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A Pilot Study of School Counselor's Preparedness to Serve Students with Diabetes: Relationship to Self-Reported Diabetes Training

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Abstract: This cross-sectional, observational pilot study investigated the knowledge, attitudes, and awareness of 132 school counselors regarding students with diabetes. Respondents were primarily white, female, with a master’s degree, aged 42 years,
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  A Pilot Study of School Counselor’s Preparedness to ServeStudents with Diabetes: Relationship to Self-ReportedDiabetes Training  Julie Wagner, Amy James ABSTRACT:  This cross-sectional, observational pilot study investigated the knowledge, attitudes, and awareness of 132 schoolcounselors regarding students with diabetes. Respondents were primarily white, female, with a master’s degree, aged 42 years, and with 10 years of school counseling experience. Most counselors worked at large, public, suburban, and high schools. A majorityreported that there were children with diabetes in their schools, and 40% had worked directly with several students with diabetes. However, most indicated that they had received no specific training about diabetes. On a standardized measure of school personnelknowledge of diabetes, school counselors showed only a basic level of practical diabetes knowledge that is insufficient to provideeffective support for diabetic students. Relative to counselors who reported no diabetes training, those who reported diabetes trainingshowed more knowledge of diabetes and its management in schoolchildren. On a standardized measure of the psychosocial impact of diabetes, those who reported training also endorsed attitudes that indicated better appreciation of the psychosocial impact of livingwith diabetes. Educational attainment and number of students with diabetes served in the past was not related to knowledge or attitudes. Awareness of recommended accommodations, educational planning, problems with school personnel, and risk for  psychological disturbance among diabetic students was limited. These findings suggest that school counselors are not well prepared tosupport diabetic students and that training may help prepare them. Practical suggestions for school counselors’ care of diabeticstudents are offered.  (J Sch Health. 2006;76(7):387-392) D iabetes is prevalent among schoolchildren, and ratesare rising. More than 210,000 people under the ageof 20 have diabetes. 1 Type 1 diabetes mellitus (previouslycalled insulin-dependent or juvenile diabetes) typically oc-curs in young people and is the most frequently diagnosedmetabolic disorder of childhood. Type 2 diabetes mellitus(previously called non-insulin--dependent or adult diabetes)is most common in adults; however, 40% of newly diag-nosed diabetes is now in individuals younger than 20 years,with onset coinciding with puberty. 2 Thus, all schools arelikely to enroll students with diabetes at some point, 3 andschool personnel must be prepared to meet the unique chal-lenges faced by students with diabetes.Children with diabetes encounter challenges in the medi-cal,psychosocial,andacademicdomains.Medically,childrenwith diabetes have to follow a regimen of self-care behaviorsthat includes carbohydrate counting and medication adminis-tration, which often includes multiple daily insulin injectionsor continuous subcutaneous insulin infusion (an insulin‘‘pump’’). Regimen components must be balanced in order todecrease the likelihood of unpleasant and potentially danger-ous episodes of hyperglycemia (high blood glucose) andhypoglycemia (low blood glucose). Detection of these epi-sodes requires frequent monitoring of blood glucose. Quick and accurate responses to out-of-range glucose levels mayinclude modifications to carbohydrate intake, medication,and physical activity. Persons with diabetes report frustrationand burden with this regimen. 4 In the psychosocial domain,students with diabetes are at higher risk for depression andanxiety, 5 and eating disorders. 6 They may suffer teasing orfeel alienated from their nondiabetic peers. 7 Academicallythese students may require special considerations in theclassroom, during testing, in scheduling, in extracurricularactivities, and in post--high school planning.School nurses have indicated that students with chronic ill-ness need more support at school than they alone can pro-vide. 8 School counselors can assist in several areas, includingdetecting symptoms that may affect academic performance,scheduling, facilitating accommodations, fostering healthypeer relationships, promoting self-care, assisting with post--high school planning, and being alert to mental health risks.In order for school counselors to address diabeticstudents’ concerns, they must be informed about diabetes’effects in these multiple domains. The authors have dem-onstrated that diabetic students still experience diabetes-related problems in school and that diabetic studentsand their parents feel that school personnel, and schoolcounselors specifically, do not know enough about diabe-tes to be helpful. 7 This study also indicated that diabetestraining of school personnel and classmates is associatedwith better diabetes control and better quality of life indiabetic students. Nationally recognized guidelines for thecare of students with chronic illnesses such as diabetesaddress the issue of school personnel training, 9 and inter-ventions for teachers have produced promising results. 10-13 However, the authors know of no study investigating theknowledge, attitudes, and awareness of school counselorsregarding students with diabetes. The purpose of this studyof school counselors was to explore (1) how much theyknow about diabetes, (2) what attitudes they have aboutstudents with diabetes, (3) their level of awareness regard-ing school-related diabetes issues, and (4) whether trainingin diabetes is associated with better knowledge and morehelpful attitudes regarding students with diabetes. METHODS Sample Attendees at the 2003 Connecticut School CounselorAssociation and the 2004 Massachusetts School CounselorAssociation annual meetings were invited to participate.Approximately 500 school counselors attended each of these meetings representing 83% and 42% of the associa-tions’ memberships, respectively.  Julie Wagner, PhD  , Assistant Professor (juwagner@uchc.edu), Divisionof Behavioral Sciences and Community Health, University of Connecticut  Health Center, MC3910, 263 Farmington Ave, Farmington, CT 06030; and   Amy James, PhD  , Project Manager (ajames@uchc.edu), Institute for Pub-lic Health Research, University of Connecticut, 99 Ash Street, MC-7160,East Hartford, CT 06108. JournalofSchool Health  d September2006, Vol. 76, No.7  d   2006,AmericanSchoolHealthAssociation  d 387  Procedure Numerous organizations from both industry and nonprofitsectors were at the meetings. The investigators had a boothwhere interested attendees could complete an anonymoussurvey, which were collected on site. Because the surveywas anonymous and innocuous, the University of Connecti-cut Health Center Institutional Review Board did not requireinformed consent. There was no incentive for participa-tion. Regardless of participation, all attendees were offerededucational information regarding students with diabetes. Measures  Demographics and School Characteristics.  Using asurvey designed for this study, respondents reported demo-graphics including age, race/ethnicity, gender, and educa-tional attainment. Participants reported characteristics of theschool they worked in and their role as a school counselor.  Diabetes Knowledge.  The Test of Diabetes Knowledgefor Teachers (TDKT 14,15 ) was administered. Its languagewas modified slightly to reflect the fact that school coun-selors, rather than teachers, were respondents. Thisinstrument asks multiple-choice questions regarding ahypothetical student with diabetes. A sample item is‘‘Shannon wants to participate on the track team. To dothis, Shannon must (a) always carry fast acting sugar;(b) know which days the events are scheduled so he/shecan take extra food; (c) both a & b; (d) take some insulin.’’Scores , 7 indicate ‘‘knowledge deficits,’’ scores 8-12 indi-cate ‘‘basic understanding,’’ and scores 13-16 indicate thatthe respondent is an ‘‘effective support person for studentswith diabetes.’’ This measure has shown acceptablereliability and sensitivity to change. 15 In the current sample,the scale showed good internal consistency, KuderRichardson formula 20 (KR20)  ¼  .75 (KR20 is a measureof internal consistency for dichotomously scored items suchas ‘‘correct’’ and ‘‘incorrect’’ as is the case for this measure 16 ).  Attitudes About Diabetes.  The Psychosocial Impactsubscale of the Diabetes Attitudes Scale (DAS) version 3assesses the respondents’ attitudes about the psychosocialimpact of diabetes on the lives of people with the dis-ease. 17 A sample item is ‘‘Diabetes is hard because younever get a break from it.’’ Scores range 0-5, with higherscores indicating greater appreciation of the demands of living with diabetes. The DAS has been used in numerousstudies and shows good psychometric properties. 18 In thisstudy, the reliability of the DAS was .59, acceptably closeto the .60 threshold recommended for reliability in explor-atory research. 19,20  Awareness of Diabetes-Related Issues.  A questionnairedesigned for this study assessed awareness of 5 educa-tional, 3 mental health, and 3 interpersonal issues germaneto students with diabetes. Participants responded to itemson a 5-point Likert-type scale from ‘‘agree completely’’ to‘‘disagree completely.’’ Agreeing, or not disagreeing, withthese items indicates an awareness of the issues (Table1).Counselors were also asked how frequently they thoughtdiabetic students had problems with peers, school adminis-trators, and teachers. Response options were ‘‘rarely,’’ ‘‘sel-dom,’’ ‘‘occasionally,’’ and ‘‘often.’’  Experience With Students With Diabetes and RelevantTraining.  Participants reported whether or not theyreceived training in serving students with diabetes. Nodefinition of ‘‘training’’ was provided; the respondent wasthe arbiter of what constituted training. Participants alsostated how many students with diabetes they had served,and they rated their own helpfulness in serving those stu-dents on a scale from 1 to 10, with 1  ¼  ‘‘least helpful’’and 10  ¼  ‘‘most helpful.’’ Analyses and Selection of Covariates To test associations between categorical and continuousvariables, analyses of covariance with follow-up Tukeytests were performed. Values reported are adjusted means.Participants with more education, and those who haveworked with a greater number of diabetic students, mayhave more knowledge and more informed attitudes regard-ing diabetes. Therefore, participant educational attainmentand number of diabetic students served were covariates inrelevant analyses. Analyses were performed using SPSSversion 11.1 (SPSS Inc., Chicago, IL). RESULTS Participants Surveys were completed by 132 school counselors(52% from Connecticut and 42% from Massachusetts).Participants were primarily white (86%), female (80%),with a master’s degree (70%), an average age 42 years,and with a mean of 10 years’ experience as a school coun-selor. They worked at primarily public (92%), suburban(53%), and high schools (61%), with enrollment  . 1000(44%). They reportedly spent about half of their workdayin individual and small-group counseling (Table2). Training and Experience With Diabetic Students A majority (83%) reported that there were childrenwith diabetes in their schools; however, some (14%) indi-cated that they did not know if there were children withdiabetes in their schools. Most (87%) indicated that theyhad received no specific training about diabetes, yet 40%had reportedly worked directly with students with diabe-tes. Those counselors who had worked with school-agechildren whom they knew had diabetes reported havingworked with an average of 4 students. They indicated thatstudents with diabetes were referred to counselors by theschool nurse (56%), a parent (27%), a self-referral (12%),an administrator (8%), or a teacher (7%). About half (46%) of the counselors reported that they were responsi-ble for the academic planning for diabetic students. Coun-selors also reported that the school nurse (49%), theschool psychologist (5%), and a social worker (3%) wereresponsible for the academic planning. On a scale of 1-10with 1  ¼  ‘‘least helpful’’ and 10  ¼  ‘‘most helpful,’’ coun-selors rated their own helpfulness with diabetic studentsas mean  ¼  6.9 (SD  ¼  2.3). Knowledge Scores on the TDKT were normally distributed, withmean  ¼  10.3 (SD  ¼  3.4), indicating a basic understand-ing of diabetes according to criteria established by thescale’s authors. 14 Knowledge deficits were demonstrated by15% of the sample, basic understanding by 57%, andscores indicative of being an effective support for childrenwith diabetes by 28%. The TDKT scores were investi-gated as a function of diabetes training status. Covariates 388  d JournalofSchoolHealth  d September2006, Vol. 76,No.7  d   2006, AmericanSchool HealthAssociation  were respondent educational attainment and number of diabetic students the respondent had worked with directly.Respondents who reported diabetes training had higherTDKT scores (mean  ¼  13.04) than those who did not(mean  ¼  10.51), F(3,90)  ¼  8.62, p  ,  .01. Neither covari-ate contributed significantly to the equation. Attitudes Scores on the DAS were normally distributed, withmean  ¼  3.9 (SD  ¼  .5). The DAS scores were investigatedas a function of diabetes training status. Covariates wereas above. Respondents who reported diabetes training hadhigher DAS scores (mean  ¼  4.27) than those who did not(mean  ¼  3.96), F(3,91)  ¼  6.55, p  ,  .05. Neither covari-ate contributed significantly to the equation. Awareness Many school counselors endorsed items which wouldhinder their ability to serve students with diabetes. Specif-ically, counselors were neutral or agreed with unhelpfulstatements such as ‘‘diabetes restricts extracurricularactivities’’ (35% did not disagree) and ‘‘the most appropri-ate place for children with diabetes to test blood sugar isin the nurse’s office’’ (87% did not disagree). There weremisperceptions regarding the appropriateness of 504 plans(10%), individualized educational plans (10.3%), schedul-ing considerations (13%), and post--high school planning(29%) for students with diabetes. There was also a lack of awareness about diabetic youth’s increased risk of anx-iety (24%), depression (29%), and eating disorders (32%)(Table1). School counselors were asked about their per-ception of the source of diabetes-related problems atschool. The modal responses for problems with adminis-tration, teachers, and peers were ‘‘rarely,’’ ‘‘seldom,’’ and‘‘occasionally,’’ respectively. DISCUSSION The purpose of this study was to explore school coun-selors’ knowledge, attitudes, and awareness regarding stu-dents with diabetes and to determine the associationbetween training and these outcomes. Those who reporteddiabetes training showed more knowledge of diabetes andits management in children. However, even trained coun-selors demonstrated only a basic understanding, which isconsidered insufficient for being a qualified support per-son for students with diabetes. Similarly, counselors whoreported diabetes training endorsed attitudes that indicatedbetter understanding of the psychosocial impact of livingwith diabetes. These data complement our previousresearch that showed that diabetic students with trainedschool personnel had better diabetes control. 7 Importantly,educational attainment and experience serving studentswith diabetes were not associated with knowledge or atti-tudes. Thus, the school counselors in this sample did not‘‘pick up’’ the skills necessary to support diabetic studentsduring their formal education or by simply working withstudents with diabetes. These data suggest that specifictraining in the care of students with diabetes may be neces-sary for skill acquisition. These data complement reportsthat training improves diabetes knowledge among teachersand expand upon these reports by focusing on school coun-selors specifically. 10-13 Table 1 Educational Accommodation and Mental Health Risk Awareness Item % Disagree or Strongly Disagree % Neutral % Agree or Strongly Agree School-based teams should create 504 plansfor children with diabetes10 24 66School-based teams should create IEPfor children with diabetes46 29 25Children with diabetes require specialscheduling considerations13 32 56Diabetes restricts participation in cocurricularactivities such as athletics65 21 14Diabetes affects post--high school planning 29 25 46Children with diabetes should be ableto snack at any time10 17 72The most appropriate place for children withdiabetes to test blood sugar is in thenurses office13 16 71A support group addressing aspectsof chronic illness is appropriatefor children with diabetes3 15 82Children with diabetes are more likely toexperience anxiety than their peers24 37 39Children with diabetes are more likely toexperience depression than their peers29 37 34Children with diabetes are more likely todevelop eating disorders than their peers32 44 24 JournalofSchool Health  d September2006, Vol. 76, No.7  d   2006,AmericanSchoolHealthAssociation  d 389  A sizable minority of respondents endorsed statementsthat would hinder their ability to support the academic,mental health, and interpersonal needs of diabetic stu-dents. This is consistent with a previous investigation bythe authors in which diabetic students reported that schoolcounselors were not very helpful for nonmedical diabetes-related school problems (5/10 on the same helpfulnessscale used in the current study). 21 School counselors in thecurrent study were somewhat overconfident in their ownabilities and rated themselves as being relatively morehelpful (7/10). Finally, school counselors tended to under-estimate the difficulty that diabetic students face withschool personnel. Respondents believed that diabetes-related problems in school were more frequent with peersthan with teachers or administrators. However, the authorshave reported that the number of diabetic students whoreport problems with school personnel is at least as high(23%) as those who reported problems with peers (21%). 7 Why These Findings Are Importantfor School Counselors Many school counselors will serve students with diabe-tes, yet few receive training to do so. There is a great dealof diversity in the state, district, and even school buildingpolicies that apply to students with diabetes. Ultimately,though, federal laws designate diabetes as a disability,prohibit discrimination based on diabetes status, andrequire schools to make reasonable accommodations toallow children with diabetes to participate in all schoolactivities while minimizing disruption to the child’s andschool’s routine. 22,23 School counselors responsible for indi-vidual student planning are expected to help all students 24 with special care for students with disabilities. 25 Counselors are charged with acquiring training to work with, 24 and advocate for, 26 diverse populations includingthose with special needs. The use of multidisciplinaryschool-based teams to meet the needs of children with dia-betes has been noted. 27-29 However, the potential contribu-tions of school counselors are rarely articulated. Specific Ways the School Counselor Can HelpStudents With Diabetes There are numerous ways that school personnel can behelpful to diabetic students. 30 First, school counselors cansupport the self-care regimen with the aim of achieving opti-mal glycemic control. Hypoglycemia is associated with cog-nitive deficits that pose difficulties particularly during testtaking. 31 In the long term, poor glucose control increases risk of developing life-threatening complications. Students donot always respond to glucose fluctuations appropriately. 32 Counselors can work on student motivation, skill, and prob-lem solving around diabetes self-care.Second, counselors can recognize and intervene on dia-betes symptoms that may be misinterpreted by school per-sonnel. Students experiencing hyperglycemia mayexperience dehydration leading to excessive thirst and fre-quent urination. Repeated requests to leave the classroomfor water or bathroom breaks may be interpreted as avoid-ance of class time. Symptoms of low blood glucose can bemistakenly attributed to alcohol or drug use. Additionally,school personnel may mistakenly challenge the possessionof medical equipment, consequently putting diabetic chil-dren in acute medical danger and inviting legal action (eg,Cross v East Haddam CT Board of Education 33 ).Third, as frontline mental health professionals, schoolcounselors are in the position to identify students withmental health concerns. Youth with diabetes are atincreased risk for depression and anxiety 5 and eating dis-orders, 34,35 and some girls manipulate insulin intake to regu-late weight. 6 Diabetic athletes may mismanage glucose Table 2 Counselor and School Demographics Age in yearsMean ¼ 42(SD ¼ 13) Female (%) 80Ethnicity (%)White 86Black 5Latino 5Asian/Native American/other 4Education (%)Bachelor’s 9Master’s 706th-year certificate 19PhD 2Years as a school counselor Mean ¼ 10,Range 0-39% time spent in (%)Individual academic counseling 24Individual personal counseling 25Small-group counseling 12Comprehensive developmental classroom 10Prevention 10Administration 19School level (%)Elementary 7Junior/middle 28High 61Combined 4School type (%)Public 92Private secular 2Private religious 5Regional 1Enrollment (%) , 300 3300-500 16500-1000 37 . 1000 44Community served (%)Urban 26Suburban 53Rural 19Regional 2Trained in diabetes? (% yes) 14Number of students with diabetesworked withMean ¼ 4.2(SD ¼ 8.0)How helpful have you been tothem (1-10)?Mean ¼ 6.9(SD ¼ 2.3) 390  d JournalofSchool Health  d September2006, Vol. 76, No.7  d   2006, AmericanSchoolHealthAssociation  levels in order to participate in sports. Promoting a healthybody image is critical for students with diabetes.Fourth, school counselors can facilitate the academicplanning of children with diabetes. Students with diabeteshave similar academic achievement to their healthierpeers. 31,36 However, students with diabetes report pooreracademic self-efficacy than their healthy peers, and aca-demic deficits have been noted in those with poor meta-bolic control. 36 The creation of Individualized EducationalPlans (IEP) or more frequently 504 section of the 2004 In-dividuals With Disabilities Education Act plans ensuresthat the least restrictive environment is assured for studentswith diabetes. For example, the benefits of performing dia-betes self-care behaviors in proximity to the normallyscheduled school activity, rather than the nurse’s office, hasbeen reported. 7 There are multiple examples of such 504plans available on the Internet. 37 Students with diabetesmay also benefit from scheduling accommodation such asplacing physical education after lunch or providing accessto the cafeteria during study hall.Finally, school counselors can help with transition planningin consideration of diabetes, including vocational, educational,and health transitions from pediatrics to adult services. Theproximity of colleges to emergency medical services may bea factor in selecting a college. Health insurance options shouldbe explored. Individuation from parents during this develop-mental transition may be complicated by the chronic illness. Limitations and Future Directions There are several important limitations to this pilot study.First, the study used a convenience sample that may not berepresentative of the national population of school counselors.Those who belong to professional organizations and thosewho attend professional conferences may be more invested inprofessional training and come from better funded schools thatwould provide attendance at such a conference. Among them,those who go on to participate in a research study are an addi-tionally biased segment of the population. Further, the confer-ences were geographically restricted to the New Englandregion, thus limiting generalizability to national populations.Second, the cross-sectional, observational design preventsthe assertion of causality between training, knowledge, andattitudes. Those counselors who know more and have betterattitudes regarding diabetic students may be more likely toseek training in diabetes. It is also possible that a third, asyet unknown factor accounts for these associations. Forexample, perhaps having a family member with diabeteswould be associated with better knowledge and attitudes, aswell as the pursuit of specialized training in diabetes.Finally, there was no  a priori  definition of ‘‘diabetestraining.’’ The respondent was the sole judge of what con-stituted training, and the characteristics of that training (eg,length, format, content) were not described. Thus, thenature of the training associated with beneficial knowledgeand attitudes remains an empirical question.Future directions should investigate a broader sample of school counselors who represent a demographically and geo-graphically diverse sample. Future studies that use a national,random sample of members of the American School Coun-seling Association will yield a more representative sampleof school counselors. Following the lead of interventions de-signed for teachers, a controlled trial of a school counselortraining program could be designed to see if such trainingmakes an impact on educational, psychosocial, and diseaseoutcomes for students with diabetes. The active ingredientsof training could be identified and disseminated. If success-ful, such a program of research could ultimately inform pol-icy for the care of diabetic children in school. j References 1. Centers for Disease Control and Prevention. National Diabetes FactSheet. Available at: http://www.cdc.gov/diabetes/pubs/estimates/htm#prev2.Accessed March 1, 2005.2. Grey M, Berry D, Davidson M, Glasso P, Gustafson E, Melkus G.Preliminary testing of a program to prevent type 2 diabetes among high-risk youth.  J Sch Health . 2004;74:5-10.3. Nichols PJ, Norris SL. A systematic literature of the effectiveness of diabetes education of school personnel.  Diabetes Educ . 2002;28:405-414.4. Polonsky W. Emotional and quality-of-life aspects of diabetes man-agement.  Curr Diab Rep . 2002;2(2):153-159.5. Kovacs M, Goldston D, Obrosky DS, Bonar LK. Psychiatric disor-ders in youths with IDDM: rates and risk factors.  Diabetes Care .1997;20:36-44.6. Takii M, Komaki G, Uchigata Y, Maeda M, Omori Y, Kubo C. Dif-ferences between bulimia nervosa and binge eating disorder in femaleswith type 1 diabetes: the important role of insulin omissions.  J Psychosom Res . 1999;47:221-231.7. Wagner J, Heapy A, James A, Abbott G. Glycemic control, qualityof life, and school experiences among students with diabetes.  J Pediatr Psychol . 2005. Epub ahead of print.8. Thies KM, McAllister JW. The health and education leadership pro- ject: a school initiative for children and adolescents with chronic healthconditions.  J Sch Health . 2001;71:167-172.9. National Asthma Education and Prevention Program—School Sub-committee, National School Boards Association, American School HealthAssociation, American Diabetes Association, American Academy of Pediatrics, Food Allergy and Anaphylaxis Network, Epilepsy Foundation.Students with chronic illnesses: guidance for families, schools, andstudents.  J Sch Health . 2003;73:131-132.10. Jarrett L, Hillam K, Bartsch C, Lindsay R. The effectiveness of pa-rents teaching elementary school teachers about diabetes mellitus.  Diabe-tes Educ . 1993;19:193-197.11. Gesteland HM, Sims S, Lindsay RN. Evaluation of two ap-proaches to educating elementary school teachers about insulin-dependentdiabetes mellitus.  Diabetes Educ . 1989;15:510-513.12. Vanelli M, Chiari G, Ghizzoni L, Costi G, Giacalone T, ChiarelliF. Effectiveness of a prevention program for diabetic ketoacidosis in chil-dren: an 8-year study in schools and private practices.  Diabetes Care .1999;22:7-9.13. Siminerio LM, Koerbel G. A diabetes education program forschool personnel.  Pract Diabetes Int  . 2000;17:174-177.14. Husband A, Pacaud D, Grebenc K, McKiel E. The effectiveness of a CD-ROM in educating teachers who have a student with diabetes.  Can J  Diabetes . 2001;25:286-290.15. Husband A, Grebenc K, McKeil E, Pacaud D. Available at: http:// www.diabetes.ca/Files/kwd_quiz.pdf. Accessed June 29, 2005.16. DeVellis RF. Scale development: theory and applications. 2nd ed.  Applied Social Research Methods Series . Thousand Oaks, Calif: Sage Pub-lications; 2003.17. Anderson RM, Funnell M, Fitzgerald JT, Gruppen LD. The thirdversion of the diabetes attitude scale.  Diabetes Care . 1998;21:1403-1407.18. Anderson RM, Donnelly MB, Gressard CP, Dedrick RF. Develop-ment of diabetes attitude scale for health-care professionals.  DiabetesCare . 1989;12:120-127.19. Nunnally JC.  Psychometric Theory . 2nd ed. New York, NY:McGraw-Hill Inc; 1978.20. Droge C. How valid are measurements?  Decis Line . 1996;Sept/ Oct:10-12.21. Wagner J, James A, Khalique S, Martin M, Abbott G. School ex-periences of students with type 1 diabetes; educational and psychosocialissues [abstract].  Int J Behav Med  . 2004;11(Suppl):117.22. American Diabetes Association. Diabetes care in the school andday care setting.  Diabetes Care . 2005;28:S43-S49.23. Kaufman R. Diabetes at school: what a child’s health care teamneeds to know about federal disability law.  Diabetes Spectr  . 2002;15:63-64. JournalofSchoolHealth  d September2006, Vol. 76,No.7  d   2006, AmericanSchool HealthAssociation  d 391

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