Chronic Health Conditions and Student Performance at School

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  • 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 studys 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 childrens 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 outcomesschool 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, (htaras@ucsd.edu), Division of CommunityPediatrics, University of California, San Diego, Gilman Drive #0927,La Jolla, CA 92093-0927; and William Potts-Datema, MS, Director,(wpottsda@hsph.harvard.edu), Partnerships for Childrens 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(C

    ontinuedonnextpage)

    Reference(Origin)

    ExperimentalDesign

    Outcome

    FoxMA,ChenRS,HolmesCS.Genderdifferencesin

    memory

    andlearninginchildrenwithinsulin-dependent

    diabetesmellitus(IDDM)overa4-yearfollow-up

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

    (UnitedStates)

    Childrenbetweenages7and16years,whohaddiabetes

    foratleast6months,were

    recruitedfrom

    hospital

    endocrinologyclinics.143childrenwere

    giventheRey

    Auditory

    VerbalLearningTestduringaninitial

    assessmentandthenagain4years

    later.Initially,after

    achild

    withdiabeteswasenrolledinthestudy,acontrol

    child

    withnochronichealthconditionswasrecruited

    from

    therosters

    ofparticipatingschools(samegrade,

    gender,race,andsocioeconomicstatus).Glycosylated

    hemoglobin(HbA1)levelswere

    drawn,andparents

    were

    askedto

    recallthenumberofhypoglycemic

    episodes.

    Unlikeothergroups,boyswithdiabetesdidnotmake

    expecteddevelopmentalgainsonauditory

    verbal

    learningtests.Boyswithdiabetesshowedaplateauin

    wordslearned.Girlswithdiabetesdidnotplateaubut

    losttheirrelativegenderadvantageforverbal

    inform

    ationthatgirlswithoutdiabeteshad.Longer

    diseasedurationpredictedpoorerlearningovertime.

    HbA1levelsornumberofhypoglycemicepisodeswere

    notsignificantlyassociatedwithverballearning.

    HagenJW,BarclayCR,AndersonBJ,etal.Intellective

    functioningandstrategyuseinchildrenwith

    insulin-dependentdiabetesmellitus.Child

    Dev.1990;

    61:1714-1727.

    (UnitedStates)

    30childrenwithdiabetesandage-m

    atched30

    nondiabeticchildren(age8-16)were

    assessedfor

    intelligence(W

    ISC-R),academicachievement

    (2subtestsfrom

    thePeabodyIndividualA

    chievement

    Test),inform

    ationprocessing,andself-competence.

    Childrenwithdiabeteshadmeanintelligencescoresof

    104,ascomparedto

    113forcontrolgroupchildren.

    Childrenwithdiabetesscoredloweronsubscale

    perform

    anceandwere

    more

    likelyto

    requireremedial

    educationservices.There

    wasevidencethatthese

    childrenwere

    deficientintheiruseofstrategiesto

    organizeandrecallinform

    ationparticularlyforthose

    withonsetofdiabetespriorto

    age5.

    HannonenR,TupolaS,AhonenT,RiikonenR.

    Neurocognitivefunctioninginchildrenwithtype-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

    (adevelopmentalneuropsychologicalassessmentof

    language,executivefunctions,visuospatialprocessing,

    learning,memory).

    Childrenwithahistory

    ofsevere

    hypoglycemiahadmore

    neuropsychologicalimpairments,more

    learning

    difficulties(parentreport),andneededmore

    part-time

    specialeducationthanthoseinothergroups.

    Significantdifferenceswere

    foundinverbalshort-term

    memory

    andphonologicalprocessing.

    HersheyT,LillieR,SadlerM,WhiteNH.Theeffectof

    severe

    hypoglycemiaoncognitioninchildrenand

    adolescentswithtype1diabetesmellitus.Diabetes

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

    (UnitedStates)

    25children(age9-16)withtype1diabeteswere

    randomly

    assignedto

    eitherintensiveorconventionaldiabetes

    therapy(Note:intensivetherapyincreasestheriskof

    hypoglycemicepisodes).16nondiabeticchildrenwere

    alsostudied.Allchildrenreceivedmemory

    tests

    (WISC-IIIvocabulary

    andblockdesigntests).

    Diabetic

    childrenwhoreceivedintensive

    therapyhada3-fold

    higherrateofsevere

    hypoglycemiaandperform

    edless

    accuratelyonaspatialdeclarativememorytask

    andmore

    slowly(butwith

    equalaccuracy)onapattern

    recognition

    task,comparedtochildrenonconventionaltherapyand

    controlsubjects.Allchildrenwith

    diabeteswere

    significantly

    impairedonamotorspeedtask

    ascompared

    tonondiabetic

    peers.

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

  • Table1

    PublishedResearchArticlesThatAddressDiabetesandSchoolPerform

    anceand/or

    CognitiveAbilityin

    School-AgedChildren

    (Continuedfrom

    previouspage)

    Reference(Origin)

    ExperimentalDesign

    Outcome

    HolmesC,DunlapWP,ChenRS,CornwellJM.Gender

    differencesinthelearningstatusofdiabeticchildren.

    JConsultClin

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

    (UnitedStates)

    95children(age8-16)withdiabetesand97

    grade-m

    atchedcontrolswere

    evaluatedwith

    theWISC-R

    intelligencemeasure.

    DiabeticboyshadsignificantlylowerFreedom

    From

    Distractibilityscoresthandiabeticgirlsandcontrols.

    40%

    ofboys(vs16%

    ofgirls)hadlearningproblems

    thatwarrantedspecialinstructionorgraderetention.

    Diabeticchildrenexperiencedmore

    learningdifficulties

    thancontrols(24%

    vs13%).

    McCarthyAM,LindgrenS,MengelingMA,TsalikianE,

    EngvallJC.Effectsofdiabetesonlearninginchildren.

    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

    controlofdiabetes(HbA1c),diseaseduration.

    Childrenwithdiabeteshavenosignificantlylower

    academicperform

    ancescoresthancontrolsiblingsor

    classmate

    controlsandactually

    hadhigherreading

    scores.Childrenwithdiabeteshadsignificantlymore

    absencesthantheirsiblings(andbehavioralproblems).

    McCarthyAM,LindgrenS,MengelingMA,TsalikianE,

    EngvallJ.Factors

    associatedwithacademic

    achievementinchildrenwithtype1diabetes.Diabetes

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

    (UnitedStates)

    244children(age8-18)withtype1diabeteswere

    recruitedfrom

    clinics.Parentsgaveschooldata

    for

    currentacademicyear(IowaTestofBasicSkillsfor

    math,reading,andlanguagetransform

    edto

    standard

    scores),anddiabetesdata

    were

    takenfrom

    clinic

    medicalrecords.PediatricBehaviorScalewasgiven

    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

    achievementscoresthanthosewithbettercontroland

    nohospitalizations.Frequentschoolabsencewasnot

    associatedwithacademicscores.Behaviorproblems

    ratedbyparentswere

    significantlyassociatedwith

    academicachievement.Highesthealthpredictors

    ofacademicachievementwere

    numberof

    diabetes-relatedhospitalizationsandHbA1c

    (measure

    ofmetabolic

    control).

    Northam

    EA,AndersonPJ,JacobsR,etal.

    Neuropsychologicalprofilesofchildrenwithtype1

    diabetes6years

    afterdiseaseonset.DiabetesCare.

    2001;24(9):1541-1546.

    (Australia)

    90childrenwithdiabetes(age6-17)hadbeenassessed

    attimeofdiagnosis,2years

    later,andnow6years

    afterdiseaseonset.84nondiabeticchildrenofthe

    sameagewere

    alsoassessedascontrols.Assessment

    includedtheWISC-III,testsofattentionandprocessing

    speed,theReyAuditory

    VerbalLearningTest,

    ControlledOralW

    ord

    AssociationTest,andothers.

    After6years,verbalIQwassignificantlyloweramong

    childrenwithdiabetes(97vs103)andespecially

    those

    withonsetpriorto

    age4years.Childrenwithdiabetes

    alsoscoredmore

    poorlyonmeasuresofattention,

    processingspeed,andexecutiveskills.

    Northam

    EA,AndersonPJ,WertherGA,etal.Predictors

    ofchangeintheneuropsychologicalprofilesofchildren

    withtype1diabetes2years

    afterdiseaseonset.

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

    (Australia)

    113childrenwithdiabetes(age3-14)were

    assessed

    soonafterdiagnosisand2years

    later.WISC-R

    measure

    ofintelligencewasusedforschool-aged

    subjects.OthermeasurementsincludedtheRey

    Auditory

    VerbalLearningTest,ControlledOralW

    ord

    AssociationTest,andothers.

    Ageononsetofdiabetespredictedpoorerperform

    ance

    onintelligencetests2years

    later.Recurrentand

    severe

    hypoglycemiaandchronichyperglycemiawere

    associatedwithmemory

    andlearningcapacitydeficits.

    Journal ofSchool Health d September 2005, Vol. 75, No.7 d 257

  • Table1

    PublishedResearchArticlesThatAddressDiabetesandSchoolPerform

    anceand/or

    CognitiveAbilityin

    School-AgedChildren

    (Continuedfrom

    previouspage)

    Reference(Origin)

    ExperimentalDesign

    Outcome

    RovetJF,EhrlichRM.Theeffectofhypoglycemic

    seizuresoncognitivefunctioninchildrenwithdiabetes:

    a7-yearprospectivestudy.JPediatr.1999;134:

    503-506.

    (Canada)

    16childrenwhowere

    enrolledin2separate

    studieswere

    measuredattimeofdiagnosisofdiabetesandfollowed

    forrepeatmeasurementat1,3,and7years

    beyond

    diagnosis.Eachsubjectwasmatchedwithacontrol

    subject(nodiabetes)forage,sex,andsocioeconomic

    status.9ofthediabeticchildrenhadexperiencedat

    least1hypoglycemicseizure

    (atmeanageof6.6).

    Childrenwithdiabetesdemonstratedsignificantdeclines

    inverbalIQ(butnotvisuospatialabilities)ascompared

    tocontrols.Thiswasmostpronouncedamongthose

    whohadahypoglycemicseizure.Thosewith

    ahypoglycemicseizure

    alsohaddeficitsonperceptual

    motor,memory,andattentiontasks7years

    after

    diagnosis.

    RovetJ,AlvarezM.Attentionalfunctioning

    inchildrenandadolescentswithIDDM.

    Diab...

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