; Dalby, M.; Maarbjerg, S.J. Language-learning impairments: A 30-year follow-up of language-impaired children with and without psychiatric, neurological and cognitive difficulties. J. Lang. Commun. Disord. 2011, 46, 437–448, doi:10.1111/j.1460-6984.2011.00004.x.
    44. Fantuzzo, J.; Leboeuf, W.; Rouse, H.; Chen, C.-C. Academic achievement of African American boys: A city-wide, community-based investigation of risk and resilience. Sch. Psychol. 2012, 50, 559–579, doi:10.1016/j.jsp.2012.04.004.
    45. Shonkoff, J.P.; Garner, A.S. Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2012; 129, e232–e246.
    46. Kovaleski, J.F.; VanDerHeyden, A.M.; Shapiro, S. The RTI Approach to Evaluating Learning Disabilities; The Guilford Press: New York, NY, USA, 2013.
    47. Akaltun, I.; Yapça, Ö.; Ayaydin, H.; Kara, T. An evaluation of attention deficit hyperactivity disorder and specific learning disorder in children born to diabetic gravidas: A case control study. J. Psychiatry 2019, 20, 442–448, doi:10.5455/apd.10445.
    48. Altarac, M.; Saroha, E. Lifetime Prevalence of Learning Disability Among US Children. Pediatrics 2007, 119, S77–S83, doi:10.1542/peds.2006-2089l.
    49. Choudhary, M.G.; Jain, A.; Chahar, C.K.; Singhal, A.K. A Case Control Study on Specific Learning Disorders in School Going Children in Bikaner City. Indian J. Pediatr. 2012, 79, 1477–1481, doi:10.1007/s12098-012-0699-7.
    50. Fluss, J.V.; Ziegler, J.C.; Warszawski, J.; Ducot, B.; Richard, G.; Billard, C. Poor Reading in French Elementary School: The Interplay of Cognitive, Behavioral, and Socioeconomic Factors. Dev. Behav. Pediatr. 2009, 30, 206–216, doi:10.1097/dbp.0b013e3181a7ed6c.
    51. Gorker, I.; Bozatli, L.; Korkmazlar, U.; Yucel, K.M.; Ceylan, C.; Sogut, C.; Aykutlu, H.C.; Subay, B.; Turan, N. The probable prevalence and sociodemographic characteristics of specific learning disorder in primary school children in Edirne. Noro Psikiyatr Ars. 2017, 54, 343–349.
    52. Morsanyi, K.; Van Bers, B.M.; McCormack, T.; McGourty, J. The prevalence of specific learning disorder in mathematics and comorbidity with other developmental disorders in primary school-age children. J. Psychol. 2018, 109, 917–940, doi:10.1111/bjop.12322.
    53. Rathore, S.; Mangal, S.; Agdi, P.; Rathore, K.; Nema, R.; Mahatma, O. An overview on dyslexia and its treatment. Glob. Pharma Technol. 2010, 2, 18–25.
    54. Sun, Z.; Zou, L.; Zhang, J.; Mo, S.; Shao, S.; Zhong, R.; Ke, J.; Lu, X.; Miao, X.; Song, R. Prevalence and Associated Risk Factors of Dyslexic Children in a Middle-Sized City of China: A Cross-Sectional Study. PLoS ONE 2013, 8, e56688, doi:10.1371/journal.pone.0056688.
    55. Vlachos, F.; Avramidis, E.; Dedousis, G.; Chalmpe, M.; Ntalla, I.; Giannakopoulou, M. Prevalence and Gender Ratio of Dyslexia in Greek Adolescents and Its Association with Parental History and Brain Injury. J. Educ. Res. 2013, 1, 22–25, doi:10.12691/education-1-1-5.
    56. Bonti, E. Ειδικές Μαθησιακές Δυσκολίες: Μια εναλλακτική προσέγγιση για όλους. [Specific Learning Difficulties: An Alternative Approach for All]; Methexis: Thessaloniki, Greece, 2013; p. 624.
    57. Schmitt, J.; Romanos, M. Prenatal and Perinatal Risk Factors for Attention-Deficit/Hyperactivity Disorder. Pediatr. Adolesc. Med. 2012, 166, 1074–1075, doi:10.1001/archpediatrics.2012.1078.
    58. McInerny, T.K. Children who have difficulty in school: A primary pediatrician’s approach. Rev. 1995, 16, 325.
    59. Fennell, E.B. The Role of Neuropsychological Assessment in Learning Disabilities. Child Neurol. 1995, 10, S36–S41, doi:10.1177/08830738950100s109.
    60. Fletcher, J.M.; Lyon, G.R.; Barnes, M.; Olson, R.K.; Shaywitz, S.E.; Shaywitz, B.A. Classification of learning disabilities: An evidence based evaluation. Available online: (Accessed on 22 December 2020)
    61. S. Department of Education. Individuals with Disabilities Education Act, 20 U.S.C. § 1400. 2004. Available online: (accessed on 29 January 2019).
    62. Daud, M.K.M.; Noor, R.M.; Rahman, N.A.; Sidek, D.S.; Mohamad, A. The effect of mild hearing loss on academic performance in primary school children. J. Pediatr. Otorhinolaryngol. 2010, 74, 67–70, doi:10.1016/j.ijporl.2009.10.013.
    63. Genizi, J.; Matar, A.K.; Schertz, M.; Zelnik, N.; Srugo, I. Pediatric mixed headache -The relationship between migraine, tension-type headache and learning disabilities—In a clinic-based sample. Headache Pain 2016, 17, 42, doi:10.1186/s10194-016-0625-x.
    64. Creavin, A.L.; Lingam, R.; Steer, C.; Williams, C. Ophthalmic abnormalities and reading impairment. Pediatrics 2015, 135, 1057–1065.
    65. Schulte-Körne, G. Mental Health Problems in a School Setting in Children and Adolescents. Aerzteblatt Online 2016, 113, 183–90, doi:10.3238/arztebl.2016.0183.
    66. Mishna, F. Learning disabilities and bullying: Double jeopardy. Learn Disabil. 2003, 36, 336–347.
    67. Fakier, N.; Wild, L.G. Associations among sleep problems, learning difficulties and substance use in adolescence. Adolesc. 2011, 34, 717–726, doi:10.1016/j.adolescence.2010.09.010.
    68. Every Student Succeeds Act: Opportunities for school psychologists. National Association of School Psychologists. Communiqué 2016, 44, 13.
    69. Mobasseri, M.; Shirmohammadi, M.; Amiri, T.; Vahed, N.; Fard, H.H.; Ghojazadeh, M. Prevalence and incidence of type 1 diabetes in the world: A systematic review and meta-analysis. Health Promot. Perspect. 2020, 10, 98–115, doi:10.34172/hpp.2020.18.
    70. Chiang, J.L.; Maahs, D.M.; Garvey, K.C.; Hood, K.K.; Laffel, L.M.; Weinzimer, S.A.; Wolfsdorf, J.I.; Schatz, D.A. Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association. Diabetes Care 2018, 41, 2026–2044, doi:10.2337/dci18-0023.
    71. Dabelea, D.; Mayer-Davis, E.J.; Saydah, S.; Imperatore, G.; Linder, B.; Divers, J.; Bell, R.; Badaru, A.; Talton, J.W.; Crume, T.; et al. Prevalence of Type 1 and Type 2 Diabetes Among Children and Adolescents From 2001 to 2009. JAMA 2014, 311, 1778–1786, doi:10.1001/jama.2014.3201.
    72. Mayer-Davis, E.J.; Lawrence, J.M.; Dabelea, D.; Divers, J.; Isom, S.; Dolan, L.; Imperatore, G.; Linder, B.; Marcovina, S.; Pettitt, D.J.; et al. Incidence Trends of Type 1 and Type 2 Diabetes among Youths, 2002–2012. Engl. J. Med. 2017, 376, 1419–1429, doi:10.1056/nejmoa1610187.
    73. Moheet, A.; Mangia, S.; Seaquist, E.R. Impact of diabetes on cognitive function and brain structure. N. Y. Acad. Sci. 2015, 1353, 60–71, doi:10.1111/nyas.12807.
    74. Arbelaez, A.M.; Semenkovich, K.; Hershey, T. Glycemic extremes in youth with T1DM: The structural and functional integrity of the developing brain. Diabetes 2013, 14, 541–553, doi:10.1111/pedi.12088.
    75. Musen, G.; Jacobson, A.M.; Ryan, C.M.; Cleary, P.A.; Waberski, B.H.; Weinger, K.; Dahms, W.; Bayless, M.; Silvers, N.; Harth, J.; et al. Impact of Diabetes and Its Treatment on Cognitive Function Among Adolescents Who Participated in the Diabetes Control and Complications Trial. Diabetes Care 2008, 31, 1933–1938, doi:10.2337/dc08-0607.
    76. Perantie, D.C.; Lim, A.; Wu, J.; Weaver, P.; Warren, S.L.; Sadler, M.; White, N.H.; Hershey, T. Effects of prior hypoglycemia and hyperglycemia on cognition in children with type 1 diabetes mellitus. Diabetes 2008, 9, 87–95, doi:10.1111/j.1399-5448.2007.00274.x.
    77. Gaudieri, P.A.; Chen, R.; Greer, T.F.; Holmes, C.S. Cognitive Function in Children With Type 1 Diabetes: A meta-analysis. Diabetes Care 2008, 31, 1892–1897, doi:10.2337/dc07-2132.
    78. Ryan, C.M.; Williams, T.M.; Finegold, D.N.; Orchard, T.J. Cognitive dysfunction in adults with Type 1 (insulin-dependent) diabetes mellitus of long duration: Effects of recurrent hypoglycaemia and other chronic complications. Diabetologia 1993, 36, 329–334, doi:10.1007/bf00400236.
    79. Cato, A.; Hershey, T. Cognition and Type 1 Diabetes in Children and Adolescents. Diabetes Spectr. 2016, 29, 197–202, doi:10.2337/ds16-0036.
    80. Cato, M.A.; Mauras, N.; Ambrosino, J.; Bondurant, A.; Conrad, A.L.; Kollman, C.; Cheng, P.; Beck, R.W.; Ruedy, K.J.; Aye, T.; et al. Cognitive Functioning in Young Children with Type 1 Diabetes. Int. Neuropsychol. Soc. 2014, 20, 238–247, doi:10.1017/s1355617713001434.
    81. Ryan, C.M.; Geckle, M.O.; Orchard, T.J. Cognitive efficiency declines over time in adults with Type 1 diabetes: Effects of micro- and macrovascular complications. Diabetologia 2003, 46, 940–948, doi:10.1007/s00125-003-1128-2.
    82. Musen, G.; Lyoo, I.K.; Sparks, C.R.; Weinger, K.; Hwang, J.; Ryan, C.M.; Jimerson, D.C.; Hennen, J.; Renshaw, P.F.; Jacobson, A.M. Effects of Type 1 Diabetes on Gray Matter Density as Measured by Voxel-Based Morphometry. Diabetes 2006, 55, 326–333, doi:10.2337/diabetes.55.02.06.db05-0520.
    83. Wessels, A.M.; Simsek, S.; Remijnse, P.L.; Veltman, D.J.; Biessels, G.J.; Barkhof, F.; Scheltens, P.; Snoek, F.J.; Heine, R.J.; Rombouts, S.A.R.B. Voxel-based morphometry demonstrates reduced grey matter density on brain MRI in patients with diabetic retinopathy. Diabetologia 2006, 49, 2474–2480, doi:10.1007/s00125-006-0283-7.
    84. Marzelli, M.J.; Mazaika, P.K.; Barnea-Goraly, N.; Hershey, T.; Tsalikian, E.; Tamborlane, W.; Mauras, N.; White, N.H.; Buckingham, B.; Beck, R.W.; et al. Neuroanatomical Correlates of Dysglycemia in Young Children With Type 1 Diabetes. Diabetes 2013, 63, 343–353, doi:10.2337/db13-0179.
    85. Zupan, M. Pathogenesis of Leukoaraiosis: A Review. Stroke 1997, 28, 652–659, doi:10.5772/63655.
    86. Jeerakathil, T.; Wolf, P.A.; Beiser, A.; Massaro, J.; Seshadri, S.; D’Agostino, R.B.; DeCarli, C. Stroke risk profile predicts white matter hyperintensity volume: The Framingham Study. Stroke 2004, 35, 1857–1861.
    87. Menon, R.K.; Sperling, M.A. (Eds.) Pediatric Diabetes; Springer Science & Business Media: New York, NY, USA, 2003; p. 480.
    88. Los, E.; Wilt, A.S. Diabetes Mellitus Type 1 in Children. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2020.
    89. Silverstein, J.; Klingensmith, G.; Copeland, K.; Plotnick, L.; Kaufman, F.; Laffel, L.; Deeb, L.; Grey, M.; Anderson, B.; Holzmeister, L.A.; et al. Care of Children and Adolescents With Type 1 Diabetes: A statement of the American Diabetes Association. Diabetes Care 2004, 28, 186–212, doi:10.2337/diacare.28.1.186.
    90. Wherrett, D.K.; Chiang, J.L.; Delamater, A.M.; DiMeglio, L.A.; Gitelman, S.E.; Gottlieb, P.A.; Herold, K.C.; Lovell, D.J.; Orchard, T.J.; Ryan, C.M.; et al. Defining Pathways for Development of Disease-Modifying Therapies in Children With Type 1 Diabetes: A Consensus Report. Diabetes Care 2015, 38, 1975–1985, doi:10.2337/dc15-1429.
    91. Nadeau, K.J.; Anderson, B.J.; Berg, E.G.; Chiang, J.L.; Chou, H.; Copeland, K.C.; Hannon, T.S.; Huang, T.T.-K.; Lynch, J.L.; Powell, J.; et al. Youth-Onset Type 2 Diabetes Consensus Report: Current Status, Challenges, and Priorities. Diabetes Care 2016, 39, 1635–1642, doi:10.2337/dc16-1066.
    92. McCarthy, A.M.; Lindgren, S.; Mengeling, M.A.; Tsalikian, E.; Engvall, J.C. Effects of diabetes on learning in children. Pediatrics 2002, 109, e9, doi:10.1542/peds.109.1.e9.
    93. Kongkaew, C.; Jampachaisri, K.; Chaturongkul, C.A.; Scholfield, C.N. Depression and adherence to treatment in diabetic children and adolescents: A systematic review and meta-analysis of observational studies. J. Nucl. Med. Mol. Imaging 2013, 173, 203–212, doi:10.1007/s00431-013-2128-y.
    94. Sildorf, S.M.; Breinegaard, N.; Lindkvist, E.B.; Tolstrup, J.S.; Boisen, K.A.; Teilmann, G.K.; Skovgaard, A.M.; Jannet, S. Poor Metabolic Control in Children and Adolescents With Type 1 Diabetes and Psychiatric Comorbidity. Diabetes Care 2018, 41, 2289–2296, doi:10.2337/dc18-0609.
    95. Grey, M.; Cameron, M.E.; Lipman, T.H.; Thurber, F.W. Psychosocial Status of Children With Diabetes in the First 2 Years After Diagnosis. Diabetes Care 1995, 18, 1330–1336, doi:10.2337/diacare.18.10.1330.
    96. Hankins, M.A. The Effect of Group Therapy on Diabetes Specific Knowledge. Available online: (accessed on 25 September 2020).
    97. Wodrich, D.L.; Cunningham, M.M. School-based tertiary and targeted interventions for students with chronic medical conditions: Examples from type 1 diabetes mellitus and epilepsy. Sch. 2007, 45, 52–62, doi:10.1002/pits.20278.
    98. Frank, M.R. Psychological issues in the care of children and adolescents with type 1 diabetes. Child Health 2005, 10, 18–20, doi:10.1093/pch/10.1.18.
    99. Dronjaka, D.; Kesic, A.; Cvetkovic, M. The importance of psychological counseling in reducing symptoms of depression and increasing self-esteem of children with diabetes. de l’Enfance et de l’Adolescence 2012, 60, S232, doi:10.1016/j.neurenf.2012.04.550.
    100. Butwicka, A.; Frisén, L.; Almqvist, C.; Zethelius, B.; Lichtenstein, P. Risks of Psychiatric Disorders and Suicide Attempts in Children and Adolescents With Type 1 Diabetes: A Population-Based Cohort Study. Diabetes Care 2015, 38, 453–459, doi:10.2337/dc14-0262.
    101. Cooper, M.N.; Lin, A.; Alvares, G.A.; De Klerk, N.H.; Jones, T.W.; Davis, E.A. Psychiatric disorders during early adulthood in those with childhood onset type 1 diabetes: Rates and clinical risk factors from population-based follow-up. Diabetes 2016, 18, 599–606, doi:10.1111/pedi.12469.
    102. Helgeson, V.S.; Palladino, D.K. Implications of Psychosocial Factors for Diabetes Outcomes among Children with Type 1 Diabetes: A Review. Pers. Psychol. Compass 2012, 6, 228–242, doi:10.1111/j.1751-9004.2011.00421.x.
    103. Hagger, V.; Hendrieckx, C.; Sturt, J.; Skinner, T.; Speight, J. Diabetes Distress Among Adolescents with Type 1 Diabetes: A Systematic Review. Diabetes Rep. 2016, 16, 1–14, doi:10.1007/s11892-015-0694-2.
    104. Plener, P.L.; Molz, E.; Berger, G.; Schober, E.; Mönkemöller, K.; Denzer, C.; Goldbeck, L.; Holl, R.W. Depression, metabolic control, and antidepressant medication in young patients with type 1 diabetes. Diabetes 2015, 16, 58–66, doi:10.1111/pedi.12130.
    105. Scheuing, N.; Bartus, B.; Berger, G.; Haberland, H.; Icks, A.; Knauth, B.; Nellen-Hellmuth, N.; Rosenbauer, J.; Teufel, M.; Holl, R.W.; et al. Clinical Characteristics and Outcome of 467 Patients With a Clinically Recognized Eating Disorder Identified Among 52,215 Patients With Type 1 Diabetes: A Multicenter German/Austrian Study. Diabetes Care 2014, 37, 1581–1589, doi:10.2337/dc13-2156.
    106. White, N.H.; A Cleary, P.; Dahms, W.; Goldstein, D.; Malone, J.; Tamborlane, W.V. Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group Beneficial effects of intensive therapy of diabetes during adolescence: Outcomes after the conclusion of the Diabetes Control and Complications Trial (DCCT). Pediatr. 2001, 139, 804–812, doi:10.1067/mpd.2001.118887.
    107. Sandahl, K.; Nielsen, L.B.; Svensson, J.; Johannesen, J.; Pociot, F.; Mortensen, H.B.; Hougaard, P.; Broe, R.; Rasmussen, M.L.; Grauslund, J.; et al. Increased mortality in a Danish cohort of young people with Type 1 diabetes mellitus followed for 24 years. Med. 2016, 34, 380–386, doi:10.1111/dme.13124.
    108. Delamater, A.M.; Jacobson, A.M.; Anderson, B.; Cox, D.; Fisher, L.; Lustman, P.; Rubin, R.; Wysocki, T. Psychosocial Therapies in Diabetes: Report of the Psychosocial Therapies Working Group. Diabetes Care 2001, 24, 1286–1292, doi:10.2337/diacare.24.7.1286.
    109. Rubin, R. Working with adolescents. In Practical Psychology for Diabetes Clinicians, 2nd ed.; Anderson, B.J., Rubin, R., Eds.; American Diabetes Association: Chicago, IL, USA, 2002; pp. 139–147.
    110. Ryan, C.; Vega, A.; Longstreet, C.; Drash, A. Neuropsychological changes in adolescents with insulin-dependent diabetes. Consult. Clin. Psychol. 1984, 52, 335–342.
    111. Hagen, J.W.; Barclay, C.R.; Anderson, B.J.; Feeman, D.J.; Segal, S.S.; Bacon, G.; Goldstein, G.W. Intellective functioning and strategy use in children with insulin-dependent diabetes mellitus. Dev. 1990, 61, 1714–1727.
    112. Holmes, C.S.; Richman, L.C. Cognitive profiles of children with insulindependent diabetes. Dev. Behav. Pediatr. 1985, 6, 323–326.
    113. Ryan, C.; Vega, A.; Drash, A. Cognitive deficits in adolescents who developed diabetes early in life. Pediatrics 1985, 75, 921–927.
    114. Northam, E.A.; Anderson, V.; A Werther, G.; Warne, G.L.; Adler, R.G.; Andrewes, D. Neuropsychological complications of IDDM in children 2 years after disease onset. Diabetes Care 1998, 21, 379–384, doi:10.2337/diacare.21.3.379.
    115. Ryan, C.; Longstreet, C.; Morrow, L. The effects of diabetes mellitus on the school attendance and school achievement of adolescents. Child Care Health Dev. 1985, 11, 229–240, doi:10.1111/j.1365-2214.1985.tb00466.x.
    116. Golden, M.; Ingersoll, G.M.; Brack, C.J.; Russell, B.A.; Wright, J.C.; Huberty, T.J. Longitudinal relationship of asymptotic hypoglycemia to cognitive function in type 1 diabetes. Diabetes Care 1989, 12, 89–93.
    117. Rovet, J.; Alvarez, M. Attentional Functioning in Children and Adolescents With IDDM. Diabetes Care 1997, 20, 803–810, doi:10.2337/diacare.20.5.803.
    118. Rovet, J.; Ehrlich, R.; Hoppe, M. Specific intellectual deficits in children with early onset diabetes mellitus. Child Dev. 1988, 59, 226–234.
    119. Northam, E.A.; Anderson, V.; Werther, G.A.; Warne, G.L.; Andrewes, D. Predictors of change in the neuropsychological profiles of children with type 1 diabetes 2 years after disease onset. Diabetes Care 1999, 22, 1438–1444, doi:10.2337/diacare.22.9.1438.
    120. Ryan, C.M. Neurobehavioral Complications of Type I Diabetes: Examination of Possible Risk Factors. Diabetes Care 1988, 11, 86–93, doi:10.2337/diacare.11.1.86.
    121. Ryan, E. Effects of Diabetes Mellitus on Neuropsychological Functioning: A Lifespan Perspective. Clin. Neuropsychiatry 1997, 2, 4–14.
    122. Edmunds, S.; Roche, D.M.; Stratton, G.; Wallymahmed, K.; Glenn, S.M. Physical activity and psychological well-being in children with Type 1 diabetes. Health Med. 2007, 12, 353–363, doi:10.1080/13548500600975446.
    123. Lowes, L.; Lyne, P. Chronic sorrow in parents of children with newly diagnosed diabetes: A review of the literature and discussion of the implications for nursing practice. Adv. Nurs. 2000, 32, 41–48, doi:10.1046/j.1365-2648.2000.01418.x.
    124. Whittemore, R.; Jaser, S.; Chao, A.; Jang, M.; Grey, M. Psychological experience of parents of children with type 1 diabetes: A systematic mixed studies review. Diabetes Educ. 2012, 38, 562–579.
    125. Streisand, R.; Mackey, E.R.; Elliot, B.M.; Mednick, L.; Slaughter, I.M.; Turek, J.; Austin, A. Parental anxiety and depression associated with caring for a child newly diagnosed with type 1 diabetes: Opportunities for education and counseling. Patient Educ. Couns. 2008, 73, 333–338, doi:10.1016/j.pec.2008.06.014.
    126. Kovacs, M.; Feinberg, T.L.; Paulauskas, S.; Finkelstein, R.; Pollock, M.; Crouse-Novak, M. Initial coping responses and psychosocial characteristics of children with insulin-dependent diabetes mellitus. Pediatr. 1985, 106, 827–834, doi:10.1016/s0022-3476(85)80368-1.
    127. Jacobson, A.M.; Hauser, S.T.; Lavori, P.; Willett, J.B.; Cole, C.F.; I Wolfsdorf, J.; Dumont, R.H.; Wertlieb, D. Family environment and glycemic control: A four-year prospective study of children and adolescents with insulin-dependent diabetes mellitus. Med. 1994, 56, 401–409, doi:10.1097/00006842-199409000-00004.
    128. Hamilton, J.; Daneman, D. Deteriorating Diabetes Control during Adolescence: Physiological or Psychosocial? Pediatr. Endocrinol. Metab. 2002, 15, 115–26, doi:10.1515/jpem.2002.15.2.115.
    1. Please check and comment entries here.