Academic Achievement in Children With Asthma
| Status: | Completed |
|---|---|
| Conditions: | Asthma |
| Therapuetic Areas: | Pulmonary / Respiratory Diseases |
| Healthy: | No |
| Age Range: | 11 - 14 |
| Updated: | 4/13/2015 |
| Start Date: | August 2014 |
| End Date: | June 2015 |
Background: Asthma is the most common chronic disease of childhood with a prevalence that is
1.6 times greater in African American (AA) children than in Non-Hispanic White children.1
Nationally, 700,000 children are seen for asthma in Emergency Departments (ED) every year,
1% of which are seen at Children's National Health System (CN) in Washington, DC. School
performance and school attendance has not been well studied in urban children with asthma,
especially at the middle school level.
Objective: Our purpose is to test the hypothesis that middle school children with asthma
have worse school performance than middle school children without asthma in Washington DC
and Prince George's county schools.
Methods: The investigators will conduct a cross-sectional observational study of
middle-school (grades 6-8 in the 2013-2014 school year) aged children with and without
asthma recruited from the Emergency Departments and the IMPACT DC asthma clinic at CN. The
investigators will collect demographic information, asthma severity information (for cases),
and request that parents mail report cards and standardized test scores directly to the
investigators. The investigators will use multivariable linear and logistic regression to
determine if the presence of asthma is associated with school performance.
1.6 times greater in African American (AA) children than in Non-Hispanic White children.1
Nationally, 700,000 children are seen for asthma in Emergency Departments (ED) every year,
1% of which are seen at Children's National Health System (CN) in Washington, DC. School
performance and school attendance has not been well studied in urban children with asthma,
especially at the middle school level.
Objective: Our purpose is to test the hypothesis that middle school children with asthma
have worse school performance than middle school children without asthma in Washington DC
and Prince George's county schools.
Methods: The investigators will conduct a cross-sectional observational study of
middle-school (grades 6-8 in the 2013-2014 school year) aged children with and without
asthma recruited from the Emergency Departments and the IMPACT DC asthma clinic at CN. The
investigators will collect demographic information, asthma severity information (for cases),
and request that parents mail report cards and standardized test scores directly to the
investigators. The investigators will use multivariable linear and logistic regression to
determine if the presence of asthma is associated with school performance.
Academic Achievement in Children with Asthma
Research Plan A. Background and Specific Aims Asthma is the most common chronic disease of
childhood with a prevalence that is 1.6 times greater in African American (AA) children than
in Non-Hispanic White children.1 Nationally, 700,000 children are seen for asthma in
Emergency Departments (ED) every year, 1% of which are seen at Children's National Medical
Center (CN) in Washington, DC. The asthma prevalence rate among African America (AA)
children and teens in Washington, DC is 20% higher than the national rate2 and overall ED
utilization rates for asthma are 4.3 times the national rate.3 In 2007, approximately 10.5
million school days were lost due to asthma.1
Asthma severity may impact academic performance due to increased absenteeism. A study of
Canadian school children showed that children with the most severe asthma had the lowest
math and reading scores.4 Tsakiris also showed that children with asthma on inhaled
corticosteroids had better academic achievement than children with asthma not on long-term
controller therapy, suggesting that poor control is associated with worse school
performance.5 However, academic performance is dependent on many other factors, such as
socio-economic status of the local district and resources available. Availability of skilled
nursing differs between schools, impacting children with asthma; Hillemeier's study of
children with asthma in Pennsylvania schools showed that less than half of secondary schools
had adequate school nurse coverage, and that this reduced services provided to children with
asthma.6 Children whose asthma is not managed at school may be absent more often. Parental
education also plays a part in a child's school performance. Tsakiris et al, showed that in
Greece, lower parental education level was independently associated with poor school
performance in children with asthma.5
Early adolescence (ages 10-13) is identified as a time of great transition with both
developmental and biologic changes; in this time period male children with asthma generally
improve and female with asthma develop worsening asthma, likely due to hormone effects. It
has been shown that programs to reduce asthma symptoms in both younger children (elementary
school) and older children (high school) do not work well in early adolescent children
(middle school).7
In addition, despite the National Asthma Education Prevention Program (NAEPP, 2007)
guidelines that encourage the assessment of the quality of life (QOL) in children, there has
been minimal research on QOL in children with asthma.
Given the scarcity of information on the association between pediatric asthma and academic
achievement, school attendance, and the QOL, and the need to establish baselines within
individual communities, we have designed a study to examine the association between asthma
in middle school (grades 6 through 8, inclusive) children and academic achievement, school
attendance, and the QOL. Our overall hypothesis is that children with asthma will have
worse school performance compared to children without asthma.
Specific Aim 1: To determine the association between asthma and school performance by
comparing grade point averages (GPA) in middle school aged children with and without asthma.
We will enroll 200 children in grades 6-8 with asthma (cases) from the ED/IMPACT DC and
compare them with a group of 200 children in grades 6-8 without asthma (controls) recruited
from the ED. Report cards will be collected between August 2014 and December 1, 2014 or
until 200 cases and 200 controls have been recruited, and GPAs will be compared. We expect
children with asthma will have lower GPAs .
B.
Significance:
School achievement in middle school students with asthma is not well understood; this study
will be pivotal in identifying if middle school students with asthma in the Washington DC
are are performing more poorly than their non-asthmatic counterparts.
C. Preliminary studies We have not previously studied academic success in children with
asthma.
D. Research Design and Methods
We are proposing a cross-sectional case-control observational study of middle school (grades
6-8) children to compare academic achievement and school attendance between children with
and without asthma. 200 children with asthma (cases) will be recruited from the IMPACT DC
clinic and/or ED and 200 children without asthma (controls) will be recruited from the ED.
Inclusion criteria for cases include asthma diagnosed by a clinician for greater than 1 year
with a history of exacerbation requiring systemic corticosteroids within the past 2 years.
Controls will have no history of asthma. All children, cases and controls, must (1) be in
grade level 6-8 in the 2013-2014 school year, attend public school in Washington, DC (DCPS)
or Prince George's County Public Schools (PGCPS), and reside in their school district;(2) be
accompanied by their parent or legal guardian. Exclusion criteria for cases and controls
will be (1) presence of a chronic medical condition other than asthma; (2) triage category 1
or 2 in the emergency department; and (3) a family that does not speak English or Spanish
Demographic Data for Cases and Controls Demographic information will be obtained by a
structured interview; the questionnaire (Appendix A) will be used on both cases and
controls: the parent/caregiver will be asked about the child's age, gender, race/ethnicity,
insurance type. health care utilization, medications usage, highest level of education of
the parent/ caregiver, income of the household, and parental report of school services.
Cases will complete an additional 11 questions to determine asthma severity to determine
NAEPP score and the Asthma Control Test (ACT) score (Appendix F and G).
We will utilize the child's electronic medical record (Cerner for ED charts and
eClinicalWorks for the IMPACT DC charts) to determine insurance type and health care
utilization.
Reporting of Academic Achievement and School Attendance At the time of recruitment, families
will be given a self-addressed, stamped envelope to send the child's 2013 first term (if
available), standardized test score report (if available), and final report card to the
research team. All report cards/score reports will be returned to the family via US Mail
with a $25 gift card as incentive for sending in their report card. Academic achievement,
standardized test scores, and school attendance will be recorded from the report cards. All
report cards in the DCPS and PGCPS system use the same grading scale.. Both systems record
attendance on the report cards and there are 180 school days in a year in both systems.
Reporting of the Quality of Life using the Peds QL 4.0 Form QOL will be measured using the
validated PedsQL 4.0 for children, teens, and parents (Appendices B, C, D, and E). The
PedsQL 4.0 has four scales with 23 questions which ascertain physical functioning, emotional
functioning, social functioning, and school functioning. A 5-point Likert scale is used in
the child self-report and for the parent proxy reports. Items are reverse scored and
linearly transformed to a 0 to 100 scale (0=100, 1=75, 2=50, 3=25, and 4=0), so higher
scores indicate better QOL.
E. Statistical analysis Descriptive statistics will be used to analyze demographic variables
(rates, proportions, means, medians, ranges). Univariate comparisons will be performed using
appropriate categorical or continuous statistical analyses. Multivariate testing will be
performed using logistic and/or liner regression where appropriate.
Sample Size: The study will be powered on the proportion of patients in each group with a
grade point average >3.0. The overall proportion of DC public middle school students in the
2012-2013 school year with a GPA >3.0 was approximately 35%. Assuming that this figure is
similar for children without asthma (controls), we will need 70 cases and 70 controls to
have 80% power detect a 20% absolute difference in the proportion of children with asthma
(cases) with a grade point average >3.0 (alpha = 0.05, two-sided).
We have chosen to include 200 children in each group, as we expect that less than 50% of all
included patients will return their final year report cards via the self-addressed, stamped
envelope.
Research Plan A. Background and Specific Aims Asthma is the most common chronic disease of
childhood with a prevalence that is 1.6 times greater in African American (AA) children than
in Non-Hispanic White children.1 Nationally, 700,000 children are seen for asthma in
Emergency Departments (ED) every year, 1% of which are seen at Children's National Medical
Center (CN) in Washington, DC. The asthma prevalence rate among African America (AA)
children and teens in Washington, DC is 20% higher than the national rate2 and overall ED
utilization rates for asthma are 4.3 times the national rate.3 In 2007, approximately 10.5
million school days were lost due to asthma.1
Asthma severity may impact academic performance due to increased absenteeism. A study of
Canadian school children showed that children with the most severe asthma had the lowest
math and reading scores.4 Tsakiris also showed that children with asthma on inhaled
corticosteroids had better academic achievement than children with asthma not on long-term
controller therapy, suggesting that poor control is associated with worse school
performance.5 However, academic performance is dependent on many other factors, such as
socio-economic status of the local district and resources available. Availability of skilled
nursing differs between schools, impacting children with asthma; Hillemeier's study of
children with asthma in Pennsylvania schools showed that less than half of secondary schools
had adequate school nurse coverage, and that this reduced services provided to children with
asthma.6 Children whose asthma is not managed at school may be absent more often. Parental
education also plays a part in a child's school performance. Tsakiris et al, showed that in
Greece, lower parental education level was independently associated with poor school
performance in children with asthma.5
Early adolescence (ages 10-13) is identified as a time of great transition with both
developmental and biologic changes; in this time period male children with asthma generally
improve and female with asthma develop worsening asthma, likely due to hormone effects. It
has been shown that programs to reduce asthma symptoms in both younger children (elementary
school) and older children (high school) do not work well in early adolescent children
(middle school).7
In addition, despite the National Asthma Education Prevention Program (NAEPP, 2007)
guidelines that encourage the assessment of the quality of life (QOL) in children, there has
been minimal research on QOL in children with asthma.
Given the scarcity of information on the association between pediatric asthma and academic
achievement, school attendance, and the QOL, and the need to establish baselines within
individual communities, we have designed a study to examine the association between asthma
in middle school (grades 6 through 8, inclusive) children and academic achievement, school
attendance, and the QOL. Our overall hypothesis is that children with asthma will have
worse school performance compared to children without asthma.
Specific Aim 1: To determine the association between asthma and school performance by
comparing grade point averages (GPA) in middle school aged children with and without asthma.
We will enroll 200 children in grades 6-8 with asthma (cases) from the ED/IMPACT DC and
compare them with a group of 200 children in grades 6-8 without asthma (controls) recruited
from the ED. Report cards will be collected between August 2014 and December 1, 2014 or
until 200 cases and 200 controls have been recruited, and GPAs will be compared. We expect
children with asthma will have lower GPAs .
B.
Significance:
School achievement in middle school students with asthma is not well understood; this study
will be pivotal in identifying if middle school students with asthma in the Washington DC
are are performing more poorly than their non-asthmatic counterparts.
C. Preliminary studies We have not previously studied academic success in children with
asthma.
D. Research Design and Methods
We are proposing a cross-sectional case-control observational study of middle school (grades
6-8) children to compare academic achievement and school attendance between children with
and without asthma. 200 children with asthma (cases) will be recruited from the IMPACT DC
clinic and/or ED and 200 children without asthma (controls) will be recruited from the ED.
Inclusion criteria for cases include asthma diagnosed by a clinician for greater than 1 year
with a history of exacerbation requiring systemic corticosteroids within the past 2 years.
Controls will have no history of asthma. All children, cases and controls, must (1) be in
grade level 6-8 in the 2013-2014 school year, attend public school in Washington, DC (DCPS)
or Prince George's County Public Schools (PGCPS), and reside in their school district;(2) be
accompanied by their parent or legal guardian. Exclusion criteria for cases and controls
will be (1) presence of a chronic medical condition other than asthma; (2) triage category 1
or 2 in the emergency department; and (3) a family that does not speak English or Spanish
Demographic Data for Cases and Controls Demographic information will be obtained by a
structured interview; the questionnaire (Appendix A) will be used on both cases and
controls: the parent/caregiver will be asked about the child's age, gender, race/ethnicity,
insurance type. health care utilization, medications usage, highest level of education of
the parent/ caregiver, income of the household, and parental report of school services.
Cases will complete an additional 11 questions to determine asthma severity to determine
NAEPP score and the Asthma Control Test (ACT) score (Appendix F and G).
We will utilize the child's electronic medical record (Cerner for ED charts and
eClinicalWorks for the IMPACT DC charts) to determine insurance type and health care
utilization.
Reporting of Academic Achievement and School Attendance At the time of recruitment, families
will be given a self-addressed, stamped envelope to send the child's 2013 first term (if
available), standardized test score report (if available), and final report card to the
research team. All report cards/score reports will be returned to the family via US Mail
with a $25 gift card as incentive for sending in their report card. Academic achievement,
standardized test scores, and school attendance will be recorded from the report cards. All
report cards in the DCPS and PGCPS system use the same grading scale.. Both systems record
attendance on the report cards and there are 180 school days in a year in both systems.
Reporting of the Quality of Life using the Peds QL 4.0 Form QOL will be measured using the
validated PedsQL 4.0 for children, teens, and parents (Appendices B, C, D, and E). The
PedsQL 4.0 has four scales with 23 questions which ascertain physical functioning, emotional
functioning, social functioning, and school functioning. A 5-point Likert scale is used in
the child self-report and for the parent proxy reports. Items are reverse scored and
linearly transformed to a 0 to 100 scale (0=100, 1=75, 2=50, 3=25, and 4=0), so higher
scores indicate better QOL.
E. Statistical analysis Descriptive statistics will be used to analyze demographic variables
(rates, proportions, means, medians, ranges). Univariate comparisons will be performed using
appropriate categorical or continuous statistical analyses. Multivariate testing will be
performed using logistic and/or liner regression where appropriate.
Sample Size: The study will be powered on the proportion of patients in each group with a
grade point average >3.0. The overall proportion of DC public middle school students in the
2012-2013 school year with a GPA >3.0 was approximately 35%. Assuming that this figure is
similar for children without asthma (controls), we will need 70 cases and 70 controls to
have 80% power detect a 20% absolute difference in the proportion of children with asthma
(cases) with a grade point average >3.0 (alpha = 0.05, two-sided).
We have chosen to include 200 children in each group, as we expect that less than 50% of all
included patients will return their final year report cards via the self-addressed, stamped
envelope.
Inclusion Criteria:
- Inclusion criteria for cases include asthma diagnosed by a clinician for greater than
1 year with a history of exacerbation requiring systemic corticosteroids within the
past 2 years. Controls will have no history of asthma. All children, cases and
controls, must (1) be in grade level 6-8 in the 2013-2014 school year, attend public
school in Washington, DC (DCPS) or Prince George's County Public Schools (PGCPS), and
reside in their school district;(2) be accompanied by their parent or legal guardian.
Exclusion Criteria: Exclusion criteria for cases and controls will be (1) presence of a
chronic medical condition other than asthma; (2) triage category 1 or 2 in the emergency
department; and (3) a family that does not speak English or Spanish
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