childhood asthma and student performance at school

Childhood Asthma and Student Performance at SchoolHoward Taras, William Potts-Datema

ABSTRACT: To better understand what is known about the association between childhood asthma, school attendance, and academicoutcomes, the authors reviewed published studies investigating this topic. Tables with brief descriptions of each study’s researchmethodology and outcomes are included. Research reveals evidence that rates of absenteeism are higher among students with asthma.The exact magnitude of absenteeism is difficult to ascertain. However, the studies have helped to identify characteristics of childrenwith asthma that are most likely to be associated with the highest absenteeism rates. Some interventions to improve rates ofabsenteeism among school-aged children with asthma show promise, but it cannot yet be concluded that students who adhere tomedical routines for controlling asthma will as a result increase their rates of attendance. Studies thus far have shown that there iseither only a weak or nonexistent association between asthma and school achievement. Further studies are required to verify if certainsubpopulations of children with asthma (eg, those with severe and ongoing symptoms, those with disturbed sleep, kindergartenchildren) are at higher risk for poor school achievement. (J Sch Health. 2005;75(8):296-312)

Health professionals frequently remind educators ofthe correlation between children’s health and their

academic potential. Such generalizations are not alwaysaccompanied by specific examples and more rarelyaccompanied by evidence.

To clarify and quantify the relationship between healthand child performance and ability at school, the NationalCoordinating Committee on School Health and Safety(NCCSHS) called for a review of the state of this re-search. The project involves a literature search of peer-reviewed, published research reporting on the relationshipbetween students’ health and their performance in school.The NCCSHS is an organization that comprises represen-tatives from several federal departments and national non-governmental organizations. This article summarizes whatis known through data collection about the association ofasthma among school-aged children with attendance andacademic outcomes. The associations of school perfor-mance with other chronic diseases are summarized ina separate article.

Criteria for an article to be selected for review werethat the article had to have been published within the past15 years (1989 or later), the subjects of study wereschool-aged children (ages 5-18 years), and the researchincluded school attendance or academic achievement.Studies were identified using MedLine and similar Inter-net-based searches. If a full article could not be retrieved,studies with detailed abstracts were included. Many stud-ies cited here had major outcome measures other thanthose pertinent to the objectives of this project. Thesealternative outcomes may not be described at all or arebriefly mentioned.

ASTHMA AND SCHOOLSChildren with asthma are conceivably at risk for

decreased school functioning due to acute exacerbationsof this disease, increased absenteeism secondary to symp-toms, iatrogenic effects of students’ asthma medication(eg, oral steroids), poor medical management of the dis-ease, and/or the stress associated with having a chronicillness.1 Although teachers generally have accepting atti-tudes toward students with asthma, their knowledge aboutasthma is low2 and they do not feel adequately prepared toassist children with the management of asthma in the class-room.3 To help address this situation, many federal agen-cies and national organizations in the fields of healthservices, education, health education, and air quality havedeveloped resources to assist schools to manage studentswith asthma and minimize symptoms of asthma by opti-mizing the school environment. These resources are listedon the Web site of the NCCSHS at http://www.healthy-students.org/resources/.

AbsenteeismOf the 66 reviewed studies addressing asthma and

school attendance, virtually all showed a correlationbetween this disease and high rates of student absentee-ism. The number of missed school days that a child witha given severity of asthma is still unknown, as is the causefor missed school days (ie, doctor’s appointments, symp-toms of asthma, avoidance of environmental triggers). Alittle is known about the timing of missed school days (eg,season of the year, prevalence of flu) (Table 1). Althoughthe relationship between asthma and school attendancemay not have changed over the past couple of decades(Anthracopoulos et al 2001; Centers for Disease Controland Prevention 2002; Table 1), the increased number ofschool-aged children with asthma has meant that the abso-lute number of school days missed is larger (Weiss et al2000; Table 1).

One reason for the inconsistency on the expected num-ber of days absent for a student with asthma is that stud-ies have used various definitions of asthma. Some studiesdefine asthma based on respiratory symptoms. Others usea parental report of a diagnosis of asthma. Yet others useevidence found on medical chart review. Many articlesdo not have control groups (ie, there is no comparisonof attendance among children with asthma against

Howard Taras, MD, Professor ([email protected]), Division of CommunityPediatrics, University of California, San Diego, Gilman Drive #0927,La Jolla, CA 92093-0927; and William Potts-Datema, MS, Director,([email protected]), Partnerships for Children’s Health, Har-vard School of Public Health, 677 Huntington Ave, 7th Floor, Boston, MA02115. This article is 1 of 6 articles that are part of a project ofthe National Coordinating Committee on School Health and Safety(NCCSHS). This NCCSHS project was funded by the US Department ofHealth and Human Services, Department of Education, and US Depart-ment of Agriculture. Opinions expressed in this article are not necessarilyshared by these federal agencies or other institutions that compriseNCCSHS membership.

296 d Journal of School Health d October 2005, Vol. 75, No. 8

Table1

PublishedResearchArticlesThatAddressAsthmaandAbsenceFrom

School(Continuedonnextpage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign

MajorFindingsRelatedto

Absenteeism

AdamsRJ,WeissST,FuhlbriggeA.How

andbywhom

care

isdeliveredinfluences

anti-inflammatory

usein

asthma:results

ofanationalp

opulationsurvey.JAllergy

Clin

Immunol.2003;112(2):445-50.

(USA)

Data

derivedfrom

anationalsample

ofparents

ofchildrenwith

asthma(andadultswithasthma),included519childrenaged6-15

years.Numberofmissedschoold

aysin

thepastyearandasthma

diagnosiswere

determ

inedbyinterview(aske

daboutdiagnosis

andmedicationin

thepastyear).Thepurposewasto

investigate

characteristicsthatinfluencedanti-inflammatory

use.

Missing6ormore

daysfrom

schoolw

asoneofthefactors

ina

multiple

logisticregressionmodelthatwasassociatedwithuse

ofananti-inflammatory,controllermedication.Greaterasthma

morbidity(includinglostschoold

ays),youngage,

white,recenthospitalization,andregulardoctorvisitswhere

asthmaiswelltaughtare

allasso

ciatedwith

useofanti-inflammatory

controllermedications.

Al-DawoodKM.Sch

oolboys

with

bronch

ial

asthmainAl-KhobarCity,SaudiA

rabia:

are

theyatincrease

drisk

ofschool

abse

nteeism?JAsthma.2002;39(5):

413-420.

(SaudiA

rabia)

Parents

of1482male

students

(ages6-15)completed

questionnairesthatascertaineddiagnosedasthmaand

asthmasymptomsnotpreviouslydiagnosed.School

recordswere

usedto

assess

daysabsent.

Students

withasthmasymptoms,butnopreviousphysician

diagnosis,were

absent13.6

daysperyear.Students

with

physician-diagnose

dasthmawere

absent3.7

daysperyear.

Youngerchildrenlostmore

schoold

aysthanolderchildren,

asdid

students

withlowersocioeconomicclass,

pets

athome,

smokers

athome,andabsenceofanappropriate

controller

medicatio

nandhistory

ofhospitalizationoremergencyvisit.

Al-GhamdyYS,Al-HaddadNS,Adelgadir

MH,Quresh

iNA,SalehMA,KhalilMM.

Socio-clinicalp

rofile

ofchildrenwith

asthmain

Al-Majm

aahhealthprovince

.SaudiM

edJ.2000;21(9):847-851.

(SaudiA

rabia)

Data

were

collectedfrom

multiple

sourcesregarding606children

(0-13years),recruitedfrom

pediatricclinicsandhospitals.Parents

were

interviewedaboutsymptoms,asthmawasdeterm

inedfrom

history

(diagnosis,medication,orsymptoms),andchildren

receivedafullphysicale

xaminationandpeakflowrate

measurement.

Thepercentagesofchildrenmissingbetween1and3weeksof

schoola

ndmissinggreaterthan3weeksofschool,respectively,

were

6%

and7%

forstudents

withmild

asthma,23%

and12%

for

thosewithmoderate

asthma,and39%

and17%

forthosewith

seve

reasthma.

AnthracopoulosM,KaratzaA,LioliosE,

TrigaM,TriantouK,PriftisK.Prevalence

ofasthmaamongschoolchildrenin

Patras,Greece

:threesurveysover

20years.Thorax.2001;56:569-571.

(Greece)

InthemonthsofJanuary

andFebruary

of1978,1991,and1998,

students

(ages8-10years)in

3rd

and4th

gradeswere

surveyed

(parents

ofbetweenapproxim

ately3000-4000students

respondedto

questionnairesin

eachofthese

years).Thosewith

apositivehistory

ofasthmawere

theninterviewedin

1991and

1998.Onequestionwas,‘‘H

owmanyschoold

ayswere

lost

becauseofasthmaand/orwheezingduringtheprevious2years?’’

Theprevalence

ofacurrentdiagnosisofasthmaincreasedfrom

4.6%

to6%

between1991and1998;themeannumberofschool

dayslostbecause

ofasthmadid

notchangesignificantlybetween

1991(6.75daysover2years)and1998(5.7

daysover2years)

amongthose

withasthma.

BauerEJ,LurieN,YehC,GrantEN.

Screeningforasthmain

aninner-city

elementary

schoolinMinneapolis,

Minnesota.JSch

Health.1999;69(1):

12-16.

(USA)

Thisresearchwasdoneprimarilyto

studythepracticeofidentifying

students

withasthmaaspartofaschool-basedhealth

center’s

outreach.School-wideasthmascreening(5

symptomsquestions

forparents)occurredover2years

in1elementary

schoolw

ith

about1200students.Parentreportofschoola

ttendancewas

comparedto

parentreportofasthmahistory.

Between26%

and30%

ofallstudents

were

reportedabsentatleast

1dayin

thepreviousmonth,comparedto

40%

ofthosewith

monthlyasthmasymptoms.

BaumanLJ,WrightE,LeicklyFE,etal.

Relationship

ofadherenceto

pediatric

asthmamorbidityamonginner-city

children.Pediatrics.2002;110(1):e1-e7.

(USA)

Parents

of1199children(ages4-9)withasthma,recruitedfrom

emergencydepartments

andresearchcenters

inmultiple

cities,

were

interviewed4timesovera9-m

onth

period.Includedin

the

interviewwere

questionsto

measure

adherenceto

medical

regim

ensandriskfornonadherence(characteristicsthatresearch

hasdemonstratedto

beasso

ciatedwithnonadherence

)and

parentreportofnumberofschoold

aysmissedasaresultof

asthmain

theprevious3months.

Onaverage,childrenmissed6.5

daysin

theprevious100days.

Childrenofparents

whoadmittedto

highnonadherenceto

medicalregim

ensmissed8.9

daysversusonly5.4

daysfor

childrenofparents

withlownonadherence.Children

ofparents

whohadhighriskofnonadherencemissed

8.1

daysascomparedto

only4.1

daysforchildren

ofparents

atlowriskfornonadherence

.

CDC,Centers

forDiseaseControla

ndPrevention;ER,Emergencyroom.

Journal of School Health d October 2005, Vol. 75, No. 8 d 297

Table

1PublishedResearchArticlesThatAddressAsthmaandAbsenceFrom

School(Continuedfrom

previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

BenerA,AbdulrazzaqYM,Debuse

P,Abdin

AH.Asthmaandwheezingasthecause

ofschoola

bsence.JAsthma.

1994;31(2):93-98.

(UnitedArabEmirates)

30schoolsin

1citywere

chosento

representthegeneralp

opulation;

1910students

(ages6-14)were

eitherdeterm

inedto

have

asthmafrom

schoolh

ealthrecordsorreportedto

havesymptoms

ofwheezing.

Themediandaysofabsence

from

schoola

mongthose

withasthma

was5daysayear(6

daysforthosewithdiagnosedasthma,5

daysamongthose

reportingwheezingwithoutadiagnosis).

Students

aged6-9

were

more

likelyto

missatleast1daythan

thosewhowere

10-14years

(57%

vs43%).Absenteerates

amongnonasthmaticsare

notprovided.

BlancFX,Postel-VinayN,BoucotI,

DeBlic

J,Sch

einmannP.TheAIRE

study:data

analysisof753European

childrenwithasthma.RevMalR

espir.

2002;19:585-592.

(Western

Europe)

73,880house

holdsin

France,Spain,UK,Netherlands,Italy,

Sweden,andGerm

anywere

contactedbytelephone,andthe

753householdswithachild

(underage16)withasthmawere

interviewed.

Inthepreceding12months,43%

ofstudents

missedschoolb

ecause

ofasthma.Alargenumberofstudents

receivedinadequate

treatm

ent,basedontheseverity

ofsymptoms.

Brito

A,Wurm

G,DelamaterAM,etal.

Sch

ool-basedidentificationofasthma

inalow-incomepopulation.Pediatr

Pulm

onol.2000;30:297-301.

(USA)

Parents

of154childrenwithahistory

ofasthmasymptomswere

interviewed.Students

(ages5-9

years)allattended1of9

elementary

schoolsassociatedwithamobile

clinic.

Asthmawasconfirm

edin

145children.Parents

reportedthattheir

childrenmissedameanof2.4

schoold

aysin

theprevious

2weeks.

CassinoC.Effectofmaternala

sthmaon

perform

anceofparentingtasksand

children’sschoola

ttendance.JAsthma.

1997;34(6):499-507.

(USA)

Case-controlledstudyof24mothers

withasthmamatchedwith

27mothers

withoutasthma.Schoola

bsenteeism

was

determ

inedbyreport.

Childrenofmothers

with

asthmahadasignifica

ntly

impairedability

toattendschoolcomparedto

childrenofco

ntrolm

others.22%

of

mothers

with

asthmareportedthattheirownhealth

cause

dtheir

child’sabse

nce

atleast

once

permonth,and27%

reportedtheir

childrenwere

regularlylate

forthatreaso

n(comparedto

5%

and0%

fornonasthmatic

mothers).

Centers

forDiseaseControla

ndPreventio

n.

Surveillanceforasthma—UnitedStates

1980-1999.MMWRMorb

MortalW

kly

Rep.2002;51(SS01):1-13.

(USA)

CDC’sNatio

nalC

enterforHealth

Statisticsco

nductstheNatio

nal

Health

InterviewSurvey(N

HIS)annually,whichincludesquestions

regardingasthmaandlim

itatio

nsofasthma.Approximately120,000

house

holdsare

reach

ed.D

atareportedhere

are

forages5-17ye

ars.

Thenumberofasthma-associatedschoola

bse

nce

days

inthe

previous2weeks

wasco

llectedforch

ildrenaged6-16ye

ars

during

1980-1982andforthose

aged5-17ye

ars

during1985-1996.

Schoola

bsencedaysamongchildrendecreasedfrom

1980/1982

(averageof4.9

days/year)to

1994/1996(3.7

days/year).The

percentageofchildrenwith1ormore

absenceforasthmain

the

previous2weekswas8%

in1980/1982and5.4%

in1994/1996.

Dropsin

absenteeism

ratesovertheseyears

were

not

statistically

significant.

Christia

nsenSC,Martin

SB,Sch

leicherNC,

KoziolJA,MathewsKP,ZurawBL.

Currentprevalence

ofasthma-related

symptomsin

SanDiego’spredominantly

Hispanicinner-citychildren.JAsthma.

1996;33(1):17-26.

(USA)

9984th-gradestudents

inanim

poverishedurbanareawere

surveyed.Thestudywaslargelydoneto

compare

asthma

diagnosisandsymptomsbetweenethnicgroups.questionnaire

onsymptomsledto

acategorizationofprobable

asthma,

possible

asthma,andunlikelyto

haveasthma.Parents

were

askedaboutschoola

bsenceswithin

thepastyear.

77(15%)Hispanicstudents

and32(24%)black

students

were

determ

inedto

‘‘probablyhaveasthma’’andthesestudents

missedanaverageof1.8

and0.9

daysofschool,respectively.

Ethnicgroupwasaweakpredictorofactualn

umberofdays

absentfrom

school,whereasasthmacategory

(probable

asthma,

possible

asthma,andunlikelyto

haveasthma)stronglypredicted

daysabsent.

DoullIJ,WilliamsAA,FreezerNJ,Holgate

ST.Descriptivestudyofcough,wheeze

,andschoola

bsencein

childhood.Thorax.

1996;51:630-631.

(UK)

Identifie

dfrom

rosters

ofprimary

care

physicians,4830parents

of

children(ages7-9

years)respondedto

mailedquestionnaires.

15%

ofrespondents

hadbeendiagnose

dwithasthma.7.2%

ofthesehadmissed5ormore

daysofschoolinprecedingyear

forrespiratory

symptoms,1%

missedmore

than20days.Cough,

notwheeze,wasthemostcommonsymptom

amongstudents

missingmore

than5daysofschool.

CDC,Centers

forDiseaseControla


298 d Journal ofSchool Health d October 2005, Vol. 75, No. 8

Table



previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

FindleyS,LawlerK,Bindra

M,Maggio

L,

Penachio

MM,MaylahnC.Elevated

asthmaandindoorenvironment

exposuresamongPuertoRican

childrenofEastHarlem.JAsthma.

2003;40(5):557-569.

(USA)

In2elementary

schools,1319parents

were

surveyedonchild

asthmasymptomsusingISAAC(InternationalS

tudyofAsthma

andAllergiesin

Children),onasthma-relatedschoola

bsence

andexclusionfrom

physicala

ctivity,andonhomeenvironment.

Averageageofchild

was7.4

years.

32%

reportedadiagnosisofasthma,25%

hadreportedsymptoms

inthepast12months.Ofthosewithcurrentasthma,56%

were

absentfrom

schoola

tleastoncedueto

asthmain

theprevious

month

and38%

hadlim

itedparticipationin

physicala

ctivity

inthe

previousmonth.Poorhomeenvironment(eg,dust,cockroaches,

mice)wasapredictorofhighasthmarate.PuertoRicanchildren

were

significantly(1.6

times)more

likelyto

havemissedschool

thanotherethnicgroups.

FontaineV,DeniaudF,LefortF,Lecoutour

X,BrunJ.Epidemiologyofchildhood

asthmain

thedepartmentofCalvados.

RevPneumolC

lin.1999;55:5-11.

(France)


completedaquestionnairein

1French

region.

15%

ofstudentshadasthma,with

4.5%

havingmore

than3wheezing

episodesperweek.18.5%

ofstudentswith

asthmamisse

dschool

days

withinthepastschoolyearbeca

use

ofasthmasymptoms—

with

anave

rageof2.2

days

reportedlymisse

d.

GartlandHJ,DayHD.Family

predictors

oftheincidenceofchildren’sasthma

symptoms:expressedemotion,

medicatio

n,parentcontact,andlife

events.JClin

Psychol.1999;55(5):

573-584.

(USA)

32two-parentfamilieswhohadachild

withasthma(ages5-11)were

recruitedfrom

asthmaeduca

tiongroups.Familieswere

given

measuresofexpressedemotion,lifeevents,andfamily

function

andwere

alsoaske

daboutmedicationcomplianceandschool

absence

sasso

ciatedwithasthmain

theprevious12months.

Childrenwithasthmawhohadfathers

whoscoredasbeingmore

criticalo

ftheirchildrenandexpressingmore

emotionwere

more

likelyto

befrequentlyabsentfrom

school(with

statistically

significantcorrelationsof.46and.52,respectively).

GorelickMH,ScribanoPV,StevensMW,

Sch

ultzTR.Constructvalidityand

responsivenessoftheChild

Health

Questionnairein

childrenwithacute

asthma.AnnAllergyAsthmaIm

munol.

2003;90(6):622-628.

(USA)

Aprosp

ectiveco

hortstudyat2pediatricemergency

departmentsove

r12monthsenrolled732ch

ildren(ages5-18);parentswere

contacted

14days

afterERvisitto

resp

ondto

astandardized‘‘qualityoflife’’

questionnaire.

Missing5ormore

daysofschoolinthepreviousweekwascorre-

latedwithothermeasuresofpooroutcome.

JosephCL,FoxmanB,LeicklyFE,Peterson

E,OwnbyD.Prevalenceofpossible

undiagnose

dasthmaandassociated

morbidityamongurbanschoolchildren.

JPediatr.1996;129:735-742.

(USA)

Surveyswere

senthometo

parents

ofeachchild

ingrades3-5

of2schoolsto

inquireaboutdiagnosedasthmaandwheezing

symptoms.Schoola

ttendancewasderivedfrom

schoolrecords.

Pulm

onary

functiontests

were

perform

edatschoolb

efore

and

afterphysicale

xercise.230childrencompletedthestudy.

17%

hadadiagnosisofasthma,and14%

hadadiagnosisand

symptomsin

thepastyear.Anadditional1

4%

hadundiagnose

dasthmabasedonsymptomsorpulm

onary

tests.Absenteerates

fortheentire

populatio

nwere

4.5%

ofdays.Childrenwhohad

undiagnosedasthmabasedonreportedsymptomshadhigher

ratesofabsenteeism

(6.6%).Physician-diagnosedasthmatics

missed7.7%

ofdays.Childrenwithundiagnose

dasthmawere

more

likelyto

missphysicale

duca

tionclasse

sthanthosewithout

asthma.

KattanM,MitchellH,EgglestonP,etal.

Characteristicsofinner-citychildrenwith

asthma:thenationalcooperativeinner-

city

asthmastudy.PediatrPulm

onol.

1997;24:253-262.

(USA)

1528childrenwithasthma(ages4-9)were

enrolledin

abroad-based

studythatinvolvedabaselineassessment(history,homevisits,

pulm

onary

functiontests)andintervala

sse

ssments

at3,6,and9

monthslater.Parents

were

aske

dto

recall‘‘percentofschoold

ays

missed’’in

thepreceding3-m

onth

period.

Parents,atbaseline,reportedtheirchild

missed10%

ofschoold

ays.

Thisdecreasedto

7%,6%,and6%

atassessments

3,6,and9

monthslater,respectively.

CDC,Centers

forDiseaseControla



Table



previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

Konig

P,ShafferJ.Theeffectofdrug

therapyonlong-term

outcomeof

childhoodasthma:apossible

previewof

theinternationalg

uidelines.JAllergyClin

Immunol.1996;98:1103-1111.

(USA)

Aretrospectivereviewofthechartsof175childrenwasperform

ed

(meanageoffirstchartrecord

was6.5

years).Between2and

17years

ofchartrecordswere

reviewed.Anend-of-study

questionnairewasconductedonthosewhosechartswere

reviewed.

Childrenwithmoderate

asthmareportedmissing2.4

schoold

ays

peryear,significantly

more

than2daysforthose

withmild

asthmaandsim

ilarto

2.3

daysforthosewithseve

reasthma.

Overtime,thefrequencyofschoold

aysmisseddecreasedfor

childrenwithmild,moderate,andsevere

asthmato

approxim

ately1.25daysperyear.

KuehniC

E,FreyU.Age-relateddifferences

inperceivedasthmacontrolinchildhood:

guidelinesandreality.EurRespirJ.

2002;20:880-889.

(Switzerland)

572members

from

amajororganizationforparents

ofasthmatic

childrencompletedandreturnedamailedquestionnaireabout

asthma.Childrenolderthanage16were

excluded.

Inadditionto

othersignsofsuboptimalm

anagement,

17%

ofparents

reportedabsencefrom

schoolb

ecauseof

asthmasymptomsforbetween1and6daysin

theprevious

12months;11%

ofparents

reportedschoola

bsence

sof

between1and2weeks/year,and3%

reportedmore

than

2weeksofaccu

mulativeschoola

bsencebecauseofasthma

symptoms.

KunzliN,McConnellR,BatesD,etal.

Breathlessin

LosAngeles:theexhausting

searchforcleanair.Am

JPublic

Health

.2003;93(9):1494-1499.

(USA)

Approxim

ately6000public

schoolchildrenenrolledin

Children’s

Health

Studyfrom

12LosAngelescommunitiesreceivedinitial

andannualq

uestionnairesondemographics,

physicala

ctivities,

andfamily

health

habits.Annuallungfunctiontests;school

absence

salsomeasured.Measuresofcommunity

airquality

were

obtained.

Schoola

bsenceratesincreasedwithdaily

fluctuatio

nsofozone

levels,particularlywhenlevelsrosein

communitieswithlow

concentrationsofotherpollutants

(particulate

pollution[PM10]

andnitrogendioxide).Amodest

increasein

20ppbofozonewas

associatedwithan83%

increasein

schoola

bsences.

LaiC

K,DeGuia

TS,Kim

YY,etal.Asthma

controlintheAsia-Pacificregion:the

asthmainsights

andrealityin

Asia-Pacific

study.JAllergyClin

Immunol.

2003;111:263-268.

(Asia-Pacific)

Face-to-faceinterviewswere

conductedwithheadsofover

108,000house

holdsin

8majorcitiesofChina,HongKong,

Korea,Malaysia,Philippines,Singapore,Taiwan,and

Vietnam.Amongotherquestions,parents

were

aske

difchildrenhadanylostschoold

aysin

thepast

12monthsbecauseofasthma.

Absencefrom

schoolb

ecauseofasthmawasreported

by36.5%

ofparents

ofchildrenwithasthma.

LodhaR,PuranikM,KattalN

,Kabra

SK.

Sociala

ndeconomicim

pactofchildhood

asthma.IndianPediatr.2003;40(9):

874-879.

(India)

Cross-sectionald

escriptivestudyof162children(2-16years)with

asthmabeingtreatedin

ahospital’s

outpatientchestclinic;parent

interviewselicite

dlevelo

fasthmaseve

rity

andcontrola

ndlevelo

fschoola

bsenteeism.

Of145childrenwithasthmaattendingschool,amedianof4school

daysin

theprevious6monthswere

missedbecause

ofasthma.

Medianabsence

formild

interm

ittentwas0days,andforseve

repersistent,5.5

days.Medianabsencein

well-controlledasthma

waszero;medianabsenceamongthose

withpoorlycontrolled

asthmawas27.5

days.

LeLouarn

A,HaanMC,Donato

L.Asthma

amongchildrenattendingkindergartenin

Alsace,France1998:prevalence

and

healthcare.ArchPediatr.2002;9:

1017-1024.

(France)

Parents

ofarandomizedsample

of2765kindergarten

students

(ages5-6)were

surveyedfordiagnose

dasthma,

asthmasymptoms,andschoola

bsenteeism.Parents

were

askediftheirchildrenhadbeenabsentmore

than7days

inthepast12months(themedian/averageforthe

populatio

nfrom

previousstudies).Thoseparents

witha

child

whohadasthmaorasthmasymptomswere

alsoquestionedonclinicalp

atterns,healthcare,

andhospitalizations.

Prevalenceofthediagnosisofasthmawas6.5%.Prevalence

ofasthmasymptomswithoutadiagnosiswas7.2%.37%

ofstudents

whohadasthmasymptomsin

theprevious

12monthswere

reportedabsentfrom

schoolm

ore

than7days

peryear(ascomparedto

16%

withoutasthmasymptoms).

CDC,Centers

forDiseaseControla



Table



previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

MaierWC,ArrighiH

M,MorrayB,LlewllynC,

ReddingGJ.

Theim

pactofasthmaand

asthma-likeillnessin

Seattle

school

children.JClin

Epidemiol.1998;51(7):

557-568.

(USA)

Healthinform

ationwasobtainedfrom

parents

of16651stand2nd

graders

(ages5-9).Thosewithdiagnosedasthma(11%)and

those

withoutdiagnosisbutwithahistory

ofwheezingin

thepast

12months(7%)were

comparedwitheachotherandwiththose

withoutasthma/symptoms.

48%

ofstudents

withadiagnosisofasthmahadatleast

1school

absencein

thepastmonth,ascomparedto

45%

forthose

with

symptomsonly,and33%

forchildrenwithneitheradiagnosisnor

wheezingsymptoms.

McCowanC,BryceFP,NevilleRG,Crombie

IK,Clark

RA.Schoola

bsence—avalid

morbiditymarkerforasthma?HealthBull

(Edinb).1996;54(4):307-313.

(UK)

Ofover10,000childrenregisteredin

12practices(ages1-15),3373

were

selectedforstudybasedonsomeevidenceofpossible

asthmain

medicalrecord.Ofthese,1563whoreceivedstandard

medicalcare

were

selected(balancewere

partofananother

intervention).Controlg

roupwasbasedonclassregisters

(next

child

ofsamesexonroster);schoolrecordswere

usedfor

determ

iningabsences.Asociald

eprivationindexwas

assignedto

children,basedontheirhomeaddresses.

There

were

nosignificantdifferencesbetweenthosewithasthma

symptomsnotonmedicationsandcontrolstudents.Childrenwith

asthmaonmedicationwere

absentapproxim

atelyonly2daysper

yearmore

thanchildrenin

controlg

roups.Sch

oola

bsence

isnot

avalid

markerofasthmamorbidity.

Amongthosewithasthma

receivingmedication,seco

ndary

schoolchildrenwere

absentfor

ameanof8days,comparedto

4daysforelementary

school

children.Sociald

eprivationhasastrongerinfluenceonschool

absencethanasthma.Absencesamongchildrenwithasthma

maybemore

dueto

underlyingsocialfactors

thanmedicalo

nes.

Mellinger-BirdsongAK,PowellKE,IatridisT,

BasonJ.Prevalence

andim

pactof

asthmain

children,Georgia,2000.Am

JPrevMed.2003;24(3):242-248.

(USA)

Arandom-digitdialsurveyof1503householdswithatleast

1child

aged0-17years

wasconducted.2700childrenwere

represented.

Asthmawasdefinedasacurrentdiagnosis,useofasthma

medication,orapreviousdiagnosisofasthmawithsymptomsin

thepast12months.Oneofthequestionsforparents

was‘‘how

manydaysofschoold

idthechild

missbecauseofasthma?’’

54%

ofschool-agedchildrenwithasthmamissedschoolb

ecauseof

asthma.Theestim

atedmeannumberofschoold

ayslostperyear

forachild

withasthmawas6.1

days.Sch

oold

aysmisseddueto

asthmaaccounts

for5%

oftotald

aysmissedbyallstudents

for

anyreason.

MemonIM

,LoftusBG.Spectrum

of

childhoodasthmain

Galway.

IrMedJ.1993;86(6):194-195.

(Ireland)


whohadwheeze

din

preceding12months

were

identifiedthroughasurvey.Thesechildrenwere

matched

with118controls.Students

were

clinically

examinedandparents

providedinform

ationonsymptomsandschoola

bsences.

8%

ofstudents

withasthmawere

absentfrom

schoolformore

than

10asthmaepisodesin

pastyear;19%

were

absentforbetween4

and10asthmaepisodesperyear,and25%

absentfrom

school

forfewerthan4episodesperyear.Theremainderdid

notreport

absences.

MitchellEA,StewartAW,ReaHH,etal.

Measuringmorbidity

from

asthmain

children.NZMedJ.1997;110(1036):3-6.

(NewZealand)

381ch

ildrenwith

asthma(6-11ye

ars)were

selected;asthmawas

defin

edashavingrece

ivedanantia

sthmadrugwith

inthepast

year.

Childrenwere

recruite

dviahosp

italadmissions,

physician

practices,

schools,andpreviousstudies.

Parent,physician,and

teach

ersu

rveys

andschoolandhosp

italreco

rdswere

use

dto

get

data.Parentquestionnaireca

tegorize

dch

ildaseith

erse

vere

ornot

seve

re.Purpose

ofstudywasto

compare

thismorbidity

measu

reagainst

more

traditionalm

orbidity

leve

ls.

Parents’m

easure

ofseve

rity

using2quickquestionswas

significantly

correlatedwithschoola

bsenteeism

(26vs18days).

NewacheckPW,HalfonN.Prevalence

,im

pact,andtrendsin

childhooddisability

dueto

asthma.ArchPediatrAdolesc

Med.2000;154(3):287-293.

(USA)

Data

were

derive

dfrom

the1994-1995NHIS

of62,171children

underage18years.Thisisaninterviewsurveywhere

anadult

answers

forchildrenunderage17.

1.4%

ofUSchildrenyoungerthan18years

experiencesomedegree

ofdisability

dueto

asthma.Childrenwithdisablingasthmahadan

averageof9.7

schoola

bsencedaysannually.In

comparison,

childrenwithotherdisability

conditionslostanaverageof5.3

schoold

aysdueto

theirdisability.Anestimated40%

ofchildren

withdisablingasthmawere

reportedasbeingeitherunable

orlim

itedin

theirability

toengagein

schoola

ctivities.

CDC,Centers

forDiseaseControla


Journal ofSchool Health d October 2005, Vol. 75, No. 8 d 301

Table



previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

NguyenL,RaherisonC,VernejouxJM,

Tunon-D

e-Lara

JM,Taytard

A.Im

pactof

smokinghabits

ontheevery

daylifeof

asthmatic

adolescents.RevMal

Respir.2002;19:301-309.

(France)

3302childrenaged13-14years

were

surveyedforrespiratory

symptoms,schoola

bsenteeism,aswellasonsmokinghabits

andexposure

tothetobaccosmokeofothers.

Regressionanalysisthatadjustedforconfoundingfactors

foundthat

activesmokingamongadolescentasthmaticscontributedto

more

schoola

bsences.

NriaguJ,RobinsT,Gary

L,etal.Prevalence

ofasthmaandrespiratory

symptomsin

south-centralD

urban,South

Africa.EurJ

Epidemiol.1999;15(8):747-755.

(South

Africa)

Headsof213house

holdsin

2heavily

pollutedcommunitieswere

interviewedaboutasthmadiagnosis,symptomsofasthma,

household

riskfactors,andmissedschool.

Of367childrenunderage117years,10%

hadadiagnosisof

asthma.Prevalence

ofsymptomswasnotasso

ciatedwith

household

risks(smoke

,dampness,carpets,pets,pesticides).

Asthmaprevalencewasstronglycorrelatedwithmissing

ofschoolb

ychildrenwithanoddsratio

of44.

RandCS,Butz

AM,KolodnerK,Huss

K,

EgglestonP,MalveauxF.Emergency

departmentvisits

byurbanAfrican

America

nch

ildrenwith

asthma.JAllergy

Clin

Immunol2000;105:83-90.

(USA)

Parents

of392mostlyAfricanAmericanchildren(K-6)were

interviewediftheirschoolh

ealth

emergencycard

identifiedthem

ashavingasthma.Numberofschoold

aysmissedbecauseof

asthmawasonequestionaskedofparents.

Parents

ofstudents

withasthmareportedtheirchildrenwere

absentfrom

schoola

naverageof9.7

schoold

aysperyear

becauseofasthma.

RosierMJ,BishopJ,NolanT,Robertson

CF,Carlin

JB,PhelanPD.Measurement

offunctionalseverity

ofasthmain

children.Am

JRespirCritCare

Med.

1994;149:1434-1441.

(Australia)

Asurveyonasthmasymptomswassentto

parents

ofarandom

sample

of9192childrenin

2nd,7th,and10th

grades(m

eanages

8,13,and16years).Parents

of1267childrenwhohadsymptoms

were

interviewed,andpulm

onary

functiontests

were

perform

ed.

Sch

oola

bsencewasmeasuredusingparentreportof‘‘abse

nces

dueto

wheezein

preceding12months.’’Purposeofstudywasto

developastandardizedinstrumentformeasuringseve

rity

of

chronicasthmain

children.

Asthmasymptom

questionsusedin

thissurveydemonstratedthat

symptomsofasthmacorrelatedsignificantly

with‘‘schoola

bsence

dueto

wheeze’’(w

ithacorrelationcoefficientof.35).

Spee-vanderWekkeJ,Meulm

eesterJF,

RadderJJ,Verloove-VanhorickSP.

Sch

oola

bsence

andtreatm

entin

school

childrenwithrespiratory

symptomsin

The

Netherlands:data

from

theChild

Health

MonitoringSystem.JEpidemiol

CommunityHealth.1998;52(6):359-363.

(Netherlands)

Over5000children(ages4-15years)whowere

eligible

forroutine

school-basedhealth

assessments

were

screenedforrecent/

currentrespiratory

symptoms.

Respiratory

symptomswere

amajorcauseofabsenteeism.Among

childrenwithrespiratory

symptomssuggestiveofasthma(7%),

absencefrom

schoolw

asnotstatistically

differentfrom

school

absenceratesamongchildrenwithotherrespiratory

symptoms.

Absencefrom

schoolishigherin

those

(with

andwithoutasthma)

whohadreceivedamedicationin

thepreviousmonth—

indicating

seve

rity

ofrespiratory

symptoms.

TaylorWR,NewacheckPW.Im

pactof

asthmaonhealth.Pediatrics.1992;

90(5):657-662.

(USA)

Data

basedon1988NHIS

of4.3%

of17,000householdswho

reportedachild

whohadasthmain

theprevious12months.

Both

thosewithandwithoutasthmawere

aske

d‘‘functio

nal

status’’questions,includingparents’e

stim

ate

ofnumber

ofdaystheirchild

wasabsentfrom

schoolinthe

previousyear.

Blackchildrenwithasthmamissedameanof6.5

days

ofschool,whitechildrenwithasthmamissedameanof

4daysofschool(meanforallraceswas4.5

days).Children

withmild

asthmamissed2.1

days,those

withmoderate

asthma,3days,andthose

withsevere

asthma,5.2

days.

Lowincomewasasignificantpredictorofschool

dayslost.

CDC,Centers

forDiseaseControla



Table



previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

Warm

anKL,SilverEJ,

McCourtMP,Stein

REK.Howdoeshomemanagementof

asthmaexacerbationsbyparents

of

inner-citychildrendifferfrom

NHLBI

guidelinerecommendations?Pediatrics.

1999;103:422-427.

(USA)

Parents

of220children(ages2-12)whohadbeenhospitalizedwith

asthmawere

surveyedbytelephone.

Parents

reportedanaverageof18daysofschoola

bsencein

the

previousschoolyear,withamedianof12daysabsent.

WeissKB,SullivanSD,Lyttle

CS.Trends

inthecostofillnessforasthmain

the

UnitedStates,1985-1994.JAllergyClin

Immunol.2000;106:493-499.

(USA)

Thisstudylookedatcost

estim

atesofasthmafrom

aneconomic

evaluatio

npublishedin

1992regarding1985costs.Astudyof

1994data

wasbasedonthepreviousanalyticalm

ethods.Number

ofschoold

ayslostwasequatedwiththenumberofdayslostfrom

work

fortheparent/caretaker.NHIS

data

were

usedto

calculate

thenumberofwork

dayslost.

Itwascalculatedthatin

1994,childrenaged5-17lostanestimated

11.8

millionschoold

aysbecauseofasthma,ascomparedto

7.2

millionschoold

ayslostin

1985.

WoodPR,HidalgoHA,PrihodaTJ,Kromer

ME.Hispanicchildrenwithasthma:

morbidity.Pediatrics.1993;91:62-69.

(USA)

Children(ages6-16)withasthmawere

identifiedfrom

1hospital’s

emergencyandhospitalizationrecords.Onlythosewithatleast

2acute

visits

or1hospitalizationwere

enrolledin

thestudy.

Standardizedquestionnaires,

peakflow,andschoola

ttendance

recordswere

includedin

themeasurements.

Amongthefindingsin

thestudywasthattherate

ofschool

absenteeism

was13of175days(7.4%

oftotal).Smokers

inhousehold

andlowknowledgeofasthmawere

thelargest

contributors

tomorbidityfrom

asthma.

YeattsK,ShyC,SotirM,MusicS,HergetC.

Healthconsequencesforchildrenwith

undiagnose

dasthma-likesymptoms.Arch

PediatrAdolescMed.2003;157:540-544.

(USA)

Over122,000children(ages12-14)were

surveyedin

499middle

schoolsvia

astandardizedasthmaquestionnaireandadditional

questionsonasthmaconsequence

s.

17%

ofthepopulationreportedasthma-likesymptomsin

the

past12monthswithnodiagnosisofasthma.11%

reported

physician-diagnosedasthma.20%

ofthose

withundiagnosed

asthmasymptomsmissedatleast

ahalfdayofschoolinthe

precedingmonth

becauseofsymptoms.Ofchildrenwith

physician-diagnosedasthma,47%

missedatleast

ahalfdayin

theprecedingmonth.

YeattsKB,ShyCM.Prevalence

and

consequencesofasthmaandwheezing

inAfrican-AmericanandWhite

adolescents.JAdolescHealth.

2001;29(5):314-319.

(USA)

Wheezingsymptomsandphysician-diagnose

dasthmawere

measuredin

20598th

graders

inaninternationalstudysample.

Adolescents

answeredquestionsabouttheirasthma,school

attendance,andsleepdisturbancesseco

ndary

toasthmasymptoms.

9%

ofthese

adolescents

hadphysician-diagnose

dasthma,and

another27%

reportedwheezingwithoutaphysiciandiagnosisof

asthma.Thosewithphysician-diagnosedasthmamissed2.6

timesmore

schoold

aysthanthosewithoutasthma.Those

withoutadiagnosisbutwithhistoriesofwheezingmissed1.8

timesmore

schoold

aysthanhealthyadolescents.

CDC,Centers

forDiseaseControla



attendance among children without asthma). Days absentfor symptoms of asthma are not typically distinguishedfrom days absent for other reasons. And absenteeism ismeasured differently across studies. For example, somestudies elicit the number of days absent per year, whereasothers frame the question by asking whether a child hasmissed more than a certain number of days in the pastmonth, quarter, or year.

Despite the fact that current research cannot easilycome to a consensus on the number of school daysmissed secondary to asthma, a great deal of informationhas been learned about the factors that may influenceschool absenteeism rates. The studies demonstrate linksbetween absenteeism and ethnicity that range from mereweak influences when comparing American Hispanics toAfrican Americans in one study to relatively high rates ofabsenteeism among African Americans in another studyand relatively high rates of absenteeism among PuertoRicans with asthma in New York compared to other eth-nic groups with asthma, in a third study (Christiansen et al1996; Taylor and Newacheck 1992; Findley et al 2003;Table 1).

Parenting and income (Gartland and Day 1999; McCo-wan et al 1996; Taylor and Newacheck 1992; Table 1)predict rates of school absences among children withasthma as does the severity of the disease (Wood et al1993; Warman et al 1999; Table 1). The contribution ofone’s adherence to prescribed medical regimens may playa significant role in rates of absenteeism (Bauman et al2002; Table 1). Not surprisingly, these studies allude to thepossibility that the physical home environment, access tohealth care, and/or the importance placed on attendingschool may mediate the effects of ethnic and social factorson school attendance. But this is still not well understood.

With the exception of a study in Saudi Arabia (Al-Dawood 2002; Table 1), studies demonstrate that childrenwith a physician’s diagnosis of asthma are absent moreschool days than children who have symptoms of asthmabut do not have a physician’s diagnosis (Joseph et al1996; Maier et al 1998; Yeatts et al 2003; Table 1). Stud-ies are mixed on whether younger elementary students withasthma or adolescents in high school with asthma are mostlikely to miss school.

Various studies have examined environmental factorsaffecting school attendance among children with asthma.Studies have found that missed school days are associatedwith adolescents who smoke, students without asthmawho have mothers with asthma, and children with asthmaliving in areas with high ozone levels. More studies arerequired to confirm these associations.

AchievementApproximately two thirds of the published studies that

address school performance and students with asthma(Table 2) demonstrate no difference in levels of academicachievement or ability. Among those showing a difference,the difference was limited to students with severe and per-sistent symptoms or to other contributing social factorssuch as income (Gutstadt et al 1989; Fowler et al 1992;Table 2). Of interest is the finding that kindergarten stu-dents with asthma had poorer school readiness scores andthat asthma-related interruptions in sleep for children with

asthma, rather than the severity of the condition per se,may affect school performance (Halterman et al 2001; An-nett et al 2000; Table 2).

Interventions to Mediate Asthma Effects on AttendanceTwenty-five published articles described interventions

for school-aged children with asthma and measured howrates of school attendance varied based on that interven-tion. Interventions described in these articles included re-ferrals to primary care doctors, education on asthmamanagement, student attendance at asthma camp, exis-tence of a school-based clinic, comprehensive medicationmanagement, a swimming program for children withasthma, medication delivery in school, and interventionsat the level of the primary care physician. Unfortunately,the design of many of these studies did not include mea-surement of absenteeism rates at 2 points in time amongthose students who did not receive the intervention. Thiswould have increased the validity of these figures. Studiesthat did use a control group clearly demonstrate theirimportance in this field, rendering outcomes withouta control group almost meaningless. In a number of stud-ies, very significant improvements in attendance occurredin children who received no intervention (control chil-dren) (Hill et al 1991; McGhan et al 2003; Taras et al2004; Table 3) and sometimes these improvements wereof a magnitude larger than the beneficial effect of theintervention.

Education for children and/or parents on managementof their asthma was the primary intervention in 7 studies,some in school-based settings, others at health care set-tings, and 1 by pharmacists. Evidence that education onasthma management improves school attendance is weak,although evidence that this intervention can improve con-trol of the disease is encouraging. This paradox supportsthe view that symptoms of children with asthma are lessresponsible for missed school days than are various socio-cultural causes. The Open Airways for Schools program,sponsored by the American Lung Association, is oneeducational intervention shown, in a controlled study pub-lished in 1987, to successfully improve student knowl-edge, self-management skills, and asthma morbidity.4

Interestingly, school grades improved for those taking thecourse, but there was no change in number of school daysmissed. Success is dependent on the program curricula,mode of delivery, and type of training and experience ofthe person(s) delivering the education.5,6 Two asthma campstudies demonstrated improved student attendance (Kellyet al 1998; Meng et al 1998; Table 3), which should haveheralded further research with control groups and othertighter methodological designs, but unfortunately did not.

Controlled studies that included special precautions toassure proper medication regimens (with or without com-prehensive education on management) were mixed intheir demonstrated effect on student attendance. School-based delivery of inhaled steroids (Millard et al 2003;Halterman et al 2004; Table 3) and 1of 3 interventions thatprovided children with comprehensive asthma care in a spe-cialized clinic (Battleman et al 2001; Table 3) improvedattendance. Referring school-aged children with asthma toa primary care provider (Hill et al 1991; Lurie et al 2001;Zorc et al 2003; Table 3) and improving the habits of regular


Table2

PublishedResearchArticlesThatAddressAsthmaandSchoolPerform

anceand/or

CognitiveAbilityin

School-AgedChildren(Continuedonnextpage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Achievement(Effects

onAbsenteeism

AlsoReported,IfApplicable)

AnnettRD,Aylward

EH,LapidusJ,BenderBG,DuHamelT

.Neuroco

gnitivefunctioningin

childrenwithmild

and

moderate

asthmain

thechildhoodasthmamanagement

program.TheChildhoodAsthmaManagementProgram

(CAMP)ResearchGroup.JAllergyClin

Immunol.

2000;105(4):717-724.

(USA)

Subjects

were

1041children(m

eanage8.9

years)enrolled

intheChildhoodAsthmaManagementProgram

(arandomizedtrialcomparing2anti-inflammatory

agents).

WISC(intelligencescale),Woodcock-Johnson

(achievement),WRAML(m

emory/le

arning),GDS

(standardized‘‘attentio

ntask’’device),andlungfunction

asse

ssments

were

collectedduringbaselinescreening,as

wasasthmaseve

rity

(via

a28-dayasthmadiary).Children

withnoasthmaandsevere

asthmawere

excluded.Only

those

withmild

andmoderate

asthmawere

studied.

There

were

nosignificantdifferencesbetweenpublished

norm

ativevaluesandthestudypopulationwithmild

and

moderate

asthmaforIQ

,memory,attention,andacademic

achieve

ment.Childrenwithasthmascoredbetween

two-thirdsand1standard

deviationbelownorm

sforamea-

sure

ofim

pulsecontrol—

indicatingthere

may

bedifficultywithmodulationandcontrolo

fim

pulsive

behaviors.

DietteGB,Markso

nL,SkinnerEA,NguyenTT,

Algatt-Bergstrom

P,WuAW.Nocturnala

sthma

inchildrenaffects

schoola

ttendance,school

perform

ance,andparents’w

ork

attendance.

ArchPediatrAdolescMed.2000;154(9):923-928.

(USA)

Cross-sectionalsurvey(m

ailandtelephone)of438

parents

ofasthmatic

childrenin3managed-care

organizatio

ns(identifiedviapharm

acy

data

andvisits).

Misse

dschoold

ays

andeffect

onch

ild’seduca

tionwere

derive

dfrom

parentreportsoftheprevious4weeks.

40%

ofchildrenwithasthmawere

awakenedatleast

oncein

thepreviousmonth;35%

missedatleast1dayofschool;

36%

reportedthatschoolp

erform

ancesufferedbecauseof

asthmasymptoms.Asignificanttrendexistedbetween

nightawakeningsandboth

reportedschoolp

erform

ance

anddaysmissedfrom

school.Nightawakeningwas

suggestedasanindependentdeterm

inantofabsenteeism.

FowlerMG,DavenportMG,Garg

R.Sch

oolfunctioning

ofUSchildrenwithasthma.Pediatrics.

1992;90(6):939-944.

(USA)

Cross-sectionald

ata

from

1988USNationalH

ealthInterview

Surveyofparents

onChild

Health.

Ofover10,000familiessurveyed,5%

ofchildren(536)had

asthmain

theprevious12months.Afteradjustin

gfor

demographicfactors,there

wasnodifferencein

grade

failure

orin

suspension/expulsion;those

withasthmahad

1.7

timesriskoflearningdisability—higheramongthose

reportingto

haveasthmaandbein

fairto

poorhealth.

Amongfamilieswithlowincome,thosewithasthmahad

twiceoddsofgradefailure.

GutstadtLB,GilletteJW,MrazekDA,Fukuhara

JT,

LaBrecqueJF,StrunkRC.Determ

inants

ofschool

perform

ancein

childrenwithchronicasthma.Am

JDis

Child.1989;143(4):471-475.

(USA)

Thestudyco

nsistedof99ch

ildren(ages9-17)with

seve

reasthmawhowere

admittedto

hosp

italtorece

iveanextensive

eva

luatio

nandrehabilitatio

nofse

vere

chronicasthma.This

wasapreve

ntiveprogram,nothosp

italizatio

nwith

anacu

teepisode.S

tandardizedtestsofp

ulm

onary

function,a

cademic

perform

ance

,grades(w

henava

ilable),intelligence

tests

(SlossonIntelligence

Test),schoolattendance

reco

rds,

and

psych

ologicalassessments

(Child

BehaviorChecklist)were

determ

inedinthefirst2weeks

ofthepreve

ntiveinterventio

n.

Astepwiseregressionanalysiswasuse

dto

exa

minerela-

tionsh

ipsbetweenthese

andotherva

riables.

Lowperform

ancescoreswere

associatedwithlow

socioeconomicstatus,olderage,history

ofcontin

uousoral

steroid

use(every

otherdayuseforatleast1yearpriorto

evaluation),andpresenceofemotional/behavioral

problems.Sch

oola

bsenteeism,useofmedicalresources,

thedoseoforalsteroids,otherasthmamedications,and

pulm

onary

functionwere

notasso

ciatedwithacademic

perform

ance.

Halterm

anJS,MontesG,AligneCA,KaczorowskiJM,

HightowerAD,SzilagyiP

G.Sch

oolreadinessamongurban

childrenwithasthma.AmbulP

ediatr.2001;1(4):201-205.

(USA)

Cross-sectionalstudyof1058kindergartenchildrenin

Rochester,NY,ofwhich103hadasthma(9%).Parents

were

surveyedforchild

asthmasymptomsin

thepast12

months,lim

itationsofactivity,anddevelopmentalskills.

Validatedsurveytoolw

asused.

Childrenwithasthmawhoalsohadalim

itationofactivity(63

of103asthmatic

children)hadsignificantly

lowerschool

readinessskillscomparedto

childrenwithoutasthma,

adjustin

gformultiple,potentially

confoundingvariables.

Developmentalp

roblemsforurbanchildrenwithsignificant

asthmamaybegin

before

schoole

ntry.

GDS,GordonDiagnostic

System;WISC,Wech

slerIntelligenceScale

forChildren;WRAML,WideRangeAssessmentofMemory

andLearning;WRAT-R

,WideRange-Achievement

Test,Revised.


Table

2PublishedResearchArticlesThatAddressAsthmaandSchoolPerform

anceand/or

CognitiveAbilityin

School-AgedChildren

(Continuedfrom

previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Achievement(Effects

onAbsenteeism

AlsoReported,IfApplicable)

LindgrenS,Lokshin

B,StromquistA,etal.Doesasthmaor

treatm

entwiththeophyllinelim

itchildren’sacademic

perform

ance.NEnglJ

Med.1992;24;327(13):926-930.

(USA)

255childrenwithasthma(m

eanage12)whohadtaken

astandardizedacademicachievementtestadministered

byschools;100hadsiblingswithoutasthma,whowere

controls.

Aca

demicachieve

mentamongchildrenwithasthmawas

sim

ilarto

orbetterthannorm

ativestandards.Forthe101

childrenwithsiblingcontrols,there

were

nostatistically

significantdifferencesin

testscores,includingchildrenon

theophyllineforasthma.

NallM,CorbettM,McLoughlin

J,PetroskoJ,Garcia

D,Karibo

J.Im

pact

ofshort-term

oralsteroid

useuponchildren’s

schoola

chievementandbehavior.AnnAllergy.

1992;69:218-220.

(USA)

19children(ages7-15)from

oneclinicwithchronicasthma

onnonsteroid

long-term

medications;WRAT-R

(achieve-

menttest)andBehaviorRatingProfile.Within-subject

design—

students

testedonandofforalsteroids.

Duringdaysonshort-term

oralsteroids(prednisone),there

wasnochangein

reading,spelling,andarithmeticscores

orbehavior.

Rietveld

S,CollandVT.Theim

pactofsevere

asthmaon

schoolchildren.JAsthma.1999;36(5):409-417.

(Netherlands)

25children(ages10-13)withsevere

asthma(onhighdoses

ofcorticosteroids)matchedwith25childrenin

control

groupforage,sex,

andsocioeconomicbackground;

asthmasubjectsenrolledvia

physicians’o

fficesand

controls,via

localn

ewspaperadvertisements.Standard

tests

were

usedto

measure

memory

andconcentration;

reportcardswere

usedto

asse

ssschoolp

erform

ance.

Memory

scores,concentratio

nscores,andschool

perform

ancewere

notsignificantly

differentamongthose

withandwithoutasthma.

Ross

S,G

oddenD,M

cMurrayD,etal.Socialeffectsofw

heeze

inch

ildhood:a25-yearfollowup.BMJ.

1992;305:545-548.

(UK)

Subjects

identifiedaschildrenwithadiagnosisofasthma

(97),wheezingonlywithupperrespiratory

infectio

ns

(132),andnorespiratory

symptoms(131)were

followed25years

later.

Those

identifiedashavingasthmainch

ildhoodwere

more

likelyto

have

resp

iratory

problemsduringtheirschoolyears.

Desp

itethese

reportedproblems,

educa

tionalattainment

such

asgraduatio

nfrom

highschool,furthereduca

tion,and

highere

duca

tionwere

similarforthose

with

asthma,those

with

wheezingduringupperresp

iratory

infections,

andthose

with

nosymptoms.(There

wasalsonodifference

betweenthese

3groupsforemploym

ent,housing,andeve

ntualsocialclass.)

Silverstein

MD,MairJE,KatusicSK,WollanPC,O’connell

EJ,YungingerJW.Schoola

ttendanceandschool

perform

ance:apopulation-basedstudyofchildrenwith

asthma.JPediatr.2001;139(2):278-283.

(USA)

Childrenwith

asthmawere

identifiedthroughamedical

reco

rdreviewsystem.Sch

oolattendance

,standardized

ach

ieve

menttest

scores,

gradepointave

rage(G

PA),grade

promotio

n,andclass

rankofgraduatin

gstudents

forch

il-drenwith

asthmaandco

ntrolsubjectswere

obtainedfrom

those

with

asthmawhoalsoattendedtheloca

lpublic

school

system.92students

with

asthmawere

comparedto

sex-

andage-m

atchedco

ntrolsubjects.

Sch

oolreco

rdsforthese

students

were

ava

ilableforanave

rageperiodof6.6

years.

Childrenwithasthmahadameanof8.95daysabsent

(67.95standard

deviation),comparedwith6.74(6

7.08)

daysfornonasthmaticcontrolsubjects.(C

hildrenwith

asthmahad2.2

more

daysabsentperyear.)There

were

nosignificantdifferencesin

standardizedachieve

menttest

score

(reading,math,language),in

GPA,gradepromotio

n,

orclassrank.

WeldonDP,McGeadySJ.Theophyllineeffects

oncognition,

behavior,andlearning.ArchPediatrAdolescMed.

1995;149(1):90-93.

(USA)

63asthmatic

childrenwere

drawnfrom

admissionsto

arehabilitatio

nhosp

ital(ages7-18).Asthmabase

don

spirometryandhistory

ofsym

ptom

resp

onse

.Allasthmatic

childrenwere

giventheophylline(inadditionto

otherasthma

medicatio

ns).46nonasthmatic

controlsubjectswere

drawn

from

thesa

merehabilitatio

nhosp

ital.Noch

ildrenwith

retardatio

norneurologicald

iagnose

swere

included.The

WISC(intelligence

sca

le),WRAT(aca

demicach

ieve

ment),

andahyp

eractivity

checklistwere

administered.

Studydetectednosignificantbehavioralo

rcognitive

differencesbetweenthetheophylline-treatedgroup

ofasthmaticchildrenandamatchedgroupofchildrenwith

otherchronicillnesseswhodid

notreceivetheophylline.

GDS,GordonDiagnosticSystem;WISC,Wech

slerIntelligenceScale

forChildren;WRAML,WideRangeAssessmentofMemory

andLearning;WRAT-R

,WideRange-Achievement

Test,Revised.


Table3

PublishedResearchArticlesThatAddressInterventionsAmongSchool-AgedChildrenWith

AsthmaandRatesofSchoolAbsenteeism

(Continuedonnextpage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

BattlemanDS,CallahanMA,SilberS,etal.Dedicated

asthmacenterim

prove

sthequalityofcare

andresource

utilizationforpediatricasthma:amulticenterstudy.Acad

Emerg

Med.2001;8(7):709-715.

(USA)

Aretrospectivesample

of70school-agedchildrenwho

receivedasthmacare

from

acomprehensiveasthma

centerwere

matchedbyageandasthmaseve

rity

with70

childrenwithasthmawhoreceivedcare

inemergency

departments.Aparentinterviewwasconducted

todeterm

inedaysofschoolm

issed,amongother

measuresofasthmasymptoms.

Schoola

bsenteeism

waslower(m

eanof9.5

daysmissedper

year)amongthosereceivingcare

inacomprehensive

asthmacenterthanamongthose

receivingemergency

departmentcare

(meanof16.6

days).

Christia

nsenSC,Martin

SB,SchleicherNC,KoziolJA,

MathewsKP,ZurawBL.Evaluationofaschool-based

asthmaeduca

tionprogram

forinner-citychildren.

JAllergyClin

Immunol.1997;100:613-617.

(USA)

Five20-m

inute

asthma-educationsessionswere

held

for27

4th-gradestudents

withasthmawhowere

thenfollowed

prospectivelyfor180days.15students

withasthmadid

not

receivetheeduca

tionalsessionsbutwere

followedand

measured.

Nodifferenceswere

seenbetweentheeducatio

nandcontrol

groupsin

meanschoola

bsence

s,despiteincreased

asthmaknowledge,im

prove

dskillsforpeakflowmeterand

medicationuse,andareductio

nin

seve

rity

ofasthma

symptoms.

Cunningham

SJ,Crain

EF.Reductionofmorbidity

inasthmaticchildrengivenaspacerdevice.Chest.

1994;106(3):753-757.

(USA)

Parents

of98childrenwithasthmawhopresentedto

an

emergencydepartment(ages3-10;meanage6)were

sent

homewitheitheraninhalerwithaspaceroraninhaleror

oralm

edication(control);random

selectio

n.Parents

completedaquestionnaireonasthmasymptomsand

demographics.

Follow-upbytelephoneat1weekand

2,4,and6monthsforsymptomssincethe

previouscall.

Themediannumberofschoold

aysmissedbecause

of

asthmawassignificantlylessin

thespacergroupthanin

thecontrolg

roupat2months(0

vs2days)and4months

(0vs2days)afterbeginningthetreatm

ent.There

wasno

differenceat1weekand6monthsmeasurements.

ForsheeJD,WhalenEB,Hacke

lR,etal.Theeffectiveness

of

one-on-onenurseeduca

tionontheoutcomesofhigh-risk

adultandpediatricpatients

withasthma.ManagCare

Interface.1998;11(12):82-92.

(USA)

Anasthmaself-m

anagementprogram

wasgivento

pediatric

patients

inanIPAmodelh

ealthplan.Recruitmentwasfor

those

withasthmaathighrisk,

riskbasedonresource

utilization,medicationuse,orlackofuse.Participants

included89children(m

eanage8.5).

Ofthosewithasthma,18%

hadreportedmissingschoolin

theprevious4weeks.Aftertheeducationalp

rogram,days

missedin

theprevious4weeksdecreasedfrom

1.2

daysto

0.7

days.Thiswasnotsignificantlydifferent.

GeorgiouA,BuchnerDA,ErshoffDH,BlaskoKM,Goodman

LV,Feigin

J.Theim

pactofalarge-scale

population-based

asthmamanagementprogram

onpediatricasthmapatients

andtheircaregivers.AnnAllergyAsthmaIm

munol.

2003;90:308-315.

(USA)

401house

holdswithanasthmaticchild

(ages5-13)were

randomlyselectedfrom

ahealth

plan’smedical/pharm

acy

claim

sdata

indicatin

ganasthmadiagnosis.An‘‘asthma

health

management’’intervention(educatio

nal

interventionsbasedonasthmariskandseve

rity).Parents

were

surveyedpriorto

andaftertheintervention.

Thepercentageofchildrenwhomissed1ormore

school

daysbecause

ofasthmaduringthepreviousyear

decreasedsignificantlyfrom

36%

to23%.

Halterm

anJS,SzilagyiP

G,YoosHL,etal.Benefitsof

aschool-basedasthmatreatm

entprogram

intheabsence

ofsecondhandsmokeexposure.ArchPediatrAdolesc

Med.2004;158:460-468.

(USA)

Sch

oolswere

usedassite

sto

provideanddeliverchild’s

once-daily

inhaledcorticosteroid

medications.

184children(ages3-7)were

randomizedinto

2groups:93receivedtheirdaily

doseofinhaled

corticosteroidsin

school,and91were

allocatedto

usualp

arentalcare

(control).Parents

administered

medicationsonweekends.Anindependentresearch

team,blindedto

intervention,collecteddata.

Parents

were

telephonedregularlyandasked

numberofschoold

aysmissedsincethe

previoustelephonecall.

Comparedto

controls,parents

ofchildrenreceivingtheircorti-

costeroid

medicationatschoolh

adgreaterim

provementin

quality-of-lifemeasurements,missedlessschool(7vs9

days;P¼

.43),andhadmore

symptom-freedaysin

winter.

Forthose

notexposedto

tobaccosmoke,additionalb

ene-

fits

ofschool-basedtreatm

entwere

fewerdaysrequiring

rescuemedicatio

nandfeweracute

visitsforasthma.

ER,Emergencyroom;IPA,Independentpracticeassociation.


Table

3PublishedResearchArticlesThatAddressInterventionsAmongSchool-AgedChildrenWith


(Continuedfrom

previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

HillR,WilliamsJ,BrittonJ,Tattersfie

ldA.Canmorbidity

asso

ciatedwithuntreatedasthmain

primary

school

childrenbereduced?:acontrolledinterventionstudy.

BMJ.

1991;303:1168-1173.

(UK)

Ascreeningquestionnaireaboutwheezingandschool

absencewassentto

parents

ofover17,000students

(ages

5-10years)in

102elementary

schools.Childrenwhowere

notonanycontrollerasthmamedicationandhadbeen

absentfrom

schoolinthepastyearbecauseofwheezing

andchildrenwithasthmawhowere

absentlongerthan10

daysin

thepreviousyearbecauseofsymptoms(regard-

lessoftreatm

ent)were

identified.Sch

oolswere

randomly

assignedeitherto

acontrolo

rto

receiveanintervention

(requiringthatparents

oftheirstudents

receivealetter

recommendingthattheirchild

beseenbyadoctor

andthatschooln

ursesbeupdatedonasthma).

Parents

were

aske

dto

estimate

daysabsentfrom

schoolforasthma,anddaysabsent(forallreasons)

were

takenfrom

classregisters.

There

were

228students

withasthmain

theintervention

schoolsand223in

controlschools.67%

ofstudents

ininterventionschoolscompliedwitharecommendedvisit

totheirdoctor,and38%

ofthese

receivedim

proved

medication.Thepercentageofstudents

independently

goingto

theirdoctorin

thecontrolg

roupandreceiving

improvedmedicationswasnotreported.In

both

control

andinterventionschools,absenteeism

ratesfell

significantly

from

oneyearto

thenext,butthedifference

betweencontrola

ndinterventionwasinsignificant.Inter-

ventio

nschoolswere

significantlymore

likelyto

havestu-

dents

keeptheirowninhalers,havestudents

useinhalers

priorto

physicala

ctivity,andhavecentrallists

ofstudents

withasthma.

HuangSW,VeigaR,Sila

U,ReedE,HinesS.Theeffectof

swim

mingin

asthmaticchildren—

participatingin

aswim

mingprogram

inthecityofBaltim

ore.JAsthma.

1989;26(2):117-121.

(USA)

Twenty

children(ages6-12)withasthmawere

enrolled

inanafter-school,2-m

onth-longswim

mingprogram

(1-hoursessions,3timesweekly).Atenrollm

ent,

aprevious12month-history

wastaken.Afterenrollm

ent,

history

ofsymptoms(schoola

bsenteeism

data,

emergencyroom

visits,hospitalization,history

of

symptoms)wasfollowed.Students

alsoreceiveda

physicale

xaminationandpeakflowmeasurementat

enrollm

ent.Another20age-m

atchedchildrenwith

asthmawere

randomlyselected.Theydid

notparticipate

intheswim

mingprogram

(controls).

Duringthe12monthspriorto

theswim

mingprogram,parents

reportedameanof7absentschoold

aysperpatient.

Duringthe12monthsaftertheswim

mingprogram,parents

reported1.3

absentschoold

ays.This81%

decreasein

numbers

ofabsentschoold

ayswassignificantlybetter

thanthedecreaseof13%

amongcontrolg

roupasthmatic

students.Sim

ilarim

provements

occurredin

symptoms,

hospitalizations,andemergencyroom

visits.

HuiS

H,LeungTF,HaG,WongE,LiA

M,FokTF.Evaluatio

nofasthmamanagementprogram

forChinesechildren

withmild-to-m

oderate

asthmain

HongKong.Pediatr

Pulm

onol.2002;33:22-29.

(China;HongKong)

106children(ages3-9)withasthmaandtheirparents,

recruitedthroughtheiroutpatientclinics,were

enrolledin

anasthmamanagementprogram

(educatio

nonasthma

exacerbations,

useofinhalerdevices,placementon

appropriate

controllermedicatio

nswithfollow-up).Inform

a-

tiononsymptomsandqualityoflifewasgivenbyparents

before

theprogram

andagain

at6monthsand12months

aftertheprogram.

Meannumberofschoold

aysabsentperyearreducedfrom

2daysperyearatbaselineto

0daysperyear12months

later.(Article

wasnotexplicitasto

whetherabsentdays

were

specifically

forasthma.)

Kelly

CS,Shield

SW,GowenMA,JaganjacN,AndersenCL,

StropeGL.Outcomesanalysisofasummerasthma

camp.JAsthma.1998;35(2):165-171.

(USA)

40children(ages8-13)withmoderate

orsevere

asthma

were

enrolledin

anasthmacampfor1week.

Curriculum

includeddiscussionofasthmatriggers,

earlywarningsigns,medicatio

nuseandtechniques,

andpersonala

ctionplans.Parents

reported

schoold

aysmisseddueto

asthmain

theyear

before

andyearafterattendingthecamp.

Totaln

umberofdaysmissedby33of35campers

intheyear

priorto

thecampwas266.In

theyearafterthecamp,only

181daysofschoolw

ere

missedbythese

samechildren.

ER,Emergencyroom;IPA,Independentpracticeasso

ciation.


Table



(Continuedfrom

previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

LurieN,BauerEJ,BradyC.Asthmaoutcomesatan

inner-cityschool-basedhealth

center.JSchHealth

.2001;71(1):9-16.

(USA)

Aschool-widescreeningprocessataschoolw

ithaschool-

basedhealth

centeridentified34students

withseve

re,24

withmoderate,and98withmild

asthma.32seve

reand21

moderate

asthmaticsrespondedto

aninvitatio

nto

haveat

leastaninitialvisitto

thehealthcenter,where

theyreceived

ahistory,physicale

xamination,pulm

onary

functiontests,

educatio

naboutasthma,includingenvironmentalcontrol

andmedications.Students

were

givenawrittensymptom

controlp

lanandreferraltoaregularcommunity-base

dproviderwhere

these

were

lacking.

Nochangeoccurredin

schoola

bsenteeism

afterinitiatingthe

intervention.Useofpeakflowmeter,useofmedical

specialists,anduseofinhalers

alldid

improve

.

McEwenM,JohnsonP,Neatherlin

J,Millard

MW,Lawrence

G.Sch

ool-basedmanagementofchronicasthma

amonginner-city

African-Americanschoolchildrenin

Dallas,Texas.

JSchHealth.1998;68(5):196-201.

(USA)

22students

(ages5-12)withconfirmeddiagnosesofasthma

were

givenappropriate

prescriptionsofmedications,2

peakflowmeters

(forschoola

ndhome),and2spacer

devices.Theywere

broughtto

theschoolclinic2timesper

dayformedicationadministrationandpeakflowrate

measurement.

Ove

rthecourseof13weeks,meanpeakflowmeasurements

increasedandbronchodilator(rescuemedication)use

decreasedby66%.Noeffectonstudentabsenteeism

from

schoolforasthmacould

bedeterm

inedforthisstudy.

McGhanSL,WongE,Wells

HM,etal.Eva

luatio

nofan

educa

tionprogram

forelementary

schoolchildrenwith

asthma.JAsthma.2003;40(5):523-533.

(Canada)

162childrenaged7-12years;schoolsrandomlyassignedas

intervention(asthmaeduca

tion)orcontrol(regularmedical

care);missedschoold

aysoveraperiodoftheprevious1

yearwasmeasuredbyparentsurvey.

88%

ofch

ildren(‘‘asthmaeduca

tion’’group)and79%

ofch

ildren

(‘‘regularmedicalcare’’group)reportedmissingatleast1

schooldaypriorto

study.Afterthestudy,there

wasa

significa

ntreductionofmissingatleast1schooldayto

38%

and46%,resp

ectively.Im

prove

mentinattendance

between

groupswasstatistically

similar.

MengA,TiernanK,BernierMJ,Brooks

EG.Lessonsfrom

an

evaluationoftheeffective

nessofanasthmadaycamp.

MCNAm

JMatern

Child

Nurs.1998;23(6):300-306.

(USA)

34campers

withmoderate

orseve

reasthmawhoattended

adaycampwitha6-sessioninteractiveasthma-education

curriculum.Parents

completedaquestionnairepriorto

campandwere

questionedonthetelephoneabout

missedschoold

ays;childrenwere

videotapedforpeak

flowtechniqueandcompletedpre-andpostcamp

questionnaires.

Precampfrequencyofschoold

aysmissedbecause

of

asthmawas4.1

days.Postcampfrequencyofschoold

ays

missedbecauseofasthmawas3.4

days.

Millard

MW,JohnsonPT,McEwenM,etal.Arandomized

controlledtrialu

singtheschoolforanti-inflammatory

therapyin

asthma.JAsthma.2003;40(7):769-776.

(USA)

8elementary

schoolswere

randomlydividedinto

4treatm

ents

(2schoolseach).Students

(total5

2)withpersistentasthma

receivedeither(1)school-baseddelivery

ofinhaled

steroids;(2)home-baseddelivery

ofinhaledsteroids;

(3)sameas(2)plusschool-basedasthmaeducation;or

(4)controlg

roup—

nochangein

medication.

After5weeksofthese

4treatm

ents

at8schools,school

attendanceratesbeganto

differ,basedontypeof

treatm

ent.Sch

ool-basedattendancewas91%

inschools

withschool-deliveredinhaledsteroids,85%

atschools

withhome-deliveredinhaledsteroids,and77%

incontrolschools.Steroidswere

significantlybetterthanno

steroids,andschool-baseddelivery

wassignificantly

betterthanhomedelivery—forim

provingschool

attendance.

OruwariyeT,WebberMP,OzuahP.Doschoolb

asedhealth

centers

provideadequate

asthmacare?JSch

Health

.2003;73(5):186-190.

(USA)

Childrenwhovisited1of4school-basedhealth

centers

at

leastonceforasthmawere

includedin

thisstudy.415

chartswere

reviewedandsurveyswere

senthometo

parents.Studyfocusedonhealth

provideradherenceto

asthmaguidelines,butabsenteeism

data

were

also

collectedfrom

eachofthe4schools.

Absenteeism

data

were

available

for267childrenwith

asthma.Meannumberofschoold

aysmissedwas17.6.No

associationsexistedbetweenattendanceandhowwell

health

care

providers

adheredto

asthmaguidelines.

Students

underage8hadmore

schoola

bsence

s(20days)

comparedto

thoseoverage8(16days).


ciation.


Table



(Continuedfrom

previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

Perera

BJC

.Efficacyandcost

effectivenessofinhaled

steroidsin

asthmain

adevelopingcountry.

ArchDisChild.1995;72(4):312-315.

(SriLanka

)

86childrenwithmoderate

tosevere

asthmawere

recruited

throughaprivate

hospital;theyhadlostatleast

2school

dayspermonth

dueto

asthmaandwere

followedover4

years

withintroductio

nofinhaledsteroids(ages3-7

years

atonset).

Before

treatm

entwithinhaledsteroids,81patients

hadlost

schoold

ays.Aftertreatm

ent,4patients

hadlostschool

daysdueto

asthma.

PersaudDI,BarnettSE,WellerSC,Baldwin

CD,NiebuhrV,

McCorm

ickDP.Anasthmaself-managementprogram

for

children,includinginstructionin

peakflowmonitoringby

schooln

urses.JAsthma.1996;33(1):37-43.

(USA)

36childrenwithasthmawere

identifiedwithemergencyroom

andhospitalrecords(m

eanage10years).18received8

weekly,individual2

0-m

inute

teachingsessionsonasthma,

and18receivednospecializedteach

ingonasthma.

Absenteeism

from

schoolw

aselicite

dthroughaparent

questionnaire.

Resultsofgroupcompariso

nsshowednosignificant

differencesin

thenumberofpostin

terventiondaysabsent

from

school.

Salisbury

C,FrancisC,Rogers

C,etal.Arandomized

controlledtrialo

fclinicsin

secondary

schoolsfor

adolescents

withasthma.BrJGenPract.

2002;52(485):988-996.

(UK)

Sixschoolsin

Englandthatwere

representativeofthe

population’ssocioeconomicstatusandeduca

tional

achieve

mentwere

recruited.Students

were

randomizedto

seeanurseataschoolclinicorto

goto

generalp

ractice.

More

students

intheschoolclinicgroupthanthosein

the

traditionalp

racticegrouphadtheirasthmareviewed

clinically.Alth

oughknowledgeofasthmawasgreaterin

the

schoolclinicgroup,there

wasnodifferencein

school

absenteeism.

Shiffm

anRN,FreudigmanKA,BrandtCA,LiawY,Navedo

DD.Aguidelineim

plementationsystem

usinghandheld

computers

forofficemanagementofasthma:effects

on

adherenceandpatientoutcomes.Pediatrics.

2000;105:767-773.

(USA)

Ninephysicianscollecteddata

from

atotalo

f91patients

with

asthmaencounteredin

theirpractices.Duringthecontrol

phase

,data

were

collected.Duringtheinterventionphase

,pediatriciansusedahandheld

computerdeviceto

structure

theirinteractionwiththeirpatientregardingasthma.

Patients

were

contacted7-14daysafterencounteringtheir

pediatricianto

asse

ssoutcomes.

Encounters

withpediatriciansthatwere

structuredwith

ahandheld

computerdid

notchangetheoutcomeof

missedschoold

ays.Duringthecontrolp

hase

,44%

of

students

missedanaverageof1.29daysandafter

intervention,48%

ofstudents

missedanaverageof1.04

days(notsignificantly

different).

SpencerGA,AtavS,JohnstonY,HarriganJF.Managing

childhoodasthma:theeffectiveness

oftheOpenAirways

forSchoolsprogram.Fam

CommunityHealth.

2000;23(2):20-30.

(USA)

369students

(in40schools;ages6-13)receivedtheOpen

Airways

forSchoolseduca

tionprogram

forasthma

management(6

weekly40-m

inute

sessions).Partof

evaluationwasaparentquestionnaireonmissedschool

daysin

thepreviousmonthsandaschooln

urse

questionnaireonmissedschoold

ays.Question-

naireswere

completedattimeofregistrationand

6monthslater.

53%

ofparents

respondedthattheirchild

withasthmamissed

schoolb

ecauseofasthma,withnochangefrom

baselineto

6monthsafterhealtheduca

tionprogram.Schooln

urses

whoreportedameanof5.5

daysofschoolm

issedat

baselinealsoreportedasignificantreductio

nafterthe

intervention(6

monthslater)to

3.7

days.

Stergach

isA,GardnerJS,AndersonMT,SullivanSD.

Improvingpediatricasthmaoutcomesin

thecommunity

setting:doespharm

aceutica

lcare

makeadifference?

JAm

Pharm

Assoc.

2002;42(5):743-752.

(USA)

330childrenwithasthma(ages6-17)were

identifie

dfrom

32

pharm

acies.Eligible

childrenhadaprescribedasthma

medicationforatleast

3monthsandhadrefilledtheir

medicationnolessthanonceevery

6weeks,andcould

useapeakflowmeter.Pharm

acists

from

14pharm

acies

were

trainedto

work

withpatients

onasthmadrug-related

problems.18pharm

acieswere

control(usualcare).

Pharm

acists’interventio

noccu

rredforaperiodof

1year.

Questionnaires(parents

forchildrenyoungerthan12)

includedschoold

ayslostdueto

asthma.Themeannum-

beroflostdayswas1.1

fortheinterventiongroupand1.7

daysforthecontrolg

roup.Statistically,thiswasnot

significantlydifferent.


ciation.


Table



(Continuedfrom

previouspage)

Citation(O

rigin

ofPrimary

Author)

ResearchDesign


Absenteeism

TarasH,WrightS,BrennanJ,CampanaJ,LofgrenR.Im

pact

ofschooln

ursecasemanagementonstudents

with

asthma.JSchHealth

.2004;74(6):215-221.

(USA)

Inaschooldistrictw

ith143,000students(K-12)a

ndforp

eriodof3

years,schoolnursesreco

rdedtheirasthma-relatedinvo

lve-

mentwith

students

whohadphysician-diagnose

dasthma.

Invo

lvementmayhave

includedahomevisit,co

ntactwith

parent,educa

tionofstudent,co

ntact

with

doctor,orno

invo

lvement.Nursesalsoreco

rdedwhetherstudenthad

medicatio

nandpeakflo

wmeters

atschool.Abse

nteeism

ratesforstudentswith

andwith

outasthma(base

don

days

misse

dforanyillness)were

measu

redannually

usingschoolreco

rds.

Between5%

and6%

ofallstudents

hadphysician-diagnose

dasthma.Students

withasthmawere

absent

between½

and1¼

daysperyearmore

oftenthanthose

withoutasthma.Sch

ooln

ursecasemanagement

hadnosignificanteffectonratesofstudentabsenteeism.

There

wasevidencethatschooln

urseinterventio

ns

improvedmedicalm

anagement.

WebberMP,Carpiniello

KE,OruwariyeT,LoY,BurtonWB,

AppelD

K.Burdenofasthmain

inner-cityelementary

schoolchildren:doschool-basedhealthcenters

make

adif-

ference?ArchPediatrAdolescMed.2003;157(2):125-130.

(USA)

Parents

ofstudents

(gradesK-5)in

6schoolswere

inter-

viewed.Fouroftheschoolshadschool-basedhealth

centers.Asthmawasdeterm

inedthroughsymptom

ques-

tionnaires.4775familiesreturnedquestionnaires.Absen-

teeism

data

from

schoolrecordswere

available

forover

60%

ofstudents.

20%

ofstudentshadasthma,accordingtothequestionnaire(19%

atsch

oolswith

ahealth

center,22%

atsch

oolswithout).S

tu-

dentsinschoolswithouta

health

centermisse

d16.4days

per

year,asco

mparedto14.5days

peryearforstudentsinschools

with

ahealth

center.Amongstudentswith

asthma,those

attendingschoolswithouthealth

centersmisse

d21.3days

versus18.2days

forthose

attendingschoolswith

health

centers.

Zorc

JJ,Sca

rfoneRJ,LiY

,etal.Scheduledfollow-upafter

apediatricemergencydepartmentvisitforasthma:aran-

domizedtrial.Pediatrics.2003;111(3):495-502.

(USA)

Todeterm

ineifthere

waspatientcompliancewithemergency

departmentinstructionsto

followupwithaprimary

care

providerandifthisaffectedasthmaoutcomes,parents

of

278children(ages2-18)were

instructedto

followupwith

theirdoctors.In

thecontrolg

roupthatisallthatoccurred.

Intheinterventiongroup,ERstaffassistedwithmakingthe

appointm

ents

duringtheERvisit.Telephoneinterviewof

parents

occurred1month

later.

Alth

oughinterventionin

theemergencydepartmentincreased

follow-upvisits

withprimary

care

providers,nochangein

missedschoold

aysbetweencontrola

ndintervention

groupsensued.Twodaysofschoold

uringmonth

afterER

visitwere

missed,onaverage.


ciation.


primary care providers (Oruwariye et al 2003; Shiffman et al2000; Table 3) have not yet been shown to improve atten-dance at school. One study that randomly assigned studentswith asthma to a swimming program showed astonishingimprovement in school attendance (Huang et al 1989;Table 3). Unfortunately, this was a small sample size (20 ineach group) and further studies have not ensued. Furtherinvestigation is worthwhile, not only because of the markedbenefit shown, but because it confirms an earlier finding thatphysical exercise improves school attendance7 of childrenwith asthma and supports the theory that swimming is lesslikely to bring on asthma symptoms than other exercises.8

CONCLUSIONThe review of articles examining the impact of asthma

on school performance found no clear evidence that thepresence of asthma affected academic achievement orability. Two isolated exceptions were studies that foundkindergarten students with asthma had poorer school read-iness scores and that asthma-related interruptions in sleepamong children with asthma, rather than the severity ofthe condition, may affect school performance.

Research does show a correlation between asthma andhigh rates of student absenteeism.

Inconsistencies in definitions of asthma and collection ofabsenteeism rates and lack of control groups limit the validityof the magnitude of missed school days in this population.Although studies have looked at the impact of race, socioeco-

nomic factors, severity of the disease, access to health care,and adherence to prescribed medical regimens on schoolattendance rates, further studies on these and other issues arerequired. The impact of various interventions for school-agedchildren with asthma on school attendance is often studiedwith flaws in the experimental designs that throw questioninto the reliability of the findings. n

References1. Celano MP, Geller RJ. Learning, school performance, and children

with asthma: how much at risk? J Learn Disabil. 1993;26(1):23-32.

2. Rodehorst TK. Rural elementary school teachers’ intent to managechildren with asthma symptoms. Pediatr Nurs. 2003;29(3):184-192.

3. Neuharth-Pritchett S, Getch YQ. Asthma and the school teacher:the status of teacher preparedness and training. J Sch Nurs. 2001;17(6):323-328.

4. Evans D, Clark NM, Feldman CH, et al. School health educationprograms for children with asthma aged 8-11 years. Health Educ Q. 1987;14(3):267-279.

5. Bruzzese JM, Markman LB, Appel D, Webber M. An evaluation ofOpen Airways for Schools: using college students as instructors. J Asthma.2001;38(4):337-342.

6. Gregory EK. Empowering students on medication for asthma to beactive participants in their care: an exploratory study. J Sch Nurs. 2000;16(1):20-27.

7. Szentagothai K, Gyene I, Szocska M, Osvath P. Physical exerciseprogram for children with bronchial asthma. Pediatr Pulmonol. 1987;3(3):166-172.

8. Weisgerber MC, Guill M, Weisgerber JM, Butler H. Benefits ofswimming in asthma: effect of a session of swimming lessons on symptomsand PFTs with review of the literature. J Asthma. 2003;40(5):453-464.\


childhood asthma and student performance at school

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