chronic health conditions and student performance at school

Chronic Health Conditions and Student Performance at SchoolHoward Taras, William Potts-Datema

ABSTRACT: To review the state of research on the association between common chronic health conditions and academic outcomes,the authors reviewed published studies investigating the association of school attendance, cognitive ability, and achievement witha number of chronic diseases. Tables with brief descriptions of each study’s research methods and outcomes are included.Research reveals evidence that diabetes, sickle cell anemia, and epilepsy affect student achievement and ability. Levels of academicdeficiency and specific areas of cognitive impairment are not as well understood. Many chronic conditions are not well researched.Suggestions for further research and recommendations for educators and health practitioners are provided. (J Sch Health.2005;75(7):255-266)

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

demic potential. That generalization is not often accompa-nied by a discussion of specific health conditions or factorsand more rarely accompanied by evidence. Moreover, thecharacteristics of impaired performance or ability second-ary to poor health are commonly not understood.

To clarify and quantify the relationship between healthand child performance and ability at school, the NationalCoordinating Committee on School Health and Safety,comprising representatives of federal departments andnational nongovernmental organizations, reviewed thestate of this research. The project involves conducting lit-erature searches of peer-reviewed, published research re-porting on the relationship between students’ health andtheir performance in school.

This article summarizes what is known through pub-lished research about the association of academic out-comes with diabetes, sickle cell anemia, seizure disorders,and other chronic diseases. Connections between schoolperformance and student asthma and student obesity, the2 most common chronic conditions affecting school-agedchildren, are summarized in separate articles.

The criteria for an article to be selected for reviewwere as follows: (1) subjects of study were school-agedchildren (age 5-18 years) and (2) the research included atleast 1 of the following outcomes—school attendance,academic achievement, a measure of cognitive ability(such as general intelligence, memory), and attention.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 in this review reported major outcome measuresother than those pertinent to the objectives of this project.These alternative outcomes may not be described or areonly briefly mentioned.

A recent survey of teachers and other school professio-nals in 23 elementary schools elicited their attitudes toward

and knowledge of students in their classes with 6 chronicconditions: AIDS, asthma, congenital heart disease, diabe-tes mellitus, epilepsy, and leukemia.1 There was a positiveperception of children with chronic conditions in the class-room. Two thirds of respondents expected students withAIDS to have academic difficulties affecting achievement.Academic difficulties were expected among 51% of re-spondents for students with leukemia, 41% of respondentsfor students with epilepsy, 34% for those with congenitalheart disease, and 17% and 14% for those with diabetesand asthma, respectively. Reservations teachers had aboutthese students were not based on their academic difficultiesbut on the teachers’ perception that they themselves lackboth the time and medical expertise to adequately care forthese students with chronic conditions at school. One fourthof educators felt that children with congenital heart diseasemight die in the classroom. School staff are eager to learnmore about chronic diseases, and most respondents inthis survey requested additional information on theseconditions.

DIABETESPeople with diabetes have a shortage of insulin or

a decreased ability to use insulin, a hormone that allowsglucose (sugar) to enter cells and be converted to energy.There are 2 main types of diabetes. Type 1 most often ap-pears during childhood or adolescence. Type 2 diabetes,which is linked to obesity and physical inactivity, ac-counts for 90% to 95% of diabetes cases and most oftenappears among people older than 40 years. With the onsetof the obesity epidemic, however, type 2 is being diag-nosed in higher numbers of children and teenagers. Inaddition to the recent and publicized increase in type 2diabetes among youth, the incidence of childhood type 1diabetes also has increased, although the origins of thisincrease are poorly understood. In the past century inEurope and North America, more than a 350-fold increasehas occurred in incidence rate of type 1 diabetes.2

Fifteen published articles (all published since 1994)were found and reviewed, each describing associationsbetween childhood diabetes (type 1, primarily) and stu-dent attendance, cognitive ability, or academic achieve-ment (Table 1). Most, but not all articles, demonstrate anassociation between poor cognitive functioning and earlyonset of diabetes (younger than 5 years) and/or a history ofsevere hypoglycemic episodes (ie, dangerously low bloodsugar levels, sometimes resulting in a seizure). The specificnature of the psychoeducational deficit varies from study to

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, HarvardSchool of Public Health, 677 Huntington Ave, 7th Floor, Boston, MA 02115.This article is 1 of 6 articles that are part of a project of the National Coor-dinating Committee on School Health and Safety (NCCSHS). This NCCSHSproject was funded by the US Department of Health and Human Services,Department of Education, and US Department of Agriculture. Opinions ex-pressed in this article are not necessarily shared by these federal agenciesor other institutions that comprise NCCSHS membership.

Journal ofSchool Health d September 2005, Vol. 75, No.7 d 255

Table1

PublishedResearchArticlesThatAddressDiabetesandSchoolPerform

anceand/or

CognitiveAbilityin

School-AgedChildren(Continuedonnextpage)

Reference(O

rigin)

ExperimentalDesign

Outcome

FoxMA,ChenRS,Holm

esCS.Genderdifferencesin

memory

andlearningin

childrenwithinsulin-dependent

diabetesmellitus(IDDM)overa4-yearfollow-up

interval.JPediatrPsychol.2003;28(8):569-578.

(UnitedStates)

Childrenbetweenages7and16years,whohaddiabetes

foratleast6months,were

recruitedfrom

hospital

endocrinologyclinics.143childrenwere

giventheRey

Auditory

VerbalL

earningTestduringaninitial

assessmentandthenagain

4years

later.Initially,after

achild

withdiabeteswasenrolledin

thestudy,acontrol

child

withnochronichealthconditionswasrecruited

from

therosters

ofparticipatingschools(samegrade,

gender,race,andsocioeconomicstatus).Glycosylated

hemoglobin

(HbA1)levelswere

drawn,andparents

were

askedto

recallthenumberofhypoglycemic

episodes.

Unlikeothergroups,boyswithdiabetesdid

notmake

expecteddevelopmentalg

ainsonauditory

verbal

learningtests.Boyswithdiabetesshowedaplateauin

wordslearned.Girlswithdiabetesdid

notplateaubut

losttheirrelativegenderadvantageforverbal

inform

ationthatgirlswithoutdiabeteshad.Longer

diseasedurationpredictedpoorerlearningovertime.

HbA1levelsornumberofhypoglycemicepisodeswere

notsignificantlyassociatedwithverballearning.

HagenJW,BarclayCR,AndersonBJ,etal.Intellective

functioningandstrategyusein

childrenwith

insulin-dependentdiabetesmellitus.Child

Dev.1990;

61:1714-1727.

(UnitedStates)

30childrenwithdiabetesandage-m

atched30

nondiabeticchildren(age8-16)were

assessedfor

intelligence(W

ISC-R

),academicachievement

(2subtests

from

thePeabodyIndividualA

chievement

Test),inform

ationprocessing,andself-competence.

Childrenwithdiabeteshadmeanintelligencescoresof

104,ascomparedto

113forcontrolg

roupchildren.

Childrenwithdiabetesscoredloweronsubscale

perform

anceandwere

more

likelyto

requireremedial

educationservices.There

wasevidencethatthese

childrenwere

deficientin

theiruseofstrategiesto

organizeandrecallinform

ation—

particularlyforthose

withonsetofdiabetespriorto

age5.

HannonenR,Tupola

S,AhonenT,RiikonenR.

Neurocognitivefunctioningin

childrenwithtype-1

diabeteswithandwithoutepisodesofsevere

hypoglycemia.DevMedChild

Neurol.2003;

45:262-268.

(Finland)

Childrenwithmeanageof8withdiabetesandahistory

of

severe

hypoglycemia

(11children),withdiabetesbut

nohistory

ofsevere

hypoglycemia

(10children),and

healthycontrols(10children)were

studiedwiththe

followingtests:WISC-R

(intelligencetest)andNEPSY

(adevelopmentaln

europsychologicala

ssessmentof

language,executivefunctions,visuospatialp

rocessing,

learning,memory).

Childrenwithahistory

ofsevere

hypoglycemia

hadmore

neuropsychologicalimpairments,more

learning

difficulties(parentreport),andneededmore

part-tim

e

speciale

ducationthanthosein

othergroups.

Significantdifferenceswere

foundin

verbalshort-term

memory

andphonologicalp

rocessing.

HersheyT,Lillie

R,SadlerM,WhiteNH.Theeffectof

severe

hypoglycemia

oncognitionin

childrenand

adolescents

withtype1diabetesmellitus.Diabetes

Care.1999;22(8):1318-1324.

(UnitedStates)

25children(age9-16)withtype1diabeteswere

randomly

assignedto

eitherintensiveorconventionald

iabetes

therapy(N

ote:intensivetherapyincreasestheriskof

hypoglycemicepisodes).16nondiabeticchildrenwere

alsostudied.Allchildrenreceivedmemory

tests

(WISC-IIIvocabulary

andblockdesigntests).

Diabetic

childrenwhorece

ivedintensive

therapyhada3-fold

higherrate

ofse

vere

hyp

oglyce

miaandperform

edless

accuratelyonasp

atialdeclarativememory

task

andmore

slowly(butwith

equalaccuracy)onapattern

reco

gnition

task,co

mparedto

childrenonco

nve

ntionaltherapyand

controlsubjects.Allch

ildrenwith

diabeteswere

significa

ntly

impairedonamotorsp

eedtask

asco

mpared

tonondiabetic

peers.

256 d Journal of School Health d September 2005, Vol. 75, No.7

Table

1PublishedResearchArticlesThatAddressDiabetesandSchoolPerform

anceand/or

CognitiveAbilityin

School-AgedChildren

(Continuedfrom

previouspage)

Reference(O

rigin)

ExperimentalDesign

Outcome

Holm

esC,DunlapWP,ChenRS,CornwellJM.Gender

differencesin

thelearningstatusofdiabeticchildren.

JConsultClin

Psychol.1992;60(5):698-704.

(UnitedStates)

95children(age8-16)withdiabetesand97

grade-m

atchedcontrolswere

evaluatedwith

theWISC-R

intelligencemeasure.

DiabeticboyshadsignificantlylowerFreedom

From

Distractibility

scoresthandiabeticgirlsandcontrols.

40%

ofboys(vs16%

ofgirls)hadlearningproblems

thatwarrantedspecialinstructionorgraderetention.

Diabeticchildrenexperiencedmore

learningdifficulties

thancontrols(24%

vs13%).

McCarthyAM,LindgrenS,MengelingMA,TsalikianE,

EngvallJC.Effects

ofdiabetesonlearningin

children.

Pediatrics.2002;109(1):e9.

(UnitedStates)

244children(m

eanage14.8

years)were

matchedwith

110siblingcontrolsandwith209anonymously

matchedclassmate

controls.Academicachievement

measuredusingstandardizedtests

(IowaTestofBasic

Skills),classroom

data

onperform

ance,Pediatric

BehaviorProblem

Scale,measuresofmetabolic

controlo

fdiabetes(H

bA1c),diseaseduration.

Childrenwithdiabeteshavenosignificantlylower

academicperform

ancescoresthancontrolsiblingsor

classmate

controlsandactually

hadhigherreading

scores.Childrenwithdiabeteshadsignificantlymore

absencesthantheirsiblings(andbehavioralp

roblems).

McCarthyAM,LindgrenS,MengelingMA,TsalikianE,

EngvallJ.Factors

associatedwithacademic

achievementin

childrenwithtype1diabetes.Diabetes

Care.2003;26(1):112-117.

(UnitedStates)

244children(age8-18)withtype1diabeteswere

recruitedfrom

clinics.Parents

gaveschoold

ata

for

currentacademicyear(IowaTestofBasicSkillsfor

math,reading,andlanguagetransform

edto

standard

scores),anddiabetesdata

were

takenfrom

clinic

medicalrecords.PediatricBehaviorScale

wasgiven

alongwith20diabetes-specificquestions.Three

groupswere

defined:gooddiabetescontrol,average,

andpoor—

basedonHbA1Cvalues.

Readingscores(butnotmath

scores)andGPAwere

significantlylowerforthosewithpoormetabolic

control

(106Reading,GPA2.8)thanforthosewithaverage

control(110Reading,GPA3.1).Childrenwith

hospitalizationsfordiabeteshadloweroverall

achievementscoresthanthosewithbettercontrola

nd

nohospitalizations.Frequentschoola

bsencewasnot

associatedwithacademicscores.Behaviorproblems

ratedbyparents

were

significantlyassociatedwith

academicachievement.Highesthealthpredictors

ofacademicachievementwere

numberof

diabetes-relatedhospitalizationsandHbA1c

(measure

ofmetabolic

control).

Northam

EA,AndersonPJ,JacobsR,etal.

Neuropsychologicalp

rofilesofchildrenwithtype1

diabetes6years

afterdiseaseonset.DiabetesCare.

2001;24(9):1541-1546.

(Australia)

90childrenwithdiabetes(age6-17)hadbeenassessed

attimeofdiagnosis,2years

later,andnow6years

afterdiseaseonset.84nondiabeticchildrenofthe

sameagewere

alsoassessedascontrols.Assessment

includedtheWISC-III,tests

ofattentionandprocessing

speed,theReyAuditory

VerbalL

earningTest,

ControlledOralW

ord

AssociationTest,andothers.

After6years,verbalIQ

wassignificantlyloweramong

childrenwithdiabetes(97vs103)andespecially

those

withonsetpriorto

age4years.Childrenwithdiabetes

alsoscoredmore

poorlyonmeasuresofattention,

processingspeed,andexecutiveskills.

Northam

EA,AndersonPJ,WertherGA,etal.Predictors

ofchangein

theneuropsychologicalp

rofilesofchildren

withtype1diabetes2years

afterdiseaseonset.

DiabetesCare.1999;22(9):1438-1444.

(Australia)

113childrenwithdiabetes(age3-14)were

assessed

soonafterdiagnosisand2years

later.WISC-R

measure

ofintelligencewasusedforschool-aged

subjects.Othermeasurements

includedtheRey

Auditory

VerbalL

earningTest,ControlledOralW

ord

AssociationTest,andothers.

Ageononsetofdiabetespredictedpoorerperform

ance

onintelligencetests

2years

later.Recurrentand

severe

hypoglycemia

andchronichyperglycemia

were

associatedwithmemory

andlearningcapacitydeficits.


Table


anceand/or

CognitiveAbilityin

School-AgedChildren

(Continuedfrom

previouspage)

Reference(O

rigin)

ExperimentalDesign

Outcome

RovetJF,EhrlichRM.Theeffectofhypoglycemic

seizuresoncognitivefunctionin

childrenwithdiabetes:

a7-yearprospectivestudy.JPediatr.1999;134:

503-506.

(Canada)

16childrenwhowere

enrolledin

2separate

studieswere

measuredattimeofdiagnosisofdiabetesandfollowed

forrepeatmeasurementat1,3,and7years

beyond

diagnosis.Eachsubjectwasmatchedwithacontrol

subject(nodiabetes)forage,sex,andsocioeconomic

status.9ofthediabeticchildrenhadexperiencedat

least1hypoglycemicseizure

(atmeanageof6.6).

Childrenwithdiabetesdemonstratedsignificantdeclines

inverbalIQ

(butnotvisuospatiala

bilities)ascompared

tocontrols.Thiswasmostpronouncedamongthose

whohadahypoglycemicseizure.Thosewith

ahypoglycemicseizure

alsohaddeficitsonperceptual

motor,memory,andattentiontasks7years

after

diagnosis.

RovetJ,AlvarezM.Attentionalfunctioning

inchildrenandadolescents

withIDDM.

DiabetesCare.1997;20(5):803-810.

(Canada)

103childrenandadolescents

withdiabetesand100

healthycontrolswere

testedforintelligence(W

ISC-R

)andattention(a

numberofmeasuresincluding

ModifiedMatchingFamiliarFigures,VisualS

earch

Test,ContinuousPerform

anceTest,andothers).

Onintelligencetests,childrenwithdiabetesdifferedfrom

controlsonlyonthevocabulary

subtest.Onthe

attentiontests,theresultsofonly1test(thatsuggested

poorerability

toselectinform

ation)differedfrom

controls.Thosewithdiabeteswhohadalsosuffered

ahypoglycemicseizure

hadlowerverbalIQ

and

greaterdifficultywithselect,focus,andinhibit

attentionalcomponents.Childrenwithdiabeteswho

alsohadhighbloodglucoselevelswere

lessable

than

others

toinhibitim

pulseresponses.

RovetJF,EhrlichRM,Czuchta

D.Intellectual

characteristicsofdiabeticchildrenatdiagnosisandone

yearlater.JPediatrPsychol.1990;15:775-788.

(Canada)

63children(m

eanage7.3

years)withnewlydiagnosed

diabeteswere

examinedforneurocognitivefunctionsat

onsetofillnessand1yearpostdiagnosis.Numerous

tests

ofgeneralintelligence,visuospatiala

bilities,

language,memory,andachievementwere

perform

ed

(eg,WISC-R

,WRAT).Siblingsservedascontrols.

History

ofhypoglycemicevents

wasrecorded.

Nodifferencesbetweenthosewithdiabetesandtheir

siblingswere

detectedafter1yearofillness.Children

diagnosedwithdiabetesearlierthanage5scored

lowerin

spatiala

bility

attimeofdiagnosisand

1yearlater.

RovetJF,EhrlichRM,HoppeM.Specificintellectual

deficitsin

childrenwithearlyonsetdiabetesmellitus.

Child

Dev.1988;59(4):226-234.

(Canada)

27childrenwithearlyonsetdiabetes(underage4),24

withlate

onset(overage4),and30siblingcontrols

were

comparedin

intelligence(components

ofthe

WISC-R

and4othertests)andacademicachievement

(WRAT,parentalinterview).Parents

were

alsotested

forintelligence.

Children(especially

girls)withearlyonsetdiabetes

scoredlowerthanothergroupsonmeasuresof

visuospatialb

utnotverbalintelligence.

Schoenle

EJ,Schoenle

D,MolinariL,LargoRH.Im

paired

intellectuald

evelopmentin

childrenwithType1

diabetes:associationwithHbA1c,ageatdiagnosisand

sex.Diabetologia.2002;45(1):108-114.

(Switzerland)

64childrenwithdiabetes(age7-16)were

assessedat

least4timesusingtheGerm

anversionoftheWISC-R

.

Acontrolg

roupwasmeasuredaswell.

Asignificantdeclinein

perform

ancebyage7andin

verbalintelligencebetweenages7and16years

was

observedin

boyswithdiabetesdiagnosedbyage6,but

notthosediagnosedatanolderageorin

girls.

Intellectuald

eteriorationwasnotassociatedwith

severe

hypoglycemicepisodesbutwascorrelatedwith

thedegreeofmetabolic

deteriorationattimeof

diagnosisandwithhighlevelsofHbA1clevels(a

blood

testindicativeofhighbloodsugarlevels).


study and depends on the measures the researchers used aswell as on differences between populations observed in thevarious studies. Verbal IQ, visuospatial/nonverbal function-ing, memory, and attention have all shown to be affected.Research since 1994 confirms many of the same findings.3

Despite differing research methods, there appears to be anemerging consensus from the data, which is that childrenwith diabetes are more likely to be at an academic disad-vantage. The existence and magnitude of this disadvantageis related to (1) early onset diabetes and (2) severe fluctua-tions in metabolic control, especially if the child experi-enced seizures, unconsciousness, or ketoacidosis as resultof the poor control. Boys appear to be at a relatively greaterrisk for learning problems than girls.

Of these 2 risk factors, only the second factor (preven-tion of wide fluctuations in glucose control) can be influ-enced by school policies and practices. In the past 5-10years, more children with diabetes have access to newtechnologies designed to keep them free from severe fluc-tuations. Most notable among these technologies is theinsulin pump, a computerized device that delivers insulinto the body through a flexible tube attached to a needleinserted under the skin. The relevance of good glucosecontrol to long-term and short-term health as well as toacademic functioning should serve to make the supportof using these technologies in school more compellingfor educational reasons. Theoretically, the associationbetween better control and academic functioning can bean incentive to public and private educational systemsand their professionals and staff to provide assistance andsupport to students with diabetes who require help withpump therapy,4 close observation for signs of hypoglyce-mia, and rapid responses by staff members trained torespond to severe hypoglycemic episodes.

SICKLE CELL ANEMIASickle cell anemia is an inherited blood disorder charac-

terized primarily by chronic anemia and periodic episodesof pain. The underlying problem is with oxygen-carryinghemoglobin, a component of red blood cells. In sickle cellanemia, the hemoglobin is defective, causing red bloodcells to become stiff and assume a sickle shape. In theUnited States, sickle cell anemia affects approximately72,000 people, predominately African Americans. Thedisease occurs in about 1 in every 500 African Americanbirths and 1 in every 1000 to 1400 Hispanic Americanbirths.5

Sickle-shaped red blood cells often block the flow ofblood in narrow blood vessels. This causes fever as wellas pain and swelling, particularly in the hands, feet,joints, and various organs. Pain may last for hours toweeks. In addition to pain, those with sickle cell diseaseare also prone to have anemia, retinal problems, and de-layed growth and puberty. These complications couldconceivably affect attendance or performance at school.One of the biggest threats to cognitive functioning fromsickle cell disease is a narrowing of small blood vesselsin the brain that results in strokes (also known as infarctsor cerebral vascular accidents). Some strokes are so minorthat they go undetected (silent infarcts), while majorstrokes are obvious and result in permanent debilitationand even threaten life.

Table


anceand/or

CognitiveAbilityin

School-AgedChildren

(Continuedfrom

previouspage)

Reference(O

rigin)

ExperimentalDesign

Outcome

Wolters

CA,YuSL,HagenJW,KailR.Short-term

memory

andstrategyusein

childrenwithinsulin-

dependentdiabetesmellitus.JConsultClin

Psychol.

64(6):1397-1405.

(UnitedStates)

Children(age9-16)withonsetofdiabetesbefore

age5

(29),afterage5(32),andthosewithoutdiabetes(36)

were

administeredameasure

ofshort-term

memory.

Vocabulary

andblockdesignsubtests

ofWISC-IIIwere

administeredaswasthePauseTim

eMemory

Task.

Parents

andchildrenwere

interviewed.

Childrendiagnosedwithdiabetespriorto

age5used

sim

ilarstrategiesbuthadpoorerrecallthanthosewith

lateronsetofdiabetesorcontrolchildren.Childrenwith

poorcontrolo

ftheirdiabetesdid

notusestrategies

designedto

increaserecallasoftenoraswellasthose

inbettercontrol.

GPA,GradePointAverage;NEPSY,DevelopmentalN

europsychologicalA

ssessment;WISC-III,WechslerIntelligenceScale

forChildren—

ThirdEdition;

WISC-R

,WechslerIntelligenceScale

forChildren—

Revised;WRAT,WideRangeAchievementTest.


In 2002, Schatz coauthored a meta-analysis on 18 pub-lished articles that addressed cognitive functioning inchildren with sickle cell anemia.6 For each study, method-ological factors were evaluated according to the size andfrequency of group differences. The conclusion of thisanalysis is that there are small but reliable decrements incognitive functioning as measured by components of IQtests for children with sickle cell anemia, as compared tomatched controls. There is an approximate 4-point differ-ence in overall IQ. Additional studies, many with rigorousmethods, confirm this pattern. Measures of specific cogni-tive abilities appear to be more sensitive than a general IQscore. Reviews by Kral et al7 and White and DeBaun8

found that the most significant neurocognitive impairmentsare in language and verbal abilities, visual motor and visualspatial processing, processing of subtle prosodic informa-tion, attention, and memory. Middle childhood appears tobe a critical period as this is the time in a child’s life whenthese cognitive deficits become measurable.

Table 2 contains a summary of published studies notincluded in Schatz’s meta-analysis. Many of these articlesverify that deleterious problems with children’s concentra-tion and attention are likely the first indications that sicklecell disease, possibly through silent infarcts, is interferingwith school functioning. Table 2 also contains studies dem-onstrating loss of school days, particularly for those whohave frequent painful crises.

Implications for schools are that special attention needsto be paid to students with this diagnosis, particularly forthose having any academic difficulties, but also for anystudent with this disease as middle childhood approaches.Any student with sickle cell anemia with acute chest pain,severe anemia, or a diagnosis of elevated blood pressureis at risk for strokes. Children who have had 1 stroke areat significant risk for having subsequent events. Familiesshould be encouraged to keep appointments and remainvigilant with medical management, such as blood trans-fusions (designed to lower levels of sickle cell hemoglo-bin and reducing risks of further infarction, albeit with itsown medical complications).9

EPILEPSYThe Epilepsy Foundation reports that annually 45,000

children under age 15 develop epilepsy (also known asa chronic seizure disorder) and that 315,000 school chil-dren through age 14 have epilepsy. The difficulties withdescribing the direct effect of this chronic condition onschool performance are that (1) this condition is highlylinked to other conditions that affect school functioning(eg, seizures occur in 10% of children with mental retar-dation, 10% of those with cerebral palsy, as well as inlarge proportions of children with head injuries and withvarious underlying genetic disorders); (2) there are manyforms of epilepsy, each with its own risks to cognitivefunctioning; and (3) when measuring academic function-ing, it is difficult to differentiate the effects of a seizuredisorder from the effects of medications used to manageseizures.

Table 3 lists a series of studies that have looked at epi-lepsy very generally in relation to academic performance.A number of the methodological designs controlled for fac-tors like mental retardation and distinguished between dif-

ferent forms of epilepsy in their analyses. All found lowerintelligence and/or academic achievement levels amongchildren with epilepsy when compared to healthy controlsor, in 1 article, to children with another chronic condition(asthma). Children with classic absence seizures werefound to have normal intelligence. Among those with anyform of epilepsy, students’ levels of attention were found tohave the strongest association with academic achievement.

OTHER CHRONIC DISEASESThe association of school performance with chronic

diseases other than diabetes, sickle cell disease, and epi-lepsy is not so well studied (with the exception of asthmawhich is reported elsewhere). It is known that childrenwith cancer are less likely to attend school regularly overlong periods of time than children with other chronic con-ditions or healthy children.10,11 Some show poor schoolperformance as a result.12 Children with congenital heartconditions have such varying degrees of debilitation that itis hardly surprising that generalizations cannot be made foracademic consequences. Those with cardiac deficits relatedto velocardiofacial syndrome demonstrated no difference inacademic performance or intelligence,13 whereas those witha history of a heart/lung transplant demonstrated compara-ble cognitive ability but lower levels of achievement.14 Bothcognitive ability and achievement are decreased amongchildren who have survived hypoplastic left heart syndromeor have had surgery for other cyanotic heart diseases.15,16

Children with hemophilia have been shown in 3 separatestudies to have higher rates of absenteeism than healthychildren, with days absent related to the number of bleed-ing episodes they experience.17-19 These articles also dem-onstrate that lower achievement in reading and/or mathmay be associated with a diagnosis of hemophilia if thereare also frequent episodes of bleeding. Human immunode-ficiency virus infection itself does not seem to affect cogni-tive ability (until the disease has progressed extensively,especially with brain involvement).17,20,21 Phenylketonuriais a disease that is now typically identified soon after birththrough public health mandated screens. Special, restricteddiets are necessary to prevent children during years of rapidgrowth and development from becoming mentally retarded.Nevertheless, children and adolescents treated soon afterbirth still demonstrate mild deficits in both intelligence andachievement during their school-age years.22,23

The effects of pain on school attendance and achieve-ment have yet to be extensively studied. One third of 706Hispanic females in the United States reported that recur-rent menstrual pain caused them to miss full or partialdays of school and to have poorer grades.24 This is a highercost to academic performance than is reported by girls inAustralia, where 7% to 14% of girls were found to havemenstrual cycle-associated mood changes associated withpoor academic grades.25 The authors of this latter studynoted that cultural perceptions of menstrual periods andpain may influence attendance and even cognition. This issupported by yet another study in Malaysia. In that culture,boys and girls with recurrent, severe abdominal pain haveno detectable deficits in academic performance.26

Chronic infection with intestinal parasites, a phenome-non studied almost exclusively in developing countries,has been shown to affect children’s academic achievement,


Table2

PublishedResearchArticlesThatAddressSickle

CellAnemia

andSchoolPerform

anceand/orCognitive

Abilityin


Reference(O

rigin)

ExperimentalDesign

Outcome

Arm

strongFD,ThompsonRJJr,WangW,etal.

Cognitivefunctioningandbrain

magneticresonance

imagingin

childrenwithsickle

celldisease.

Pediatrics.1996;97:864-870.

(UnitedStates)

135childrenwithsickle

celldiseasewere

evaluated

withbrain

magneticresonanceim

aging(M

RI)and

neuropsychologicale

valuation.MRIs

were

categorizedaccordingto

imagessuggestiveof

infarctandthenfurthercategorizedonthebasisof

aclinicalh

istory

ofcerebrovascularaccident(C

VA;

stroke).Anabnorm

alM

RIbutnoclinicalh

istory

of

CVAwasclassifiedasa‘‘silentinfarct.’’

Assessments

ofglobalintellectualfunctioningand

specificacademicandneuropsychologicalfunctions

were

perform

ed.

22%

ofchildrenwithsickle

celldiseasehad

abnorm

alitiesidentifiedonMRI.Clinicalh

istory

of

CVAwasidentifiedin

only5%.Childrenwith

ahistory

ofCVAperform

edsignificantlypoorerthan

childrenwithsilentinfarcts

ornoMRIabnorm

alityon

mostneuropsychologicale

valuationmeasures.

Childrenwithsilentinfarcts

onMRIperform

ed

significantlypoorerthanchildrenwithnoMRI

abnorm

alityontests

ofarithmetic,vocabulary,and

visualm

otorspeedandcoordination.

BrownRT,DavisPC,LambertR,HsuL,HopkinsK,

EckmanJ.Neurocognitivefunctioningandmagnetic

resonanceim

agingin

childrenwithsickle

cell

disease.JPediatrPsychol.2000;25:503-513.

(UnitedStates)


celldiseasewhowere

referred

toacenterto

investigate

cognitive,academic,and

emotionalfunctioningwere

givenaneuroco

gnitive

battery

(WISCforintelligence,Woodcock-Johnson

totestachievement,andothers)andanMRI.

Childrenwithovertcerebralvascularaccidents

(strokes)onMRIaswellasthosewithsilentinfarcts

(noclinicalm

anifestations,butanabnorm

alM

RI)

differedfrom

theirpeers

onmeasuresofattention

andexecutivefunctioning.

EatonML,HayeJS,Arm

strongFD,PegelowCH,

ThomasM.Hospitalizationsforpainfule

pisodes:

associationwithschoola

bsenteeism

andacademic

perform

ancein

childrenandadolescents

withsickle

cellanemia.IssuesComprPediatrNurs.1995;

18:1-9.

(UnitedStates)

21children(age8-18)withsickle

cellanemia

withhigh

frequencyofpainfule

pisodesand11children(same

ageanddisease)withlowfrequencyofpainful

episodeswere

comparedforacademicachievement

(WRAT-R

)andschoolrecords.Highfrequencywas

definedasmore

than4hospitalizationsforpain.

Lowfrequencywasdefinedaszero

or1

hospitalizationforpain

inthestudyperiod.These2

groupsofchildrenwere

matchedforage.

Childrenwithsickle

cellanemia

withhighfrequencyof

pain

hadhigherfrequencyofabsenteeism

(35days

over2years)thanthosewithlowfrequencyofpain

(17daysover2years).The2groupsdid

notdiffer

oneithergradesorWRAT-R

scoresofacademic

achievement.

FowlerMG,WhittJK,LallingerRR,etal.

Neuropsychologicandacademicfunctioningof

childrenwithsickle

cellanemia.JDevBehav

Pediatr.1988;9(4):213-220.

(UnitedStates)

28school-agedchildrenwithsickle

cellanemia

and28

healthyage-,sex-,andsocioeconomically

matched

AfricanAmericanpeers

were

gradedforillness

severity

(physicale

xam,dayshospitalized,

hemoglobin

level,dayswithdisability,absenteeism

levels).Allwere

evaluatedneuropsychologically

usinganumberofsubtests

oftheWISC-R

(intelligencetests),theVMI(visual-motor

integration),aswellastests

forvisuala

ttention.The

WRATwasadministeredasameasure

ofacademic

perform

ance.

Childrenwithsickle

cellanemia

scoredsignificantly

loweronreadingandspellingachievementscores

thanhealthymatchedpeers.Olderchildrenwith

sickle

celldiseaseperform

edsignificantlylesswell

thanyoungerchildrenwiththisdisease.Mostillness

severity

measures(exceptingforthenumberof

painfulcrises)did

notpredictachievementand

neuropsychologicalscores.

Journal of School Health d September 2005, Vol. 75, No.7 d 261

Table

2PublishedResearchArticlesThatAddressSickle

CellAnemia

andSchoolPerform

anceand/orCognitive

Abilityin

School-AgedChildren

(Continuedfrom

previouspage)

Reference(O

rigin)

ExperimentalDesign

Outcome

KralM

C,BrownRT,NietertPJ,AbboudMR,Jackson

SM,HyndGW.TranscranialD

oppler

ultrasonographyandneurocognitivefunctioningin

childrenwithsickle

celldisease.Pediatrics.

2003;112(2):324-331.

(UnitedStates)

Childrenwithsickle

celldiseaseare

proneto

cerebral

vascularaccidents

(strokes),aswellasto

more

silent,subtledamageto

thebloodvesselsthat

nourishthebrain.Thisstudyusedultrasoundto

measure

theintegrity

ofthesebloodvessels(by

measuringbloodflow)in

60children(age6-16

years)withsickle

celldisease.Alsomeasuredwere

verbalIQ

(theWechslerAbbreviatedScale

of

Intelligence),academicachievement(broadreading

andmath

components

ofWoodcock-Johnson

PsychoeducationalB

attery,history

ofgrade

retention,speciale

ducationplacement),sustained

concentration/attention(C

onner’sContinuous

Perform

anceTest),anumberoftests

forexecutive

function(m

emory

test,TrailMakingTest,parentand

teacherratings).

Childrenwithabnorm

alb

loodflowto

brain’scerebrum

perform

edmore

poorly(thanchildrenwithnorm

al

tests)onmeasuresofverbalintelligenceand

executivefunction.Sustainedattention/

concentrationwasrelativelypooramongchildren

withconditionalb

loodflow.Adeclinein

intellectual

abilities,sustainedattention/concentration,and

executivefunctionsoccurredwithage.

Nabors

NA,Freymuth

AK.Attentiondeficitsin

children

withsickle

celldisease.PerceptMotSkills.

2002;95:57-67.

(UnitedStates)

26children(age6-13)withsickle

celldisease(12had

priorhistory

ofstroke)and13sim

ilar-agedsiblings

withoutsickle

celldiseasewere

comparedfor

intellectualfunctioning(W

ISC-R

),achievement

(WRAT-R

),anumberofmeasuresofattention,

parentresponseto

thePediatricNeurobehavioral

Inventory,andADHDratingscalesandothertests.

Childrenwithsickle

celldiseasewithoutstrokesdid

not

differsignificantlyfrom

controls.Forthosewith

strokes,there

were

significantdifferencesin

Coding

SubtestofWISC-R

,thereading,arithmetic,and

spellingsubtests

oftheWRAT-R

,andtimedtestof

visualscanning.

NettlesAL.Scholasticperform

anceofchildrenwith

sickle

celldisease.JHealthSocPolicy.1994;

5(3-4):123-40.

(UnitedStates)


celldiseasewere

comparedto

15withSickle-C

disease(a

lesssevere

form

).Childrenwere

aged6-16years.Both

thesegroups

were

comparedto

healthyAfricanAmericanchildren

withsim

ilardemographiccharacteristics.

Achievementwasmeasuredin

allbut7children

usingtheCalifornia

AchievementTest(31children),

theSRA(2

children),ortheIowaTestofBasicSkills

(1).Attendancerecordsfortheentire

sample

were

obtainedfrom

schooltranscripts

ofthemostrecent

academicschoolyear.

Healthychildren’sreadingandmath

scoresaswellas

attendance(173days/year)were

significantlybetter

thanboth

groupswithsickle

celldisease.The

students

withSickle-C

disease(m

ildform

)perform

edmore

poorlyonreadingandmath

and

attended161days/year.Childrenwithsickle

cell

diseasehadthelowestattendance(148days/year).

262 d Journal ofSchool Health d September 2005, Vol. 75, No.7

Table

2PublishedResearchArticlesThatAddressSickle

CellAnemia

andSchoolPerform

anceand/orCognitive

Abilityin

School-AgedChildren

(Continuedfrom

previouspage)

Reference(O

rigin)

ExperimentalDesign

Outcome

Richard

HW,BurlewAK.Academicperform

ance

amongchildrenwithsickle

celldisease:setting

minim

um

standardsforcomparisongroups.

PsycholR

ep.1997;81:27-34.

(UnitedStates)

42AfricanAmericanchildren(age7-11)with

sickle

celldiseasewere

comparedto

26ofsim

ilarage,sex,race,and

socioeconomicstatus.Schoold

ata

collectedincludedCalifornia

AchievementTest,graderetention,

andattendance.

There

were

nosignificantdifferences

betweenthe2groupsin

academic

perform

anceorgraderetention.Children

withsickle

celldiseasewere

absent

16daysascomparedto

14daysfor

controls—

anonsignificantdifference.

Schatz

J,BrownRT,PascualJM,HsuL,DeBaunMR.

Poorschoola

ndcognitivefunctioningwithsilent

cerebralinfarcts

andsickle

celldisease.Neurology.

2001;56:1109-1111.

(UnitedStates)


celldiseaseand

silentinfarcts

(strokes)and45with

sickle

celldiseaseandnosilentinfarcts

(strokes)were

studied.Infarcts

were

diagnosedusingMRIscans.18siblings

were

alsoincludedascontrols.All

childrenhadnorm

aln

eurologicalfindingson

physicale

xamination.Academicachievement

wasdeterm

inedthroughparentinterviewand

Woodcock-Johnsontest.Neuropsychological

testingwasassessedusingnumerous

standardizedtests.

Statistically

significantdifferenceswere

asfollows:(1)58%

ofchildrenwith

sickle

celldiseaseandsilentinfarcts

had

history

ofgraderetentionorspecial

education,ascomparedwith27%

of

thosewithoutsilentinfarcts

and6%

ofsiblingcontrols;(2)samefigures

forlessthanexpectedacademic

achievement;(3)neuropsychological

abnorm

alitiesin

attentionandexecutive

skillswere

more

commonamongthose

withsilentinfarcts.

ADHD,AttentionDeficit/HyperactivityDisorder;SRA,SpecialR

eviewAssessment;WISC,WechslerIntelligenceScale

forChildren;WISC-R


for

Children—

Revised;WRAT-R

,WideRangeAchievementTest—

Revised.

Journal of School Health d September 2005, Vol. 75, No.7 d 263

Table3

PublishedResearchArticlesThatAddressEpilepsyandSchoolPerform

anceand/or

CognitiveAbilityin


Reference(O

rigin)

ExperimentalDesign

Outcome

AustinJK,HubertyTJ,HusterGA,DunnDW.Does

academicachievementin

childrenwithepilepsy

changeovertime?DevMedChild

Neurol.

1999;41:473-479.

(UnitedStates)

98childrenwithepilepsyand96withasthma(m

ean

age14.5)were

evaluatedforseverity

oftheir

conditionandforacademicachievement.5areas

were

measured(C

omposite,Reading,Mathematics,

Language,andVocabulary)usingschool-

administeredtestscores.

Childrenwithepilepsyperform

edsignificantlyworsein

all5areasthanthosewithasthma.Thosewith

inactiveorlow-severity

epilepsyhadmeanscores

comparable

tonationaln

orm

s.Thosewithhigh

seizure

activityhadmeanscoresrangingfrom

3to

5points

belowthenationaln

orm

s.Changesin

academicachievementdid

notim

proveovertime,

evenifthemedicalconditionim

proved.

AldenkampAP,Overw

eg-PlandsoenWC,Diepman

LAM.Factors

involvedin

learningproblemsand

educationald

elayin

childrenwithepilepsy.Child

Neuropsychol.1999;5:130-136.

(Netherlands)

24children(m

eanage8.8

years)withconfirm

ed

epilepsyandanaccompanyingdiagnosisoflearning

disability

were

includedin

thestudy.Thecontrol

groupconsistedof24childrenwithepilepsybutno

learningdisability,matchedforage,school-type,

grade,andintelligence.

Measuresofschoola

chievementwere

notdifferent

betweenthe2groups,in

thatboth

groupswere

delayedbyameanof1.5

years.Thetypeofseizure

disorderwasassociatedwithlevelo

fachievement:

thosewithidiopathicgeneralizedepilepsyhadlower

scoresthanthosewithlocalizedepilepsy,butthose

withidiopathicgeneralizedseizureshadepilepsy

thatwasunderpoorercontrol(more

seizures).The

authors

concludethatfrequentseizures

(uncontrolledepilepsy)are

associatedwithschool

achievement.

Farw

ellJR,DodrillCB,BatzelL

W.Neuropsychological

abilitiesofchildrenwithepilepsy.Epilepsia.

1985;26:395-400.

(UnitedStates)

118epilepticchildren(6-15years)underw

entdetailed

neuropsychologicaltestingincludingtheWechsler

IntelligenceScale

forChildren-R

evisedandage-

appropriate

Halstead-R

eitanbattery.Diagnoses

were

classicala

bsenceseizuresonly(8),classic

absenceandgeneralizedtonic-clonicseizures(8),

generalizedtonic-clonicseizuresonly(30),partial

seizuresonly(31),partialseizuresandgeneralized

seizures(20),atypicala

bsenceseizures(15),and

minormotorseizures(5).Acontrolg

roupof100

childrenwithoutseizures,matchedto

thegeneral

populationforintelligenceandmatchedto

the

seizure

casesforage,underw

entidenticaltesting.

Intelligencewassignificantlyloweramongthosewith

seizures.Degreewasrelatedto

seizure

type(lowest

forstudents

withminormotororatypicala

bsence

seizures).Students

withclassicabsenceseizures

hadnorm

alintelligence.Intelligencealsocorrelated

withdegreeofseizure

controla

ndinversely

correlatedwithnumberofyears

withseizures.

Childrenwithseizureshadbeenplacedin

special

educationorhadrepeatedagradein

schoola

lmost

twiceasfrequentlyascontrols.

HubertyTJ,

AustinJK

,RisingerMW,McN

elis

AM.

Relatio

nsh

ipofse

lectedse

izure

variablesinch

ildren

with

epilepsy

toperform

ance

onschool-administered

ach

ieve

menttests.

JEpilepsy.1992;5:10-16.

(Unite

dStates)

136children(age8-12)withepilepsyandnorm

al

intelligencewere

includedin

thestudy.Seizure

type

wasdeterm

inedfrom

history

andEEG.Parent

interview,California

AchievementTest,andIowa

TestofBasicSkillswere

used.

Ageofseizure

onset,thetypeofepilepsy,andseizure

frequencywere

notrelatedto

achievementscores

orto

graderetention,exceptingthatchildrenwith

secondary

generalizedseizureswere

more

likely

toberetainedin

agrade.


Table

3PublishedResearchArticlesThatAddressEpilepsyandSchoolPerform

anceand/or

CognitiveAbilityin

School-AgedChildren

(Continuedfrom

previouspage)

Reference(O

rigin)

ExperimentalDesign

Outcome

Seidenberg

M,BeckN,GeisserM,etal.Academic

achievementofchildrenwithepilepsy.Epilepsia.

1986;27(6):753-759.

(UnitedStates)

122childrenwithepilepsy(age7-15)were

administeredtests

ofacademicachievementandof

intelligence(W

RATandWISC-R

).Allchildren

chosenforstudyhadIQ

.70.Seizureswere

generalizedtonic-clonic(46children),absence(16),

tonic-clonic(10),sim

ple

partialseizures(6),

complexpartial(25),andpartialsecondarily

generalized(19).

Asagroup,thesechildrenwere

makinglessacademic

progressthanexpectedfortheirageandIQ

level.

Academicdeficiencieswere

greatestforarithmetic,

followedbyspelling,readingcomprehension,and

word

recognition.Ageofseizure

onset,lifetimetotal

seizure

frequency,aswellasageofchild

were

predictiveofacademicperform

ance.

Seidenberg

M,BeckN,GeisserM,etal.

Neuropsychologicalcorrelatesofacademic

achievementofchildrenwithepilepsy.JEpilepsy.

1988;1:23-29.

(UnitedStates)

Seizure

characteristicsandneuropsychologicaltest

perform

ancewere

assessedin

48children

(age9-14),whowere

dividedinto

2groups:18who

hadsatisfactory

perform

anceand30whowere

makingpooracademicprogress.

Pooracademicprogresswasassociatedwithspecific

cognitivedeficiencies(verbal-languageabilitiesand

attention-concentration)ratherthanwithageneral

cognitivedysfunction.Durationoftheseizure

disorderwasfoundto

beinverselyrelatedto

academicsuccess.

Sturniolo

MG,GallettiF

.Idiopathicepilepsyand

schoola

chievement.ArchDisChild.1994;70:

420-428.

(Italy)

41children(6-10years)affectedwithidiopathic

epilepsyunderw

entneuropsychological(WISC,

Bendertest)andbehaviorala

ssessment.There

was

amatchedcontrolg

roup.Furtherinform

ationwas

obtainedfrom

teachers’reports.

61%

hadschoolu

nderachievement,unrelatedto

sex,

socialb

ackground,ageofonset,seizure

type,

durationofillness,featuresseenon

electroencephalography,ortreatm

ent.Poor

perform

anceoccurredin

alm

ostallacademicfields

andwasassociatedwithhighervisuomotor

impairment.Emotionalm

aladjustm

entwas

associatedwithpoorschoolp

erform

ance.

WilliamsJ,PhillipsT,GriebelM

L,etal.Factors

associatedwithacademicachievementin

children

withcontrolledepilepsy.EpilepsyBehav.

2001;2:217-223.

(UnitedStates)

65children(age8-13)withwell-controlledepilepsy

were

evaluatedforacademicachievement.Allhad

beenonananticonvulsantforatleast6monthsthat

would

havenocentraln

ervoussystem

sideeffects,

andnomore

than4seizuresin

previous6months.

Nochild

hadmentalretardation,adiagnosisofan

attentiondisorder,orahistory

ofasignificanthead

injury.Standardizedtests

forintelligence,attention,

verbalm

emory,story

memory,self-esteem,and

academicachievementwere

administered.

Whenintelligencewascontrolled,attentionlevel

amongchildrenwithepilepsywastheonlyvariable

associatedwiththeiracademicachievementscores.

Seizure

typeanddurationofepilepsywere

not

associatedwithdifferencesin

academic

perform

ance.

EEG

Electroencephalogram;WISC-R


forChildren—

Revised;WRAT,WideRangeAchievementTest.


with achievement correlating with the severity of theinfection.27-30

Notably absent from the body of research are recentstudies on the effects of chronic allergic conditions (eg,nasal and sinus congestion, eczema) on student achieve-ment and attendance, despite the prevalence of these com-mon chronic conditions, the discomfort they create, andthe potential for many medications that treat chronicrespiratory allergy symptoms to cause cognitive changes.

CONCLUSIONWhile more research will further our understanding of

the role of chronic diseases in student performance, it isuseful for health practitioners and educators to be updatedon what we do already know about this complex relation-ship between chronic diseases and their effect on students’education. j

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chronic health conditions and student performance at school

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