COD E R E D

Compared to non-diabetic children, diabetic children present significantly lower scores on schoolachievement scores such as arithmetic, reading and spelling (Gath et al., 1980; Ryan et al., 1985a),increased learning difficulties, lower grades in English and language arts, more grades repeated andspecial instruction received (Hagen et al., 1990; Holmes et al., 1992; Yu et al., 2000). They were absentmore frequently from school (Holmes et al., 1992; McCarthy et al., 2002; Ryan et al., 1985a; Yu et al.,2000), and their absence rate was associated negatively with GPA (Grade Point Average) and academicachievement (Kovacs et al., 1992; Ryan et al., 1985a). Diabetic children perform within normal rangeregarding overall intelligence and cognitive functions (Ack et al., 1961; Kaufman et al., 1999; Ryan et al.,1985a; Ryan et al., 1984; Weil & Ack, 1964) and particularly on associative learning ability, verbal/visualmemory and visual-spatial tests (Ryan et al., 1984). Nevertheless, a pattern of mild deficit and slowerperformance in specific neurocognitive tests such as verbal intelligence (Hagen et al., 1990; Kovacs et al.,1992; Ryan et al., 1984), memory (Hagen et al., 1990; Holmes et al., 1992), visual-motor tasks andcoordination (Ryan et al., 1985a; Ryan et al., 1984), and visual-spatial ability (Rovet, 1987), was found. Onbehavioral aspects, Ryan, et al., concluded that children with diabetes do not have poor self-image orexcess anxiety (Ryan et al., 1984), but McCarthy, on the other hand, found diabetic children to have morebehavioral problems such as mood variability, compliance and fatigue (McCarthy et al., 2003).Further, several factors have been shown to be associated with the functional impact of diabetes:age of diabetes onset, hypoglycemic episodes or seizures, and metabolic control. Age-at-onset seems todetermine the impact of diabetes on neurocognitive development and learning ability. Children with earlyonset diabetes, diagnosed before 4-5 years of age, achieved lower intelligence test scores than theirrespective siblings (Ack et al., 1961). They performed slower in processing information than both controlsand children with late onset diabetes (Hagen et al., 1990). And, compared to controls, early onset diabeticchildren performed slower in verbal intelligence (Hagen et al., 1990; Ryan et al., 1985b), visual-spatialability, learning and memory, mental and motor speed (Golden et al., 1989; Holmes et al., 1992; Rovet,1987; Ryan et al., 1985a). Age at onset was found to be negatively related to memory (Golden et al.,1989) and to visual-perception but not to verbal comprehension, academic achievement (such as reading,math, written language, knowledge) or to overall cognitive scores (Kaufman et al., 1999). A related issueis the disease duration. While length of disease seems not to affect general intellectual functioning amongdiabetic children (Ack et al., 1961; Golden et al., 1989; Kaufman et al., 1999; Weil & Ack, 1964), diseaseduration was related to lower vocabulary and block test scores, lower school grades and higherabsenteeism (Kovacs et al., 1992).Mild/severe hypoglycemic episodes or seizures are suspected to be one of the pathways for theassociation of age of onset and cognitive impairment by affecting the brain development and increasingthe risk of later neurobehavioral deficits or delays (Ryan et al., 1985a). Presence of hypoglycemic seizureswas associated with lower scores in short and word memory, (Kaufman et al., 1999) or contrarily, has notexerted any effect on cognitive function (Ryan et al., 1984). Frequency of asymptomatic hypoglycemia isfound to be associated with abstract/visual reasoning (copying subscales) (Golden et al., 1989). Mildhypoglycemia is related to reduced functioning on basic motor on dominant hand, attention, memory(Puczynski M. S. et al., 1990; Reich et al., 1990) and concentration (Puczynski M. S. et al., 1990). Mildhypoglycemia modifies the temporary performance rather than the long-term cognitive deficits but a lagmay exist between blood sugar restoration and total mental efficiency recovery (Puczynski M. S. et al.,1990; Puczynski S. et al., 1992; Reich et al., 1990).Metabolic control (measured by glucosylated hemoglobin-HbA1) was found to be negativelyrelated with reading, math and basic academic skills (Kaufman et al., 1999). McCarthy, et al., in two largesample studies, showed that children with poor metabolic control performed worse in reading and hadlower GPAs compared to children with good control (McCarthy et al., 2003; McCarthy et al., 2002).However, it did not relate to school performance in a six-year follow-up study of 87 diabetic children;although school performance and grades declined over time, verbal performance improved slightly(Kovacs et al., 1992).E-8