A child has diabetes. This alone places special challenges upon parents. And the diabetes is there to stay—regardless of whatever else comes along. This leaves some parents unable to make head or tail of it all.

Such a situation can arise when, for example, a child is inflicted with the attention deficit hyperactivity disorder (ADHD). Although the parents usually try to sort the problem out with the school, they should know that diabetes treatment and blood sugar values also affect ADHD.  

“In the middle of difficulty lies opportunity,” said Einstein, and this also applies to the difficult combination of diabetes and ADHD. ADHD can certainly cause unfavourable blood sugar values. What is the opportunity in the middle of these difficulties? To inform the diabetes team of the ADHD.

What is ADHD and ADD?
According to the Child and Adolescents Health Survey (KiGGS), 4.8% of children and adolescents in Germany have diagnosed ADHD. This makes it the most common psychiatric disorder in this age group. Presumably, ADHD is partly genetic – researchers have observed that, for example, parents and siblings of ADHD children often suffer the same condition. The cause of ADHD is a malfunction in the two neurotransmitters, dopamine and noradrenaline, affecting the two very parts of the brain responsible for attention and planning. 

Children with this condition are very easily distracted, find it difficult to finish homework, and make a lot of careless mistakes. They are impulsive, follow spontaneous ideas, are unable to wait, talk a lot and often, and interrupt others frequently. The most striking feature is their constant fidgeting—they always seem to be in overdrive.

Children with this condition minus the hyperactivity (ADD) seem to be absent and day-dreamy. They often need a long time for school work.

The Diagnosis Needs Time 
The therapy and diagnosis of ADHD have recently fallen into sharp discussion: diagnoses reached prematurely; psychopharmaceuticals prescribed too liberally; side effects taken too lightly. Guidelines for diagnosis and treatment, however, do exist. Parents and paediatricians, child psychiatrists and psychologists must take time before making a diagnosis. There is no one single test to determine AD(H)D, but rather questionnaires, thorough consultations, behavioural observations and tests that, together, allow for an estimation as to how serious the condition is.  

Not Only at School 
Children with ADHD are a cause for great concern to parents, teachers and paediatricians alike. According to the symptoms, it is no wonder that all parties have an interest in bringing school and daily life under control. But what about the diabetes? Self-monitoring and control of blood glucose, both highly necessary with diabetes, is very difficult for kids with ADHD. Those that can only tidy up or keep their school bags in order if under constant supervision, and those that can only function with clear rules and structures are sure to have great difficulty coping with the complexities of diabetes treatment and self-monitoring, as well as the consistency so needed with diabetes.  

Metabolic Problems with ADHD 
Of the 41,516 children and adolescents with diabetes registered in the scientific database at the Ulm University, only 428 patients have ADHD. Do children and adolescents with diabetes have a lower incidence of ADHD as those without diabetes? A more likely scenario is that ADHD is not completely captured and documented in this database. 

The 428 school kids with ADHD and diabetes have a much worse metabolic state than the kids with no ADHD, with a significantly higher frequency of severe hypoglycaemic events and ketoacidosis with coma.

Diabetes Falls by the Wayside
The increased specialization in paediatrics (not only in paediatrics!), time pressure and inadequate collaboration between the specialists tend to lead to oversights. The paediatric diabetologist, as a diabetes specialist, knows less about ADHD. S/he rarely makes enquiries, and often receives no information for the simple reason that, for the parents, s/he is the one responsible for the diabetes. Seldom is ADHD and bad metabolic control brought under one roof. In turn, the ADHD specialist, while continuing the consultations with teachers, often overlooks the diabetologist. I speak from experience.

ADHD – Marc’s Story
Marc is not yet two when diagnosed with diabetes. He is taken to hospital, treated and stabilized. His blood sugar swings greatly. Consequently, his mother brings him to us in the diabetes outpatient clinic at the Wilhelmstift Catholic Children's Hospital. She tells of Marc's constant need for animation, and that she finds it difficult to keep his diabetes under control. As a toddler, Marc often had acute ketoacidosis needing hospital admission.
Training is undertaken. The mother succeeds in maintaining good metabolic control in his remission phase, but again and again he falls into ketoacidosis.

Problems at school
At school, the problems are enhanced. He finds the separation from his parents difficult to deal with. His fidgeting, his inability to concentrate, his loud, spontaneous and often disruptive behaviour lead to his placement in an integration class. Here, the limits are reached – not only with his behaviour, but also with the diabetes that has to be closely watched.

Diagnosis and treatment
Our psychologist diagnosed an attention deficit hyperactivity disorder (ADHD), and implemented medical treatment with methylphenidate, in close consultation with the mother and the school.
In general, methylphenidate should only be introduced after definite diagnosis. Children under six should only be treated with methylphenidate in exceptional cases. Dosage should be tailored to each individual. Some patients fail to respond to this medication, either because it simply doesn't affect them or because of false diagnosis.

Impulsiveness and inability to concentrate affect diabetes treatment 
Marc's impulsiveness and lack of concentration are reflected in his inability to keep his diabetes under control. He cannot inject himself because he is too distracted and doses the insulin incorrectly. Also, he needs to be constantly supervised with his prandial insulin due to careless mistakes. 
His blood sugar still swings. His HbA1c values have risen to over 10%. When playing with friends or doing sport, he is unable to notice when his blood sugar is getting too low. Consequent severe hypoglycaemia is often the result. 

Cooperation improves behaviour and control 
Only through close cooperation between the mother, the school and the psychologist has it become possible to bring Marc's behaviour under control. His HbA1c value remained around 9% until his 11th year, when it sank to 8.5%. Marc has since completed his general school and is seeking an apprenticeship.

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Dr. Klaus-Peter Otto
Paediatric diabetologist/psychotherapist
Senior Doctor
Wilhelmstift Catholic Children’s Hospital
Hamburg
E-Mail: k.otto(at)kkh-wilhelmstift(dot)de