The Link Between School
Attendance and Good Health
May 4, 2017
Mandy A Allison, MD, MSPH
Associate Professor
University of Colorado, Anschutz Medical Campus
Case Study
December 12th: Jane is an 11.5 year old female at the Child
Health Clinic with a chief complaint of vomiting. She is
accompanied by her mother.
Vomiting:
--was still vomiting at school (in Aurora last month)
--has not been vomiting since out of school for past 2 weeks but
vomited x 2 three days ago
--describes sour taste and burning in mouth frequently
Case Study
School:
--Currently not in school
--Parents are separated and Jane had been with her father; now she is with
her mother in Thornton. Mother has not been able to get Jane to school in
Aurora because of her work schedule so Jane has been out of school for
about 2 weeks.
--Was failing some subjects in school in Aurora because of poor attendance.
Per mom, when Jane did the work, she got good grades (As, Bs). She has
never had special classes or been assessed for a learning disability.
--Has had problems with bullies in past
--Now lives with mom in Thornton; mom needs to look into middle schools
there but has not done so yet.
--Jane and her mother are exploring home schooling. Mother admitted the
decision to home school was made due to the excessive phone calls she
received from the school nurse for various issues. These phone calls started
jeopardizing her job.
Case Study
Anxiety:
--see previous CLIMB team note
--has not followed through on going to outpatient psychiatry at
Children's Hospital
--Jane thinks anxiety is okay now though when we discuss going
back to school she says her stomach hurts and goes to the
bathroom to vomit. She clearly seems anxious when we discuss
school and asks several times when she is going to have to start
school.
Objectives
• What is chronic absenteeism?
• Why does chronic absenteeism matter?
• What are the health-related causes of chronic
absenteeism?
• What are evidence-based interventions to address
health-related causes of chronic absenteeism?
• What can school-based health centers do?
What (and Where) is Chronic
Absenteeism?
Attendance Terms
Average
Daily
Attendance
• The % of enrolled students who attend school each day.
It is used in some states for allocating funding.
Truancy
• Typically refers only to unexcused absences and is defined
by each state. It signals the potential need for legal
intervention under state compulsory education laws.
Chronic
Absence
• Missing 10% or more of school for any reason -- excused,
unexcused, etc. It is an indication that a student is
academically at risk due to missing too much school
starting in Kindergarten.
7
CO Urban Districts with High Chronic Absenteeism
https://www.arcgis.com/apps/MapSeries/index.html?appid=7f567623f36744dda5ad339aba32aca2
CO Rural Districts with High Chronic Absenteeism
Why Does Chronic Absenteeism
Matter?
Students Chronically Absent in Kindergarten and
1st Grade are Much Less Likely to Read Proficiently
in 3rd Grade
Percent Students Scoring Proficient or Advanced on 3rd Grade ELA
Based on Attendance in Kindergarten and in 1st Grade
100%
80%
64%
60%
43%
41%
40%
17%
20%
0%
No attendance risks
No risk
Small risk
Moderate risk
High risk
Small attendance risks
Moderate attendance risks
High attendance risks
Missed less than 5% of school in K & 1st
Missed 5-9% of days in both K & 1st
Missed 5-9% of days in 1 year &10 % in 1 year
Missed 10% or more in K & 1st
Source: Applied Survey Research & Attendance Works (April 2011)
11
Multiple Years of Elementary Chronic Absence
= Worse Middle School Outcomes
Each year of chronic absence in elementary school is associated with
a substantially higher probability of chronic absence in 6th grade
18.0x
Increase in
probability of
6th grade
chronic
absence
Chronic absence in 1st
grade is also associated
with:
7.8x
5.9x
•
•
Lower 6th grade test
scores
Higher levels of
suspension
Years of Chronic Absence in Grades 1-5
Oakland Unified School District SY 2006-2012, Analysis By Attendance Works
12
The Effects of Chronic Absence on
Dropout Rates Are Cumulative
With every year of
chronic
absenteeism, a
higher percentage
of students
dropped out of
school.
http://www.utahdataalliance.org/downloads/ChronicAbsenteeismResearchBrief.pdf
13
Poor Attendance Is A Problem Across Income;
But Even More Important For Students In Poverty
Presentation to: The Interagency Council for Ending the Achievement Gap
November 7, 2013, CT State Dept of Education.
14
Poor Attendance Is Associated with Engaging
in Risky Behaviors
Poor School Performance is Associated with
Poor Adult Outcomes
Poor School Performance is Associated with
Poor Adult Outcomes
What Are the Health-Related
Causes of School Absenteeism?
Why Are Students Chronically Absent?
Myths
Absences are only a
problem if they are
unexcused
Sporadic versus
consecutive absences
aren’t a problem
Attendance only
matters in the older
grades
Barriers
Aversion
Child struggling
academically
Lack of access to
health care
Lack of engaging
instruction
Poor
transportation
Poor school climate
and ineffective school
discipline
No safe path to school
Parents had negative
school experience
19
Acute and Chronic Health Conditions
Associated with Increased Absenteeism
•
•
•
•
•
•
•
•
•
Influenza, strep, and gastrointestinal infections
Fractures
Poorly controlled asthma
Type I diabetes
Pain—including abdominal pain, headaches
Seizure disorders
Poor oral health
Obesity
Mental and behavioral health—including anxiety, depression, history of
trauma
High Risk Groups for Chronic Absenteeism
• Children with special health care
needs
• Children with disabilities
• Children in foster care
From Attorney General’s 2014 Report on California’s Elementary
School Truancy and Absenteeism Crisis; available at:
https://oag.ca.gov/truancy/2014
Family Factors Associated with Increased
Absenteeism
• Poverty
• Poor parental health
• Need to provide care for sick adults or younger children in the home
• Neighborhood violence
• Unstable housing conditions
• Transportation difficulties
• Frequent moves/school changes
What Are Evidence-Based
Interventions to Address HealthRelated Causes of Chronic
Absenteeism?
Infection Prevention
Effect of Hand Hygiene Instruction
Effect of Influenza Vaccination
From: King, JC, NEJM December 2006
From: Lau CH, BMC Pediatr May 2012
School Nurses
• Students seen by a school nurse for an illness or injury were more
likely to return to class compared to when seen by an unlicensed
school employee
• Addition of a full time nurse decreased absenteeism among students
with asthma
• Schools with fewer students per nurse had better school-level
attendance rates
Mental Health Care
Some interventions that have specifically been shown to reduce
absenteeism include:
• Cognitive behavioral therapy
• Trauma-informed schools
School Policies and Parent Interventions
• Policies that promote a positive
school climate
• Policies that promote school
connectedness
• Communication and workshops
with parents regarding school
attendance
• Strong monitoring of attendance
by parents
Coordinated School Health
School-Based Health Centers
From: Walker SC, Journal of Adolescent Health 2010
What Can School-Based Health
Centers Do to Address
Absenteeism?
What Can SBHCs Do to Address Absenteeism?
(Consider the case of Jane)
• 1 minute: silently self-reflect on the questions: ‘What can I do in my
practice to address absenteeism?’ and/or ‘What can SBHCs do to
address absenteeism?’
• 2 minutes: generate ideas in pairs, building on ideas from selfreflection
• 4 minutes: share and develop ideas from your pair in foursomes
(notice similarities and differences)
• 5 minutes: ask, ‘What is one idea that stood out in your
conversation?’ Each group shares one important idea with all
Tier 1—Approaches for ALL Youth
• Ask about the number of missed school days in past month at every
visit
• Praise patients (and caregivers) for good school attendance
• Promote school attendance with posters, videos, handouts
• Talk about the impact of school absences on school performance and
future wellness
• Talk about how absences can add up
• Educate yourself and health center staff about appropriate and
inappropriate reasons to exclude children from school
Tier 2—Missing > 3 Days of School/Month
• Prevent, identify, and treat physical and mental health conditions that
are contributing to school absences
• Help patients (and caregivers) address family factors that are barriers
to attending school
• Communicate and collaborate with school professionals and
community partners to manage the health conditions of your patients
with chronic absenteeism
• Encourage caregivers of students with excessive absences to seek a
formal school team meeting
Tier 3—Missing > 4 Days of School/Month
• Encourage the school or school district to provide services such as
intensive case management and mentorship
• Communicate and collaborate with professionals providing support
services in school
• Consider if an alternative to current school situation is appropriate
• Serve as your patient’s advocate and medical expert
Additional Resources
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•
•
•
•
•
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America’s Promise Alliance, Grad Nation: http://www.americaspromise.org/program/gradnation
Attendance Works: http://www.attendanceworks.org/
Everyone Graduates Center: http://www.every1graduates.org/
Healthy Schools Campaign: https://healthyschoolscampaign.org/
National Center for Education Statistics, Every School Day Counts: https://nces.ed.gov/
National Center for School Engagement: http://schoolengagement.org/
Colorado Department of Education, attendance and truancy data:
http://www.cde.state.co.us/cdereval/truancystatistics
Links to resources to share with patients and parents:
• Handouts to give to parents: http://www.attendanceworks.org/tools/for-parents/parenthandouts/
• Video to show in waiting room: http://www.attendanceworks.org/tools/for-parents/bringingattendance-home-video/
Contact Information
E-mail: [email protected]
Office phone: 303-724-7450