Diabetes Mellitus Tipo 1 e Habilidades Ne Uropsicológicas Revisão de Literatura

Duarte NS, Carvalho MFO, Freire RCL et al.
Type 1 diabetes mellitus and neuropsychology

English/Portuguese
J Nurs UFPE on line. 2012 Dec;6(12):3032-40 3032
DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963

TYPE 1 DIABETES MELLITUS AND NEUROPSYCHOLOGY ABILITIES:
LITERATURE REVIEW
DIABETES MELLITUS TIPO 1 E HABILIDADES NEUROPSICOLGICAS: REVISO DE
LITERATURA
DIABETES MELLITUS TIPO 1 Y ASPECTOS NEUROPSICOLGICOS: REVISIN DE LA LITERATURA
Nietsnie Souza Duarte
1
, Maria Fernanda Oliveira Carvalho
2
, Roslia Carmen Lima Freire
3
, Izabel Hazin
4
,
Ricardo Fernando Arrais
5

ABSTRACT
Objective: to investigate the neuropsychological abilities in children and adolescents with type 1 diabetes
mellitus. Method: this is an literature review by searching the PEPSIC, which includes the databases: LILACS,
IBECS, MEDLINE, Cochrane Library and Scielo using the descriptors type 1 diabetes, cognition, cognitive
ability, neuropsychological. Results: the studies shows that Type 1 DM is a disease that can promote impact
on neuropsychological functioning, especially considered three specific variables: age at diagnosis, exposure
to hypoglycemia and exposure to hyperglycemia. Conclusion: the studies on the neuropsychological findings
and Type 1 DM controversies regarding the variables that possibly affect cognitive functioning. It should be
noted, in general, that for variables considered, such as childhood is a time of vulnerability to the impact of
Type 1 DM in neuropsychological skills. A significant part of researches suggest lower cognitive performance,
though slight, in most areas studied. Descriptores: Diabetes Mellitus Type 1; Child Development; Cognition.
RESUMO
Objetivo: investigar habilidades neuropsicolgicas em crianas e adolescentes portadores de diabetes
mellitus Tipo 1. Mtodo: trata-se de reviso da literatura por meio de busca no PEPSIC, o qual inclui as bases:
LILACS, IBECS, MEDLINE, Biblioteca Cochrane e Scielo, utilizando-se os descritores diabetes type 1, cognition,
cognitive ability, neuropsychological. Resultados: os estudos encontrados apontam que o DM Tipo 1 pode
promover impacto sobre o funcionamento neuropsicolgico, em especial quando so consideradas trs
variveis especficas: idade ao diagnstico, exposio hipoglicemia e hiperglicemia. Concluso: os estudos
acerca dos achados neuropsicolgicos e o DM Tipo 1 apresentam controvrsias no tocante a variveis que
alteram o funcionamento cognitivo. Destaca-se que para as variveis consideradas, a infncia referida como
momento de vulnerabilidade ao impacto do DM Tipo 1 nas habilidades neuropsicolgicas. Parte significativa
das pesquisas realizadas sugere desempenho cognitivo inferior na maioria dos domnios estudados.
Descritores: Diabetes mellitus Tipo 1; Desenvolvimento Infantil; Cognio.
RESUMEN
Objetivo: investigar capacidades neuropsicolgicas en nios y adolescentes con diabetes mellitus tipo 1.
Mtodo: revisin de la literatura por medio del PEPSIC, que incluye las bases: LILACS, IBECS, MEDLINE,
Cochrane Library y Scielo, utilizando los descriptores diabetes tipo 1, cognicin, capacidad cognitiva y
neuropsicolgico. Resultados: Los estudios muestra que la DM tipo 1 es una enfermedad que puede promover
el impacto en el funcionamiento neuropsicolgico, especialmente cuando se considera tres variables
especficas: la edad al momento del diagnstico, la exposicin a la hipoglucemia y a la hiperglucemia.
Conclusin: los estudios muestran controversias con respecto a las variables que afectan el funcionamiento
cognitivo. Se sealan que de las variables consideradas, la infancia es un momento de vulnerabilidad al
impacto de la DM tipo 1 en las habilidades neuropsicolgicas. Parte de la investigacin sugiere menor
rendimiento cognitivo en la mayora de las reas estudiadas. Descriptores: Diabetes mellitus tipo 1;
Desarrollo Infantil; Cognicin.
1
Psychologist, Master in Psychology Universidade Federal do Rio Grande do Norte, Brasil (in progress). Natal (RN), Brazil. E-mail:
nietsnieduarte@hotmail.com;
2
Psychologist. Brasil, E-mail: carvalho.mfernanda@gmail.com;
3
Psychologist. Master in psychology
Universidade Federal do Rio Grande do Norte, Brasil (in progress). Natal (RN), Brazil. E-mail: rosaliacarmen@hotmail.com.
4
Psychologist.
Doctor in cognitive psychology, Researcher at Universidade Federal do Rio Grande do Norte/UFRN. Natal (RN), Brasil. E-mail:
izabel.hazin@gmail.com;
5
MD, Doctor in Medicine, Researcher at Universidade Federal do Rio Grande do Norte/UFRN. Natal (RN), Brazil.
E-mail: rifarrais@gmail.com

LITERATURE INTEGRATIVE REVIEW ARTICLE
Duarte NS, Carvalho MFO, Freire RCL et al. Type 1 diabetes mellitus and neuropsychology
English/Portuguese
DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963

The Type 1 Diabetes Mellitus (DM type 1)
which is focused in this study included about
5 to 10% of the total of DM cases and starts
characteristically in childhood or adolescence.
However, this disease can also be present in
adulthood, something which is observed in
about 30% of the DM type 1 cases.
1

Concerning the clinical condition of the
disease, the DM is characterized as a disorder
of the intermediary metabolism, especially
regarding the carbohydrates, which leads to
the increase of the serum glucose levels and
acute metabolic complications with a fatality
potential, besides a series of chronic
multisystemic complications.
1
With respect to
the DM type 1 treatment, it is pointed out
that a strict therapeutic diet is demanded,
with the glycaemia monitoring and daily
insulin injections.
2

The DM type 1 has as a particularity the
deficiency or complete lack of insulin, and
this is an important hormone for the glucose
homeostasis control in the body. The glucose
has fundamental acting for the brain
development and functioning, as the brain
primarily needs glucose in order to function in
a great level and provide the maturation of
the cortical areas involved in different
cognitive activities. The glucose is the main
source of energy for the body, and it is almost
the only one for the brain. Due to the DM
etiology, the factors that contribute to the
hyperglycemia can be the reduction of the
insulin secretion, as well as the decrease of
use and increase of glucose production.
3

This way, it is questioned how the DM in
childhood can influence the brain activities,
notably in sensitive periods of the nervous
system development, something which points
to the necessity of investigating about how
the manifestation of the disease in childhood
can interfere in the neurodevelopment and,
consequently, in the cognitive functioning of
the clinical subgroup. Once it is found that
the brain development is extended from
intrauterine life until about 12/14 years old
and as the glucose is the brain nutrient
element by excellence, it is indicated that
children with atypical glycaemic patterns can
present neuropsychological impairments
resulting from these alterations.
4

Then, the objective of this article is to
investigate the neuropsychological abilities in
children and adolescents who have the type 1
DM, pointing the nature and the extension of
possible neuropsychological impairments
resulting from the presence of glycaemic
alterations along the stages of the
neurodevelopment. We intend to contribute
towards the understanding of the
neuropsychological functioning which is
characteristic of this population, benefiting
them, the other professionals who work with
these children and adolescents, especially the
school which can offer a profile of activities
and evaluations that are adequate for the
especial needs of this group, and the family
who can better understand some cognitive
alterations that can be consequence of the
disease process.

During the mentioned investigation, it was
performed a literature integrative review
through the search motor PEPSIC (Psychology
Electronic Periodicals), using the option all
the sources, which includes the data bases:
LILACS, IBECS, MEDLINE, Cochrane Library and
Scielo.
Among the descriptors used for the title,
abstract, keywords and text, it was found:
Diabetes type 1, cognition, cognitive ability,
neuropsychological. The search was delimited
by the age of the researched groups
Childhood (birth to 12 years old) and
Adolescence (13 to 17 years old), during the
last five years, with fully available electronic
articles.
It was found 22 articles, from which it was
excluded the texts which did not fit the
indicated age group, as well as the ones that
dealt with a subject different to the one
proposed here. After this restriction, it was
selected 17 articles.

The first 5 to 7 years of life are a crucial
period associated with the cognitive decline in
individuals with type 1 DM. The called
precocious beginning an important
predictor of worse cognitive performance
mediated by the adverse effects resulting
from events of severe and serious
hypoglycaemia, suggests the association of
the age of the child importance in the
diagnosis moment with the presence of peaks
of low glycaemia, and this is one of the most
supported propositions by several studies. On
the other hand, the bad glycaemic control
does not seem to present consistent relations
with the cognition.
5
Regarding the suggestion
of factors interaction for the concurrence of
impacts in the neurodevelopment, it is
indicated a greater vulnerability of children
aging less than five years old to identify the
hypoglycaemia, due to the lack of awareness
RESULTS
METHOD
INTRODUCTION
English/Portuguese
DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963
or verbal abilities to report the symptoms.
This way, the authors speculate that the
factor precocious beginning of the disease
would be secondary to the preponderant
factor of the exposure to severe
hypoglycaemia.
6

The absence of association between the
glycaemic control and the presence of
cognitive deficits in adolescents with type 1
DM corroborates the association of the
mentioned deficits with the precocious
beginning of the disease, supporting the
previously mentioned findings. In a study
performed with 70 children and adolescents,
who were divided into groups of acceptable
and non-acceptable glycaemic control, it was
carried out an evaluation through the
application of patterned battery of
psychological tests, including
neuropsychological and psychological
measures. Before this procedure and aiming
to prevent the impact of hypoglycaemia and
hyperglycaemia, the blood glucose level was
checked, as well as the participants were
trained to report hypoglycaemia symptoms
during the evaluation process performance. As
a result, it was observed some damage of the
executive functions in all the children,
independently of the glycaemic control level.

5,7
The precocious beginning of the disease
effect about the cognition was also studied,
especially in relation to the basic and
academic verbal abilities, aiming to explore
the mechanisms of learning deficits and the
dyslexia incidence. For this, it was constituted
a sample with 51 children with precocious
beginning of the disease and ages between 9
and 11 years old, who was compared with a
group of 92 children without DM. the children
were evaluated with tasks of phonological
processing, short-term memory, rapid
automatised naming, reading, spelling and
mathematics. The researchers found that the
children with type 1 DM had an inferior
performance in relation to the other group in
the phonological processing, in the spelling
precision and in mathematics. Besides, the
data indicated that the children with DM
started reading later, but the reading
performance and the dyslexia incidence was
the same for both groups. Considering the
results, the study concluded that the children
with precocious beginning of the disease are
prone to present phonological processing
deficits, causing some difficulties with the
learning in the first school years.
8

There is some consistent finding indicating
a worse cognitive performance with the
children who had precocious beginning of the
type 1 DM, although there is not yet a clear
distinction between the studies concerning
the beginning of the disease, associated to
the presence of frequent or severe events of
hypoglycemia and to a greater exposure of
time to the disease. This observation is
important so that it is performed a critical
analysis about the carried researches and an
adequate discussion about their results.
9

It is suggested that the hyperglycaemia
plays a smaller role than the hypoglycaemia
factors and the precocious beginning of the
disease, concerning the impact on the central
nervous system development.
Neuropsychological profiles of a cohort of
young people with type 1 DM were examined;
they were studied since the disease diagnosis
12 years before. When compared to the
control group, this young people had a worse
performance in the working memory. The
precocious beginning of the disease was
related to some damage to the sustained and
divided attention, new learning and mental
efficiency. The hypoglycaemia was associated
with the adverse effects in the verbal
abilities, working memory and non-verbal
processing speed; the hyperglycaemia was
only associated with the damage to the
working memory.
10

Considering the struggle between
hyperglycaemia and hypoglycaemia, a group
of researchers carried out a study aiming to
examine if the experience of hypoglycaemia
or hyperglycaemia during the brain
development would affect the hippocampus
volume. In a similar way to previous studies, it
was found some qualitative differences
regarding the exposure to the mentioned
glycaemic patterns. The obtained data
through images of magnetic resonance with
type 1 diabetic patients, aging between 7 and
17 years old, reveal that the severe exposure
to hypoglycaemia was associated with the
hippocampus expansion; the hyperglycaemia
was not linked to the hyppocampal volume.
11

In the same understanding line, it was
performed a study aiming to quantify the
magnitude and patterns of effects associated
with the precocious beginning of the type 1
DM and severe hypoglycaemia, as well as the
cognitive functioning difficulties in children
with this pathology. Through the performed
analysis, it was concluded that the severe
hypoglycaemia is related to a cognitive
performance a bit inferior in the majority of
the specific domains.
12

As it is shown in the studies, the
occurrence pattern of hypoglycaemic events
and consequent cognitive dysfunctions appear
in an insidious way among children. In 2008, it
English/Portuguese
DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963
was published a study which included, 18
years after, young people who entered the
Diabetes Control and Complications Trial
between 13 and 19 years old. However, in
contrast to the high severe hypoglycaemia
rates which were found, the cognitive
function did not show alterations. This study
suggests that the hypoglycaemia occurrence
upon the adolescents with type 1 DM seems
not to promote impacts on the cognitive
functioning.
13

Taking into consideration the study of the
relation between the type 1 DM and school,
another study used a different research
method compared to the previous ones, which
used evaluation data of teachers and school
records, as well as several medical variables
age at the beginning of the disease
(considering it as precocious when the
diagnosis happened before the seventh
birthday), type of treatment (conventional or
intensive) and glycaemic control level (last
value of the glycated hemoglobin). The
participants of the study were selected
according to criteria: being type 1 DM patient
at school age; having a teacher in class who is
aware of the diagnosis; having a healthy
sibling registered at school and aging between
5 to 18 years old; and, both patient and
sibling without mental retardation, blindness
or deafness.
14

For the evaluation of the school variables
and its relation to the DM, the researchers
created a questionnaire, which presented
items regarding the abilities, working habits
and attention: academic development
(reading, arithmetic and writing) in relation to
the school level of the student; barriers in the
classroom functioning, in which the teachers
classified how many times the student
presented difficulties in areas such as memory
and attention; variability of the daily
performance, considering the performance in
a typical week; and attention in class measure
through the inattention dimension of the
ADHD Rating Scale IV: School Version.
14
The study results mentioned above point
that, in relation to the age at the beginning of
the treatment, it was not found statistically
significant differences between precocious or
late diagnosis in the evaluated school
domains, data which match several studies, as
it is previously shown. Concerning the type of
treatment, those ones who received intensive
therapy presented less absenteeism and had a
better classification in mathematics by the
teachers. However, when compared to the
patients who received conventional therapy,
the intensive therapy patients were evaluated
by their teacher as having a difficult
performance for the academic success.
Regarding the variability of the daily
performance and the attention in class, it was
not found differences related to the type of
adopted therapy. The glycaemia stability was
related to all the academic evaluations, and
particularly to the evaluations of the teachers
of the attention in class, as well as it was
positively associated with the variability of
the daily performance. The authors concluded
that the type 1 DM affects the child at school,
but the effects do not seem to be regular both
in school academic and non-academic
aspects.
14

Still interested in the effects of the type 1
DM at schooling, the above research published
a literature review about this theme, finding
that although several studies already
performed point that the pathology is
associated with problems about the school
frequency, cognition, school performance and
interpersonal relations, it is necessary well
controlled studies for elucidating the nature
and the severity of the school problems.
15
There was still the preoccupation of
investigating the effect of a specific
treatment for the type 1 DM continuous
subcutaneous insulin infusion (CSCII) upon
the cognition, mood and behavior, through a
pilot study, with the participation of 32
children and adolescents aging between 6 and
16 years old. For the evaluation of cognitive
aspects, it was used comprehensive group
with intelligence, attention, processing speed
and executive functions measures. The
psychological and glycaemic evaluations were
administered a week before the beginning of
the CSCII and 6 to 8 weeks after its beginning.
The obtained data suggest some improvement
on the performance after the beginning of the
CSCII in the perceptual reasoning tasks,
selective attention, divided attention,
cognitive flexibility and working memory. On
the other hand, it was not observed any
changes in the vocabulary tasks, sustained and
divided attention, planning and organization,
new learning and verbal fluency. The found
data is in accord with the information
obtained from other studies, which claim that
in subtle alterations of the brain functions,
the presence of neuropsychological deficits is
less likely in tasks that require simple and
automatic responses, and it is more likely in
complex tasks that demand higher order
cognitive abilities. Although the performed
research does not enable a direct association
between the findings and the reduction of the
blood glucose variation, the data suggest that
the improvement of the glycaemic control
with the beginning of the CSCII was related to
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DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963
the improvement in the more complex
executive tasks, mood and behavior.
16
The
effect of a specific treatment for the
glycaemic control of the type 1 DM upon the
cognition specifically upon the attention in
class and similar results were found in other
researches, being observed 4 children with
the type 1 DM and glycaemic instability in
class during 10 days; after the glucose
stabilization, through the insulin pump, the
children were observed again for 10 days. The
study revealed that all the children had some
improvement on their behavior in class
concerning the attention; however, it was not
found attention alterations when it was used
classifications through the laboratory scales
and measures. So, besides demonstrating the
association between the glycaemic control
and the attention in class, this study suggests
that the use of direct observation techniques
can be important in the investigation of
effects of chronic diseases about the
functioning of children at school.
17

In a recent study it was compared the
cognitive functioning of children with
precocious beginning of the type 1 DM
(diagnosis before 6 years old) with healthy
children (without chronic diseases). It was
also aimed to examine among the children
with type 1 DM the existing relation between
the neurocognitive functioning and the
glycaemic control this was obtained through
the access to the medical records of the
children. The neurocognitive abilities were
evaluated through a group of instruments that
evaluated three domains: intellectual
capacity, language and fine motor
functioning. Before the evaluation, the blood
glucose level was checked to verify its
adequacy, considering it as low when it was
lower or equal to 70mg/dL and high when it
was higher than 200 mg/dL, taking
appropriate measures, if necessary, in order
to avoid significant hypoglycaemia or
hyperglycaemia during the evaluation. The
data did not reveal differences of the group of
children with type 1 DM and the ones of the
control group healthy, being both groups
under the average. Among the children of the
DM group, those ones with bad glycaemic
control were related to a smaller general
cognitive ability; slower fine motor speed
and, smaller punctuation in the tasks that
evaluated the receptive language. The
authors concluded that this data show that
young children with type 1 DM already present
some negative effects in association with the
chronic hyperglycaemia; the severe
hypoglycaemia was not associated with any
neurocognitive functioning measures. These
results, then, are dissonant from the ones
found by other researchers, who found a
significant relation between the severe
hypoglycaemia and the cognitive
performance.
18
The factor glycaemic control
was also associated with the cognition,
precisely with the visual memory, examining
the impact of risk factors of the type 1 DM
(bad metabolic control, severe
hypoglycaemia, long duration of the disease
and age at the diagnosis) upon the long-term
visual and verbal memories, through an
accelerated longitudinal design and the
analysis of the individual growth curve. The
individual growth curve analysis allowed the
participation of all the available patients
combined according to their ages, which was
about 9 and 17 years old.
19

The participants and caregivers answered
psychosocial and socio demographic
evaluation questionnaires. The first ones were
also submitted to the Wide Range Assessment
of Memory and Learning (WRAML) in the
initial consultation and two years later, it was
also used, in this second moment, an
additional cognitive battery. Besides this
evaluation, it was also measured the
metabolic control, hypoglycaemia crises, age
at the diagnosis and duration of the DM. After
the analysis, it was identified a significant
negative effect of the bad metabolic control
(elevated levels of glycosylated hemoglobin)
upon the scores of visual memory along the
time. It was also found significance about the
gender, as the girls presented more gains of
visual and verbal memory that the boys. On
the other hand, the other mentioned factors
did not reveal impact on the performance of
the evaluated memories, highlighting that the
verbal memory was not affected in any
hypothesis. However, the study suggests as
the only association, the presence of chronic
hyperglycaemia and the decrease of the
scores in tasks of visual memory along the
time.
19

Using a differentiated technique from the
other studies, some data support the
proposition that the natural occurrence of
events of acute hyperglycaemia and
hypoglycaemia during the daily routine can be
associated with cognitive-motor interruptions
in students (6 to 11 years old) with type 1 DM.
The researchers provided the study
participating families with a technology called
Digital Personal Assistant, which enabled the
realization of brief cognition tests in the
moment that preceded the glucose
measurement done at home. It was performed
from 3 to 5 trials a day, during 5 to 6 weeks,
accounting for 70 trials, with tests related to
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DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963
tasks of mental calculation and reaction time;
after the test realization, the glucose
measurement was done. It is highlighted that
the decrease of the tests performance was
observed as equivalent in the two glucose
extremes, however, the decrease was only
observed in the hyperglycaemia when it
became really deep. Another relevant data
approached by the study is that the glucose
extremes in blood only affect the time of the
tasks completion, but not the accuracy of
them, in other words, the number of the
correct responses to the tasks, something
which suggests the presence of a decrease of
the mental and psychomotor processing
speed. It was also informed that demographic
variables such as age and gender did not
interfere in the individual differences.
20

These findings are compatible with a study,
which was about the disease effects, notably
about the brain structural volumes, evaluated
through magnetic resonance images. It was
also found some differences between the
research subjects who developed severe
hypoglycaemia or a greater exposure to
hyperglycaemia.
21

In the same direction of the mentioned
researches, or, trying to correlate the type 1
DM in children and the possible cognitive
consequences, being based on
neuropsychological and neuropathological
evidences and neuroimages, it was raised the
hypothesis that the exposure to
hyperglycaemia and hypoglycaemia would be
able to affect different aspects of the
cognitive functioning of these individuals. For
this, it was performed a study with young
people aging between 5 and 16 years old who
were submitted to cognitive tests, aiming to
evaluate the spatial and verbal intelligence,
the spatial and verbal memory and the
processing speed. The group was
characterized in relation to the amount of
hypoglycaemic events (none, 1 to 2 events
and 3 or more); in relation to the first
hypoglycaemia event (before or after 5 years
old;) and concerning the beginning of the
diabetes (precocious before the fifth birthday
and late afterwards). The exposure to the
hyperglycaemia was estimated with the
glycated hemoglobin average, adjusted for
the duration of the diabetes for each subject.
The results indicated some different
qualitative effects between hypoglycaemia
and hyperglycaemia in the cognitive
functioning, such as the hypothesized. These
effects were partly associated with the
exposure time during the development.
Among the findings it is pointed out: lower
estimative of verbal intelligence in the
diabetic group than in the control one;
specifically in relation to the experimental
group, it was also noted that there was some
decrease in the verbal intelligence, with the
increase of the exposure to hyperglycaemia,
but not to the hypoglycaemia, and the spatial
intelligence and the delayed recall were
reduced only with repeated hypoglycaemia,
especially when these events happened before
five years old; the age at the beginning of the
pathology was not associated with the results.

9

Therefore, the three studies suggest that
the two variables contribute towards the
observed damage only when they act
intensely upon the child. It is highlighted that
the two last studies identify qualitative
differences derived from the hypoglycaemia
and hyperglycaemia, different from the
studies which claim the concurrence of
factors for the promotion of one or more
effects, as in the case of association between
the hypoglycaemia and precocious beginning
of the disease.
9,20-1

Finally, we emphasize the importance of
defining the impact of the type 1 DM, as well
as reporting the risk factors for the brain
structure and functioning. For this, the author
suggests that advanced image exams and also
the use of comprehensive neurocognitive trial
batteries in children with the type 1 DM are
necessary, in order to carry prospective
studies through the monitoring along the
time.
22

The different studies discuss about the
modality and extension of possible
neuropsychological impairments, caused by
the presence of glycaemic alterations along
the stages of the neurodevelopment. Most of
them indicate that the type 1 DM is a disease
that can promote significant impact upon the
neuropsychological functioning. From the
analysis of the selected articles, it was
observed that this impact is considered due to
three specific variables, which can be
presented combined between them, and they
are: a) age of the child at the diagnosis; b)
exposure to hypoglycaemia in children with
precocious beginning of the disease; c)
glycaemic control and exposure to
hyperglycaemia.
Regarding the impact of the variables
mentioned above, the first decisive moment
in the neurodevelopment happens between
the birth up to five years old, something that
includes the development of primary and
secondary areas of the brain, highlighting the
DISCUSSION
English/Portuguese
DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963
importance of the healthy neurodevelopment
at this age.
23
However, the diabetic children
with bad control of the disease tend to have a
great physical and mental tiredness, low
motivation, discouragement, constant
inattention and drowsiness.
24
This data
emphasize the importance of considering the
implications that the less active behavior can
bring for the development and learning
process of the subject, enabling the
neuropsychological manifestations found by
the listed studies.
This development can be influenced both
by endogenous and exogenous factors, such as
nutritional deficiency, metabolic defects or
congenital hereditary and brain lesions. The
alterations which happen along the
development represent a dynamic of
sequential organization/reorganization of
cognitive functions that are subjacent to the
maturation process in interface with the
environment experiences.
4

In the meaning of suggestion of the factors
interaction for the concurrence of impacts on
the neurodevelopment, diabetic children with
precocious beginning of the disease are more
susceptible to hypoglycaemia, having as a
consequence greater vulnerability to develop
cognitive dysfunctions. The first five years of
life constitute a critical period for the brain
development, and the occurrence of
hypoglycaemia associated with the
neuroglycopenia and/or chronic
hyperglycaemia during the critical period can
induce to functional and structural
abnormalities of the brain, which interfere
with the normal cognitive function.
25

On the other hand, the hypoglycaemia is
one of the common complications to the DM
Picture. This situation is rarely fatal,
however, the hypoglycemia picture for
prolonged time can cause permanent damage
to the brain, mainly in diabetic children who
are dependent on insulin.
26
In this respect, it
is pointed that individuals with the type 1 DM
beginning in childhood can suffer
complications with the severe hypoglycaemia
during periods of neural and cognitive
development, which can put the brain
functioning at risk, even after the
stabilization of the glucose levels.
27

Corroborating the controversy about the
theme, some researches have suggested that
differences in the intellectual ability can be a
reflex of both chronic hyperglycaemia and
severe hypoglycaemia, or even other organic
factors of the disease. It is also highlighted
that the pathogenesis of the intellectual
differences associated with the precocious
beginning of the disease remains uncertain.
28

According to what was described by the
studies about the neuropsychological findings
in children with type 1 DM, the literature
about this theme is dissonant, and there is no
unanimity in terms of the characterization
and extension of the neuropsychological
alterations associated with the variables
mentioned here. This finding reinforces the
necessity of performing studies about it,
notably in national scope.

The studies concerning the
neuropsychological findings and the type 1 DM
present controversies about the variables
which possibly alter the cognitive functioning;
the above mentioned variables are among the
most recurrent and supported in literature. It
is highlighted, in a general way, that for all
the considered variables, the childhood is
considered as a moment of greater
vulnerability to the impact of the type 1 DM
on the neuropsychological abilities, being
presented as a contributory factor of
relevance. We still point out that a significant
part of the performed researches suggests an
inferior cognitive performance, which is
discrete, in the majority of the studied
domains.
This way, it is indispensable to know how
the cognitive functioning happens in the
interface with the pathology, considering
different clinical variables, such as the
exposure time of the child to the disease, so
that new ways are found as an intervention
strategy, minimizing the possible damage or
even overcoming peculiar specific alterations
of this clinical subgroup. It is necessary to
emphasize the importance of this profile
identification, so that more efficient
interventions can be precociously
implemented in the course of development of
these children, making use of the brain
plasticity this way, which is characteristic by
excellence of this development stage.

1. Engel CL, Engel HF. Medgrupo ciclo 1
Medcurso 2010. So Paulo: Medyklin Editora
Ltda; 2010. v. 3.
2. Barros AE, Souza EN. Autoaplicao de
insulina: atitudes de um grupo de diabticos.
Rev enferm UFPE on line [Internet] 2011 May
[cited 2011 Oct 30];5(3):[about 10 p.].
Available from:
http://www.ufpe.br/revistaenfermagem/inde
x.php/revista/article/view/1354/pdf_471
3. Kolb B, Whishaw IQ. Neurocincia do
comportamento. So Paulo: Manole; 2002.
REFERENCES
CONCLUSION
English/Portuguese
DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963
4. Muszkat M. Desenvolvimento e
neuroplasticidade. In: Mello CB, Miranda MC,
Muszkat M, organizadores. Neuropsicologia do
desenvolvimento: conceitos e abordagens. So
Paulo: Memnom; 2006. p. 26-43.
5. Bielssels GJ, Deary IJ, Ryan CM. Cognition
and diabetes: a lifespan perspective. Lancelet
Neurol. [Internet]. 2008 Feb [cited 2011 Oct
14];7(2):[about 6 p.]. Available from:
http://pesquisa.bvsalud.org/regional/resourc
es/mdl-18207116
6. Fritsch S, Overton MW, Robbins RD. The
interface of child mental health and juvenile
diabetes mellitus. Child Adolesc Psychiatric
Clin N Am [Internet]. 2010 Apr [cited 2011 Oct
es/mdl-20478503
7. Ohmann S, Popow C, Rami B, Konig M,
Blaas S, Fliri C, et al. Cognitive function and
glycemic control in childrens and adolescents
with type 1 diabetes. Psychol Med [Internet].
2010 Jan [cited Oct 30];40(1):[about 8 p.].
Available from:
http://www.jpeds.com/article/S0022-
3476%2805%2900519-6/abstract
8. Hannonen R, Komulainen J, Eklund K,
Tolvanen A, Riikonen R, Ahonen T. Verbal and
academic skills in children with early-onset
type 1diabetes. Dev Med Child Neurol
[Internet] 2010 Mar [cited 2011 Oct 20]; 52(7):
[about 4 p.]. Available from:
es/mdl-20345954
9. Perantie DC, Lima A, Wua J, Weaver P,
Warren SL, Sadler M, et al. Effects of prior
hypoglycemia and hyperglycemia on cognition
in children with type 1 diabetes mellitus.
Pediatr Diabetes [Internet]. 2008 Apr [cited
Oct 30];9(2):[about 8 p.]. Available from:
http://onlinelibrary.wiley.com/doi/10.1111/j
.1399-
5448.2007.00274.x/abstract?systemMessage=
Wiley+Online+Library+will+be+disrupted+14+J
an+from+10-
12+GMT+for+monthly+maintenance
10. Lin A, Northam EA, Rankins D, Werther
GA, Cameron FJ. Neuropsychological proles
of young people with type 1 diabetes 12 yr
after disease onset. Pediatr Diabetes
[Internet], 2010 Mar [cited 2011 Oct 21];11:
[about 5 p.]. Available from:
.1399-5448.2009.00588.x/full
11. Hershey T, Perantie DC, Wu J, Weaver
PM, Black KJ, White NH. Hippocampal
volumes in youth with type 1 diabetes.
Diabetes [Internet]. 2009 Oct [cited 2011 Oct
24];59:[about 5 p.]. Available from:
http://diabetes.diabetesjournals.org/content
/early/2009/10/15/db09-1117
12. Gaudierei PA, Chen R, Greer TF, Holmes
CS. Cognitive function in children with type 1
diabetes: a meta-analysis. Diabetes Care
[Internet]. 2008 Sep [cited 2011 Oct
es/mdl-18753668
13. Musen G, Jacobson AM, Ryan CM, Cleary
PA, Waberski BH, Weinger K, et al. Impact of
diabetes and its treatment on cognitive
function among adolescents who participated
in the diabetes control and complications
trial. Diabetes Care [Internet], 2008 Oct
[cited 2011 Out 21];31(10):[about 5 p.].
Available from:
es/mdl-18606979
14. Parent KB, Wodrich DL, Hasan KS. Type 1
diabetes mellitus and school: a comparison of
patients and healthy siblings. Pediatr Diabetes
[Internet]. 2009 Dec [cited Oct
.1399-
5448.2009.00532.x/abstract?systemMessage=
Wiley+Online+Library+will+be+disrupted+14+J
an+from+10-
12+GMT+for+monthly+maintenance
15. Wodrich DL, Hasan K, Parent KB. Type 1
diabetes mellitus and school: a review.
Pediatr Diabetes [Internet] 2011 July [cited
2011 Oct 20];12(1):[about 7 p.]. Available
from:
es/mdl-20546162
16. Knight S, Northam E, Donath S, Gardner
A, Harkin N, Taplin C, et al. Improvements in
cognition, mood and behaviour following
commencement of continuous subcutaneous
insulin infusion therapy in children with type
1 diabetes mellitus: a pilot study.
Diabetologia [Internet], 2009 Feb [cited 2011
es/mdl-18987843
17. Daley KB, Wodrich DL, Hasan K. Classroom
attention in children with type 1 diabetes
mellitus: the effect of stabilizing serum
glucose. J Pediatr [Internet] 2006 Feb [cited
from:
es/mdl-16492429
18. Patio-Fernndez AM, Delamater AM,
Applegate EB, Brady E, Eidson M, Nemery R,
et al. Neurocognitive functioning in preschool-
age children with type 1 diabetes mellitus.
English/Portuguese
DOI: 10.5205/reuol.2265-25464-1-LE.0612201221 ISSN: 1981-8963
Pediatr Diabetes [Internet]. 2010 Sep [cited
http://www.mendeley.com/research/neuroco
gnitive-functioning-in-preschoolage-children-
with-type-1-diabetes-mellitus/
19. Kent S, Chen R, Kumar A, Holmes C.
Individual growth curve modeling of specific
risk factors and memory in youth with type 1
diabetes: an accelerated longitudinal desing.
Child Neuropsychol [Internet]. 2010 Mar [cited
from:
es/mdl-19859849
20. Gonder-Frederick LA, Zrebiec JR,
Bauchowitz AU, Ritterband LM, Magee JC, Cox
DJ, et al. Cognitive function is disrupted by
both hypo- and hyperglycemia in school-aged
children with type 1 diabetes: a field study.
Diabetes Care [Internet]. 2009 June [cited
from:
es/mdl-19324943
21. Perantie DC, Wu J, Koller JM, Lim A,
Warren SL, Black KJ, et al. Regional brain
volume differences associated with
hyperglycemia and severe hypoglycemia in
youth with type 1 diabetes. Diabetes Care
[Internet]. 2007 June [cited Oct 30];30:[about
6 p.]. Available from:
http://care.diabetesjournals.org/content/ear
ly/2007/06/15/dc07-0351
22. Seaquist ER. The final frontier: how does
diabetes affect the brain? Diabetes [Internet].
2010 Jan [cited 2011 Oct 14];59(1):[about 2
p.]. Available from:
es/mdl-20040482
23. Ciasca, SM, Guimares IE, Tambaquim
MLM. Neuropsicologia do desenvolvimento:
aspectos tericos e clnicos. In: Mello CB,
Miranda MC, Muszkat M, organizadores.
Neuropsicologia do desenvolvimento:
conceitos e abordagens. So Paulo: Memnom;
2006. p. 14-25.
24. Marcelino DB, Carvalho MDB. Reflexos da
diabetes tipo I e sua relao com o emocional.
Psicol Reflex e Crit. 2005 Jan-Apr;18(1):72-7.
25. Ryan CM. Does moderately severe
hypoglycemia cause cognitive dysfunction in
children? Pediatr Diabetes. 2004 June;5(2):59
62.
26. Alvarenga KF, Duarte JL, Silva DP,
Agostinho-Pesse RS, Antonio C, Costa NOA.
Potencial cognitivo p300 em indivduos com
diabetes mellitus. Revista Brasileira de
Otorrinolaringologia. 2005 Apr;71(2):202-7.
27. Hershey T, Lillie R, Sadler M, White NH. A
prospective study of severe hypoglycemia and
long-term spatial memory in children with
type 1 diabetes. Pediatr Diabetes. 2004 June;
5(2): 6371.
28. Ferguson SC, Blane A, Wardlaw J, Frier
BM, Perros P, McCrimmon RJ, et al. Inuence
of an early-onset age of type 1 diabetes on
cerebral structure and cognitive function.
Diabetes Care [Internet]. 2005 June [cited
from:
es/mdl-15920064

Sources of funding: No
Conflict of interest: No
Date of first submission: 2012/01/13
Last received: 2012/11/11
Accepted: 2012/11/12
Publishing: 2012/12/01
Corresponding Address
Nietsnie de Souza Duarte
Avenida Xavier da Silveira, 2153, Ap. 303
Lagoa Nova
CEP: 59075-450 Natal (RN), Brazil

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Duarte NS, Carvalho MFO, Freire RCL et al.

Type 1 diabetes mellitus and neuropsychology

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